Factors Affecting the Technical Difficulty of Peroral Endoscopic Myotomy for Achalasia

Abstract

Introduction: Peroral endoscopic myotomy (POEM) has been described as a novel treatment for achalasia. Owing to its technical difficulty, POEM is not widely performed. This study was aimed to prospectively assess the factor predicting technical difficulty of POEM in a single center with large volume cases. Methods: A total of 105 cases of achalasia treated by POEM from April 2011 to September 2014 were analyzed. Difficult cases of POEM were defined as procedure time ≥ 90 min, occurrence of adverse events, including mucosal perforation, pneumothorax and major bleeding. Multivariate logistic regression analyses were performed to assess the factors of difficult POEM. Results: Baseline and clinical characteristics of patients were shown in table 1. POEM was successfully completed in all the patients and no one was converted to laparoscopy. The number of cases with procedure time ≥ 90 min was 17. Mucosal perforations occurred in 6 (5.7%) patients during submucosal tunnel creation (Figure 1), major bleeding occurred in 7 (6.7%) patients (Figure 2), and 6 (5.7%) patients suffered pneumothorax immediate after procedure (Figure 3). All the complications were managed conservatively. Multivariate analysis showed that early period (odds ratio [OR] 4.173, 95% confidence interval [95% CI] 1.36-6.829, p=0.023), and triangular tip knife ([OR] 6.712, [95% CI] 1.479-30.460, p=0.014), were independent factors associated with technical difficulty regarding to longer procedure time (procedure time ≥ 90 min) (Table 2).Figure 1Figure 2Figure 3Table 2: Multivariate analysis of predictors for technical difficulty in POEM procedureConclusion: POEM is safe for the treatment of achalasia. Early period and triangular tip knife were independent risk factors for longer procedural time.Table 1: Baseline and clinical characteristics of patients