The Clinical Study Of Patients With Recurrent Achalasia Were Treated With POEM And Analysis Of Multiple Factors Affecting The Operation Time

BackgroundAchalasia is a kind of esophageal dynamic disorder,because the ganglion cells of the intermuscular plexus are affected,resulting in the disappearance of esophageal peristalsis and poor sphincter relaxation of the lower esophagus.The clinical manifestations are dysphagia,reflux,retrosternal pain,and weight loss.At present,the disease is confirmed by clinical manifestations and upper gastrointestinal barium meal examination or gastroscopy or high resolution manometry.The main treatment methods of achalasia include endoscopic surgery,surgical treatment and oral medication.Traditional endoscopic methods include balloon dilatation,botox injection and stent implantation,but the long-term effect is not good and it is easy to relapse.Surgical Heller myotomy is effective,but the patient is more traumatic.For the first time in 2008,Inoue progressed in the human body through POEM(peroral endoscopic myotomy,POEM).POEM not only achieves the therapeutic goal of esophageal lower segment sphincterotomy,but also has the advantages of minimally invasive.It has become the first choice for treatment of achalasia.Some achalasia patients have recurrent symptoms following endoscopic dilatation,stent placement,botulinum toxin injection,Heller surgery,or POEM.It has been reported that the only risk factor for recurrence after balloon dilation is duration of disease,while recurrence after POEM is considered to be closely related to Chicago classification and duration of disease,but duration of disease is an independent risk factor.Through a retrospective study,this paper analyzed the efficacy and safety of recurrent achalasia after endoscopic treatment or surgical treatment and the re-initiation of POEM.PurposeThis study aimed to explore the efficacy and safety of POEM for patients with recurrent achalasia and to conduct a preliminary analysis of the factors influencing the time of POEM through a retrospective study.Patient Selection and methods1.①Subjects Patients with achalasia who were performed POEM in the First Affiliated Hospital of Zhengzhou University from August 2012 to January 2019 were selected.Inclusion criteria:patients with achalasia aged over 18 years.Exclusion criteria:some were affected by incomplete clinical data.②Data collection Recorded clinical data,including whether there is a history of previous treatment,age,gender,the length of the disease,Eckardt scores before POEM and perioperative data,including operation time,hospital stay,Eckardt scores after POEM,intraoperative and postoperative adverse events,etc.③Cases of group According to the history of previous treatment,patients were divided into patients with treatment history and patients with no treatment history.Because previous Heller surgery has a great impact on the re-operation of POEM,patients with treatment history were divided into the non-heller treatment history group(33 cases)and the Heller treatment history group(5 cases).The non-heller treatment history group was compared with the initial treatment group.Case data of 168 patients were collected and followed up.There were 33 patients in the non-heller treatment group,31 patients had performed pneumatic dilation,2 patients had performed POEM.There were 130 patients in the initial treatment group.There were 68 males and 95 females,aged 18-83 years,with an average age of(45.25±13.79)years.④Operation:POEM:①The injection needle was inserted into the left or right wall of the esophagus,10cm above the esophagus from the cardia into the submucosa,and the normal saline was injected into the mucosal eminence of the esophagus;②The surface mucosa was incised with a Hook knife or triangle knife to form a linear incision 15-20mm long;then a Hook knife or triangle knife was used to construct a tunnel 2-3cm below the submucosa to the cardia;③The annular muscle was gradually resected to 2-3cm below the gastroesophageal junction;④Stopped bleeding and closed mucosal incision⑤Evaluation indexa.Eckardt scores:including the frequency of regurgitation,dysphagia,chest pain and the degree of weight loss.The effective index of treatment was the postoperative Eckardt score≤3 points or more than 3 points lower than the preoperative score.b.Gerd Q scale:To assess the presence of gastroesophageal reflux symptoms,the scale includes heartburn,reflux,dysphagia,painful swallowing and the scores>7 points were considered to have significant GRED symptomsc.Endoscopy:The patients with longitudinal erosion of the distal esophagus were patients with reflux esophagitisincluding previous treatment history,age,sex,course of disease,esophageal morphology and perioperative data,including operative time,intraoperative and postoperative adverse events,etc2.This study also collected 86 cases of POEM surgery performed by a gastroenterologist in the first affiliated hospital of zheng university,including 39 males and 47 females,aged 18-77 years old,with an average age of(43.79±13.58).There were 43 cases in the early stage(from June 2013 to July 2017)and 43 cases in the later stage(from July 2017 to March 2019)to analyze the factors affecting the duration of operation of POEM.Clinical data were collected including previous treatment history,age,sex,course of disease,esophageal morphology and perioperative data,including operative time,intraoperative and postoperative adverse events,etc.3.Statistical analysis All statistical analyses were performed using SPSS 22.0 software.Continuous variables that conformed to the normal distribution were expressed as mean±standard deviation.Student t-test was done to determine difference among continuous variables.Categorical variables were used chi-square test or calibration chi-square test.Multivariate logistic regression was used to analyze independent factors affecting the POEM time,α=0.05 was taken test level and P<0.05 was considered to be significant.Results1.The incidence of adverse events was 9.1%in the non-heller treatment history group and 13.8%in the initial treatment history group.There was no statistical difference between the two groups.There was no significant difference in the postoperative Eckardt score between the two groups,and the difference was significantly lower than that before the operation.The incidence of prominent GERD and reflux esophagitis in both groups were observed with no significant difference(P>0.05).The symptom relief rate were 93.9%and 96.2%respectively.And there was no significant difference(P>0.05).The average operation time was longer in the Heller treatment group,and the postoperative Eckardt score was significantly lower than that before the operation.2.The history of prior treatment(OR=17.555,95%CI:2.900-106.257,P=0.002)was independently associated with time of POEM.And POEM of the early period(OR=4.539,95%CI:1.569-13.129,P=0.005)was independently associated with time of POEMConclusionPOEM was performed safely and effectively in patients with achalasia who had undergone prior surgical or endoscopic treatment.The history of prior treatment and POEM of the early period were independently associated with time of POEM.