Endoscopy, Intraoperative and Postoperative Retrospective Analysis

 

Introduction

Since the introduction of POEM into clinical practice, more and more publications have appeared that indicate the high efficacy and safety of this intervention. Conducted a meta-analysis of 2373 cases from 36 institutions in 12 countries and indicating an early intervention success rate of 98%.

During their internship in laparoscopic technique, many of them have not received practical training with simulators Laparoscopic Trainer Box.

When searching the literature, we found several large clinical studies comparing POEM with balloon dilatation and laparoscopic Heller myotomy. According to these studies, POEM provides a better result than pneumatic dilation, but similar to the result of laparoscopic Geller myotomy, and its important advantage is its high efficiency in type 3 AP due to the possibility of increasing the length of myotomy.

Results in Postoperative Period

POEM is also a possible and safe treatment option for recurrent AP, including after an unsuccessful result in POEM. In publications evaluating the results of repeated POEM in patients with previously failed POEM, a decrease in the average score on the Eckadt scale from 4.3 to 1.64 points finds.

In case of unsuccessful attempts at endoscopic or laparoscopic treatment of patients with AP, endoscopic myotomy also gives a good clinical result with a decrease in Eckadt scores to 3 points or less. At the same time, previous treatment did not increase the incidence of intra- or postoperative adverse phenomena, which is consistent with our data. Despite previous courses of balloon hydrodilatation of the cardia and laparoscopic Heller surgery, we did not experience any complications during the intervention and in the early postoperative period in these patients.

Retrospective Multicentre Study

In a retrospective multicentre study that compared the results of POEM in 90 patients with previous Heller surgery in 90 patients without previous intervention, the incidence of adverse events was the same, but the clinical efficacy of myotomy in patients after Heller surgery was lower (94% vs. 81%)  .

According to our data, the effectiveness of intervention in the early stages after surgery was 100% with technical success in all patients. Over time (more than 1 year from the intervention), 1 patient complained of difficulty swallowing solid food, which can be interpreted as a relapse of the disease. In 2 cases in patients with stage IV of the disease, the symptoms of dysphagia, in our opinion, are associated with two factors: a decrease in the propulsive ability of the esophagus and the presence of erosive reflux esophagitis.

Intraoperative Complications

In addition, POEM has a good safety profile. According to a systematic review, including 23 studies involving 1122 patients, the death rate was less than 0.01%, and the incidence of clinically significant intraoperative complications (perforation and bleeding) was 1.4%. The most common complications during the intervention were carboxythorax and carboxyperitoneum, which resolved spontaneously in most cases. There are data on the presence of complications that occur both during the operation and in the early postoperative period with a frequency of 3 to 14%, and the treatment of these conditions includes conservative measures using endoscopic methods.

According to our data, the incidence of intraoperative complications, in particular, perforation was 2%, and bleeding occurred at the stage of mastering the technique and in both cases stops by conservative measures. The incidence of postoperative complications was 4%, and in both cases, the complications were cured using endoscopic methods, which is not high, than the rates obtained by other authors.

The most common adverse event of POEM is gastroesophageal reflux disease (GERD) with an incidence of 20–57%. However, it should be borne in mind that reflux may be asymptomatic, and the symptoms of GERD may be mistaken for symptoms of other diseases. According to gastroesophageal, reflux was asymptomatic in 60.1% of operated patients.

Meta-Analysis

This indicates the need to monitor patients after POEM, and pH-metry and endoscopic studies are the "gold standard" in this. In addition, although the use of proton pump inhibitors can successfully level this situation, it is necessary to monitor patients in order to avoid unnecessary use of drugs.

It is noteworthy and important that in the study.  Have data of 5-year results after POEM indicating the occurrence of Barrett's esophagus without dysplasia in one of the patients.

The most commonly considered causes of reflux are early treatment and posterior wall intervention. In a meta-analysis, there are indications of a lower incidence of GERD with anterior myotomy, and the length of the myotomy, AP subtype, previous treatment in history, including Heller myotomy, do not affect the development of GERD.

Postoperative Period

However, there is another point of view. A recently publishes study note that AP type, POEM technique (anterior or posterior), pre- or post-POEM manometry, and patient characteristics were not associated with the incidence of GERD in the.

At the same time, the frequency of reflux turned out to be higher than after the laparoscopic Heller operation, which confirms by the data of many authors. At the same time, a high frequency of reflux notes during POEM compared with the Heller operation.

 

For the treatment of this condition, proton pump inhibitors more often prescribe with their high efficiency in erosive reflux esophagitis. In our observation, the incidence of erosive reflux esophagitis was 36%, which corresponds to the data of other authors. At the same time, 17 patient diagnoses with grade A and B esophagitis, which coincides with the data of many specialists. In all cases, reflux esophagitis successfully treats with proton pump inhibitors, which confirms by endoscopic data.

In the absence of the effect of conservative therapy, reflux esophagitis that occurs after POEM can be the reason for performing oral fundoplication. To prevent postoperative reflux proposed to perform fundoplication immediately after POEM, which successfully implements in our country as well. However, despite the high efficiency of such an operation in the early postoperative period, it is necessary to evaluate the results in the long-term period.

Conclusion

Paroral endoscopic myotomy for esophageal achalasia, is a very effective and safe intervention. The incidence of intra- and postoperative complications that occurred in our cases does not exceed that indicated in many other studies, and the severity and nature of these complications made it possible to correct those using endoscopic technologies. The disadvantage of oral endoscopic myotomy compared to other minimally invasive interventions is a higher incidence of gastroesophageal reflux and erosive esophagitis, which requires further analysis of the immediate and long-term results of this intervention.

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