Comparative Study Of Peroral Endoscopic Myotomy And Thoracotomy Heller Myotomy Treatment For Achalasia Of Cardia

Objective:Achalasia of cardia (AC) is due to esophageal cardia neuromuscular regulation disorder, resulting in that lower esophageal sphincter (lower esophageal sphincter, LES) can not effectively relax after swallowing, as with functional disease characterized by esophageal peristalsis weaken or disappear. Because this disease often accompanies with expansion and cardiac spasm of esophageal,so it is also known as the giant of esophageal and cardiac spasm. Clinical symptoms often have different degrees of dysphagia, regurgitation, chest pain and other symptoms. The treatments of the disease are Various.The first is the drug treatment, mainly for muscle relaxants.Its curative effect is poor and easzily causes hypotension and other complications. Endoscopic botulinum toxin injection also belongs to the drug treatment, with the better short-term efficacy and poor long-term curative efficacy in the relieving dysphagia.but for the frail elderly patients with AC, it is a safe and effective therapy; then the interventional endoscopic treatment, including endoscopic dilation, stent and the recently emerging peroral endoscopic myotomy (peroral endoscopic myotomy, POEM) treatment; the last is surgical operation treatment. The advantages and disadvantages of different ways of treatment of Cardia Achalasia are still need further studied. To compare two kinds of treatment of achalasia of cardia, peroral endoscopic myotomy for surgery and thoracic Heller myotomy, and understand the advantages and disadvantages of the two ways.Methods:29cases were collected from2011December to2013December for treatment of hospitalized patients with achalasia in General Hospital of Chengdu Military Region. Data collected included:age, sex, course of disease, former special treatment history and the severity of the disease and other basic information; hospital treatment; curative effect. Achalasia of cardia were confirmed by endoscopy, upper gastrointestinal barium meal and esophageal manometry. Except for medical treatment,the previous special treatment history included esophageal stent, endoscopic balloon dilatation, POEM, surgical operation etc.. The severities of the disease were evaluated by cardiac achalasia symptoms score (Eckardt score)(Table1) and Henderson grade (Schedule2). Hospitalization treatment includde preoperative preparation, operation time, complications (postoperative), postoperative fasting time, postoperative hospital stay, hospital costs.We evaluated one month and six months curative effect after operation with indexes of subjective achalasia symptoms score (Eckardt score) and objective endoscopy, upper gastrointestinal contrast examination. Subjective score of clinical symptoms of achalasia of cardia:according to clinical symptom score (Eckardt score) on the clinical symptoms score, if the score is less than3points,the operation is invalid, or the effective. After six months, if clinical symptom score is more than4points,the operation can be considered failed. Objective index:1) It is effectively that upper gastrointestinal radiography shows cardia patency and Henderson grading esophageal dilation degree cuts down compared with the preoperative; it is invalid that upper gastrointestinal radiography shows barium goes through the cardia like a line or esophageal dilation degree compared with the preoperative does not reduce or even worse.2) it is effective that endoscopic examination shows cardia is relaxation or with little resistance entry; it is invalid that cardiac spasm or imported resistance.29patients were classified POEM group and thoracotomy Heller myotomy group according to different treatment.15cases were treated with POEM,8cases of male,7cases of female.14patients underwent thoracotomy Heller myotomy treatment,6cases of male,8cases of female; age range:POEM group36～55years, mean age45.33±1.40years, thoracic Heller myotomy group34～67years, mean age46.07±2.48years; Course of disease:POEM group1～13years, average78.73±16.96months, thoracotomy Heller myotomy group1month to20years, average62±17.07months; Past history:1case in POEM group underwent endoscopic balloon dilatation,2cases in thoracotomy Heller myotomy group underwent endoscopic balloon dilatation. Before treatment according to achalasia symptoms score (Eckardt score) score, POEM group5±0.60, thoracotomy Heller myotomy group4.93±0.68; before treatment according to Henderson grade in POEM group2cases severe expansion,13cases moderate expansion, in thoracotomy Heller myotomy group3cases severe expansion,11cases moderate expansion.The main steps of the two methods:POEM steps:(1) The saline flushs the esophagus;(2) Select the incisors30cm esophageal left wall setting up tunnel opening, submucosal injection of indigo carmine adrenalin saline, swelling mucosa, with I type cutter longitudinal incision mucosa and submucosa and muscularis propria;(3) Set up a submucosal tunnel which gradually extends to the cardia2cm with T type knife along the submucosa peel, dealing with the submucosa and muscularis propria small vessels;(4) Gradually cut gastric muscularis propria circular muscle with IT type knife, making sure cardiac relaxation.