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Peroral Endoscopic Myotomy for the Treatment of Achalasia: a Clinical Comparative Study of Endoscopic Full-Thickness and Circular Muscle Myotomy

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Peroral Endoscopic Myotomy for the Treatment of Achalasia: a Clinical Comparative Study of Endoscopic Full-Thickness and Circular Muscle Myotomy Peroral Endoscopic Myotomy for the Treatment of Achalasia: A Clinical Comparative Study of Endoscopic Full-Thickness and Circular Muscle Myotomy Quan-Lin Li, MD, Wei-Feng Chen, MD, Ping-Hong Zhou, MD, PhD, Li-Qing Yao, MD, Mei-Dong Xu, MD, PhD, Jian-Wei Hu, MD, Ming-Yan Cai, MD, Yi-Qun Zhang, MD, PhD, Wen-Zheng Qin, MD, Zhong Ren, MD, PhD BACKGROUND: A circular muscle myotomy preserving the longitudinal outer esophageal muscular layer is often recommended during peroral endoscopic myotomy (POEM) for achalasia. However, because the longitudinal muscle fibers of the esophagus are extremely thin and fragile, and completeness of myotomy is the basis for the excellent results of conventional surgical myotomy, this modi- fication needs to be further debated. Here, we retrospectively analyzed our prospectively main- tained POEM database to compare the outcomes of endoscopic full-thickness and circular muscle myotomy. STUDY DESIGN: According to the myotomy depth, 103 patients with full-thickness myotomy were assigned to group A, while 131 patients with circular muscle myotomy were assigned to group B. Symptom relief, procedure-related parameters and adverse events, manometry outcomes, and reflux complications were compared between groups. RESULTS: The mean operation times were significantly shorter in group A compared with group B (p ¼ 0.02). There was no increase in any procedure-related adverse event after full-thickness myotomy (all p < 0.05). During follow-up, treatment success (Eckardt score 3) persisted for 96.0% (95 of 99) of patients in group A and for 95.0% (115 of 121) of patients in group B (p ¼ 0.75). There were no statistically significant differences in pre- and post-treatment D-value of symptom scores and lower esophageal sphincter pressures between groups (both p > 0.05). The overall clinical reflux complication rates were also similar (21.2% vs 16.5%, p ¼ 0.38). CONCLUSIONS: Short-term symptom relief and manometry outcomes of each method were comparable. Full- thickness myotomy significantly reduced the procedure time but did not increase the procedure-related adverse events or clinical reflux complications. (J Am Coll Surg 2013;217: 442e451. Ó 2013 by the American College of Surgeons) Achalasia is a primary esophageal motor disorder charac- esophagus.1 Diagnosis and surgical treatment of achalasia terized by the absence of peristalsis and a defective relax- have been established, even if still debated, for a long ation of the lower esophageal sphincter (LES), resulting in time. The extent of open or laparoscopic Heller myotomy impaired bolus transport and stasis of food in the was defined on the basis of clinical and manometric CME questions for this article available at Presented at Digestive Disease Week 2013, Orlando, FL, May 2013. http://jacscme.facs.org Received February 6, 2013; Revised April 1, 2013; Accepted April 23, 2013. Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, From the Endoscopy Center and Endoscopy Research Institute, Zhongshan Editor-in-Chief, has nothing to disclose. Hospital, Fudan University, Shanghai, China. Financial support: This study was supported by the grants from the Correspondence address: Ping-Hong Zhou, MD, PhD, Endoscopy Medical Leading Project of Shanghai Municipal Science and Technology Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan Committee (10411969600), and the Major Project of Shanghai Munic- University, 180 FengLin Rd, Shanghai 200032, P R China. email: ipal Science and Technology Committee (10411955900, 11411950502 [email protected] and 11DZ2280400). Drs Quan-Lin Li and Wei-Feng Chen contributed equally to this work. ª 2013 by the American College of Surgeons ISSN 1072-7515/13/$36.00 Published by Elsevier Inc. 442 http://dx.doi.org/10.1016/j.jamcollsurg.2013.04.033 Vol. 217, No. 3, September 2013 Li et al Endoscopic Full-Thickness Myotomy 443 symptom remission. For these considerations, POEM Abbreviations and Acronyms with a full-thickness myotomy has been performed in EGD ¼ esophagogastroduodenoscopy about half of the achalasia patients in our center. In EGJ ¼ esophagogastric junction this study, we retrospectively analyzed our prospec- ¼ GER gastroesophageal reflux tively maintained POEM database to compare the out- HRM ¼ high-resolution manometry LES ¼ lower esophageal sphincter comes of endoscopic full-thickness and circular muscle POEM ¼ peroral endoscopic myotomy myotomy, hypothesizing that full-thickness myotomy PPI ¼ proton pump inhibitor would be superior to circular muscle myotomy alone. METHODS results.2 The standard surgical procedure involves complete