Peroral Endoscopic Myotomy With Simultaneous Submucosal and Muscle Dissection (POEM-SSMD) Is a Safe and Effective Method for Achalasia With Severe Interlayer Adhesions at Cardia

Abstract

Introduction: Severe interlayer adhesions of cardia in achalasia patients will lead to aborted peroral endoscopic myotomy (POEM) procedures. The present study aimed to determine the safety and efficacy of an innovative method, peroral endoscopic myotomy with simultaneous submucosal and muscle dissection (POEM-SSMD), for achalasia with severe interlayer adhesions at cardia. Methods: Between December 2014 and May 2017, a total of 9 achalasia patients with severe interlayer adhesions at cardia underwent POEM-SSMD (Figure 1) at our hospital. Relevant clinical data were retrospectively collected and analyzed.2770_A Figure 1. The Procedures of POEM-SSMD.Results: POEM-SSMD was successfully performed for all the 9 patients with a mean operation time of 49.22 min (27-85 min). During a mean 16.67 months (7-34 months) follow-up, symptom remission, which is defined as postoperative Eckardt score ≤3, was achieved in 8 patients (88.89 %), and the median Eckardt score decreased from 6 (5-10) preoperatively to 0 (0-4) postoperatively (P <0.05). No major adverse events were encountered (Figure 2-3).2770_B Figure 2. Preoperative and postoperative Eckardt score.2770_C Figure 3. Preoperative and postoperative lower esophageal sphincter pressures (LESP).Conclusion: This study showed that this technique produced a 88.89 % (8/9) symptom remission rate, indicating that POEM-SSMD is an effective treatment option for achalasia with severe interlayer adhesions at cardia. In terms of safety, both the gas-related adverse events rate and clinical reflux adverse events rate were 22.2% (2/9), which were comparable with the results of conventional POEM. Of note, a relatively higher mucosal penetration rate (22.2%, 2/9) was found in this study; and both these two penetrations occurred at the cardia; this might mainly attribute to the severe interlayer adhesions at this location. In the present study, fibrin sealant was used to successfully close the crevice, and the efficacy of this remedy method has been confirmed in previous studies. The most important limitation of this study is the potential selection bias. Another limitation was the lack of paired HRM results in 5 cases, owing to the retrospective design of this study. However, there existed statistically significant decreasing for median Eckardt score and increasing for mean weight postoperatively (Figure 2-3), which could also confirm the good efficacy of POEM-SSMD. In conclusion, POEM-SSMD appears to be a safe and effective treatment option for achalasia with severe interlayer adhesions at cardia. However, a further prospectively study with larger population is warranted.