(5) Treatment of suspected blood vessels, and the tunnel opening is sealed with titanium clamp, placement of gastrointestinal decompression tube for evacuation, ICU monitoring.Thoracotomy Heller myotomy steps:Indwelling catheter after general anesthesia, right arm reclining, the operation field disinfection, draping. Get Into the chest through the left seventh intercostal posterolateral. Cut the pulmonary ligament and cut open esophagus bed mediastinal pleura. Blunt separation the junction of esophagus and diaphragmatic hiatus.The abdominal segment of esophagus and cardia are pulled into the chest,Avoid esophageal sympathetic nerve and cut open the lower esophagus anterior to the submucosa from the cardia below1cm to the lower esophagus. The Incision is about6cm long.Blunt dissection between the muscular layer of esophagus and submucosa.The separation section is about1/2of the esophageal circumference.The esophageal mucosa bulges from the Incision. The Intraoperative gastroscopy shows lower esophageal myotomy is patency, the narrow part is relief. No leakage after esophageal cavity gas injection shows Esophageal mucosa integrity.Place nasojejunic nutrition tube by gastroscope.Warm saline flushs the chest. Make sure the pleural has no active bleeding. Place1the closed drainage tube In the eighth rib midaxillary line.Close the chest after checking the gauze and equipment. After the operation the patient is sent into the ICU. Statistical analysis the basic data the POEM group and thoracotomy Heller myotomy group in the operation time, complications, postoperative fasting time, postoperative hospital stay, hospital costs and efficacy analysis. The statistical software is SPSS13.0.Statistical method:two sample proportion or rate of sample were compared using Fisher’s exact probability four tables, two samples of quantitative data using t test, P<0.05is different, or for no difference.Results:Basic information:there was no significant difference between two groups in age (P=0.794), no difference in duration (P=0.493), former special treatment no difference (P=0.473), no difference in preoperative clinical symptom score (P=0.075), esophageal dilatation indifference before operation (P=0.485), the two groups were comparable.Operation time:an average of120.87±6.61min in POEM group and an average of138.21±5.31min in thoracotomy Heller myotomy group, there is no statistical significance (P=0.052). The two groups in operation time have no difference.Intraoperative hemorrhage:POEM group5～20ml, an average of9.33±4.17ml, thoracotomy Heller myotomy group50～200ml, an average of128.57±61.12ml. Comparing two groups, there is statistically significant (P<0.001). Bleeding during POEM is less than thoracotomy Heller myotomy.Postoperative complications:Esophageal perforation:POEM group had no perforation of the esophagus, while thoracotomy Heller myotomy group had1after the operation.Compareing the two groups, there is not statistically significant (P=0.483).The two groups have no difference in the incidence of esophageal perforation.Pulmonary infection:3cases of pulmonary infection occurred in the POEM group, while there were13cases of pulmonary infection in thoracotomy Heller myotomy group. Compareing the two groups, there is statistical significance (P<0.001). The lung infection rate of POEM group is lower than thoracotomy Heller myotomy group.Pleural effusion. Group POEM:small amount of pleural effusion occurred in5cases, absorption without special treatment;14cases after thoracotomy Heller myotomy underwent thoracic closed drainage. Because drainage was too much,2cases were input plasma400ml and600ml. Obviously, in this complication POEM has an advantage comparing thoracotomy Heller myotomy.Fasting time: POEM group was4.80±0.64days,while thoracotomy Heller myotomy group was8.29±0.47days. Compareing the two groups, there is statistical significance (P<0.001).Fasting time in POEM group is shorter.Postoperative hospitalization:POEM group with an average of8.67±0.64days, thoracotomy Heller myotomy group11.43±0.68days. Compareing the two groups, there is statistical significance (P=0.0061), Postoperative hospitalization of POEM group is shorter.Hospitalization expenses:POEM group with an average of29122.95±1722.10yuan, thoracotomy Heller myotomy group with an average of36599.03±2209.06yuan. Compareing the two groups, there is statistical significance (P=0.012). Hospitalization expenses of POEM group is less.Evaluation of curative effect:1month after operation:15cases followed up in POEM group.14cases score<3(Eckardt score),1case with4score;14cases followed up in thoracotomy Heller myotomy group.12cases score<3(Eckardt score),2cases with5score; combined with upper gastrointestinal radiography and gastroscopy inspection, the effective rate of POEM was93.3%(14/15), while thoracotomy Heller myotomy group was85.71%(12/14). Compareing the efficiency of the two groups, there was no significant difference (P=0.437).6months after operation:13cases followed up in POEM group (including the patient whose postoperative1month clinical score was4).All the cases Eckardt score≤3;13cases followed up in thoracotomy Heller myotomy group (including2cases whose postoperative1month clinical score was5).12cases Eckardtscore≤3,1case>3,which could be considered the operation failed. Combined with upper gastrointestinal radiography and gastroscopy inspection, the effective rate of POEM was100%(13/13), while thoracotomy Heller myotomy group was92.31%(12/13). Compareing the efficiency of the two groups, there was no significant difference (P=0.481).Conclusions:1、Both POEM and thoracotomy Heller myotomy were effective for achalasia of cardia.2、The effective rate of POEM and thoracotomy Heller myotomy for achalasia of cardia was not significantly different.3、Compareing with thoracotomy Heller myotomy for achalasia of cardia,POEM is less complications, shorter postoperative fasting time, shorter time of hospitalization and less hospitalization expenses.