division of both the longitudinal and circular Study design muscles of the esophagus from the distal esophagus This retrospective analysis was approved by the local onto the proximal stomach while preserving the mucosa. research ethics committee. The analysis included consecu- Despite improvement in perioperative outcomes after tive patients who had primary achalasia and were treated laparoscopic myotomy, it is still an invasive procedure, with POEM successfully by a single operator (PH Zhou) causes significant pain and discomfort, and is relatively at the authors’ institution between August 2010 and expensive. March 2012. Patients were eligible for enrollment in the Peroral endoscopic myotomy (POEM) has recently study if they had an Eckardt symptom score 4. The diag- been described as a scarless and less invasive surgical nosis of achalasia was made on the basis of the absence of myotomy option for treatment of achalasia.3-8 Initial pub- peristalsis and on impaired relaxation of the LES on estab- lished experience in humans is more than encouraging lished methods; barium swallow and esophagogastroduo- despite a relatively short follow-up. A circular muscle denoscopy (EGD) were performed in all enrolled myotomy preserving the longitudinal outer esophageal patients before POEM, and high resolution manometry muscular layer is often recommended during POEM, (HRM) was performed in 127 of 234 of them. Exclusion which is different from the usual full-thickness myotomy criteria were severe cardiopulmonary disease or other performed surgically. Although selective circular muscle serious disease leading to unacceptable surgical risk, pseu- > myotomy is designed in order to avoid entering the doachalasia, megaesophagus (diameter 7 cm), and hiatal > pleural space and decrease morbidity, it is often hard to hernia ( 2 cm). All included patients provided written achieve because the longitudinal muscle fibers of the informed consent to undergo POEM after detailed spoken esophagus are extremely thin, which frequently leads to and written explanations concerning the POEM proce- an unintentional splitting of the muscle fibers during dure and other possible treatment options. POEM. Either minor electrocautery damage, mechanical Procedural details were recorded prospectively in a data- trauma from maneuvering the endoscope in the tunnel, base. After thoroughly investigating the database and or air insufflation alone can result in spreading of the their medical records, patients were grouped in 2 sets longitudinal muscle fibers and adventitia and transmural according to myotomy depth: Group A underwent endo- openings into the mediastinum.8 In fact, a clear separa- scopic full-thickness myotomy, including the internal tion of circular (to be completely dissected) and longitu- circular and longitudinal muscular layer; group B under- dinal (to be left) muscular layers cannot be found any went endoscopic circular muscle myotomy alone, more at the esophagogastric junction (EGJ) and stomach. involving only the internal circular muscular layer. Moreover, although dissection of the circular muscle Patients who had only limited damage of the longitudinal fibers alone led to a significant reduction of LES pressure muscle fibers were also assigned to group B. In this study, as demonstrated by postoperative manometry in some an inadvertent full-thickness myotomy was performed in studies,3,9 in the experience of others, completeness of 37 of 154 enrolled patients before October 2011; an myotomy is a prerequisite for sufficient and long-term intentional full-thickness myotomy was performed in reduction of LES pressure and is the basis for the excellent 66 of 80 enrolled patients subsequently after considering result of conventional surgical myotomy.8,10 Given the the hypothesis that full-thickness myotomy would be fact that an incomplete myotomy with possible fibrotic superior for the excellent result. healing may be considered a major reason for postopera- tive recurrence,11,12 a full-thickness myotomy may reduce Outcomes measurements the incidence of fusion by further spreading of the cut The main outcomes measures that were compared muscular wall and theoretically inducing long-term between the 2 groups were: 444 Li et al Endoscopic Full-Thickness Myotomy J Am Coll Surg 1. Therapeutic success at the follow-up assessment, Patients were admitted 1 day before the POEM proce- defined as a reduction in the Eckardt score to 3;8 dure to undergo EGD, cleaning out food remnants from 2. Procedure-related parameters such as procedure time, the esophagus. Prophylactic intravenous antibiotics and hospital stay, and myotomy length; proton pump inhibitors (PPI) were introduced 30 3. Procedure-related adverse events such as mucosal minutes before the procedure. The POEM procedure injury/perforation, subcutaneous emphysema, pneu- was performed under general anesthesia, as described mothorax, pneumoperitoneum, pneumonia,
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