Retrospective Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 21, 2023; 29(15): 2349-2358
Published online Apr 21, 2023. doi: 10.3748/wjg.v29.i15.2349
Repeat peroral endoscopic myotomy with simultaneous submucosal and muscle dissection as a salvage option for recurrent achalasia
Yun-Juan Lin, Sheng-Zhen Liu, Long-Song Li, Ke Han, Bo-Zong Shao, En-Qiang Linghu, Ning-Li Chai
Yun-Juan Lin, Department of Gastroenterology and Hepatology, Chinese PLA General Hospital and Chinese PLA Medical School, Beijing 100853, China
Sheng-Zhen Liu, Long-Song Li, Ke Han, Bo-Zong Shao, En-Qiang Linghu, Ning-Li Chai, Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
Author contributions: Chai NL was the guarantor and designed the study; Lin YJ and Liu SZ participated in the acquisition, analysis, and interpretation of the data, and drafted the initial manuscript; Li LS, Han K, and Shao BZ revised the article critically for important intellectual content; Linghu EQ and Chai NL were the patient’s endoscopists; and all authors read and approved the final version.
Institutional review board statement: The study was reviewed and approved by the Ethics Committee of Chinese PLA General Hospital (Approval No. S2021-207-01).
Informed consent statement: All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrolment.
Conflict-of-interest statement: The authors declare no conflicts of interest for this article.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ning-Li Chai, MD, Chief Physician, Professor, Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing 100853, China. chainingli@vip.163.com
Received: January 15, 2023
Peer-review started: January 15, 2023
First decision: February 7, 2023
Revised: February 20, 2023
Accepted: March 29, 2023
Article in press: March 29, 2023
Published online: April 21, 2023
Processing time: 88 Days and 21.5 Hours
Abstract
BACKGROUND

For recurrent achalasia after initial peroral endoscopic myotomy (POEM) failure, repeat POEM (Re-POEM) has been reported as a treatment option. However, severe esophageal interlayer adhesions caused by previous procedures impede the successful establishment of a submucosal tunnel and lead to aborted Re-POEM procedures. Our team previously described POEM with simultaneous submucosal and muscle dissection (POEM-SSMD) as a feasible solution for achalasia with severe interlayer adhesions.

AIM

To investigate the effectiveness and safety of Re-POEM with simultaneous submucosal and muscle dissection (Re-POEM-SSMD).

METHODS

A total of 1049 patients with achalasia who underwent successful endoscopic myotomy at the Digestive Endoscopic Center of Chinese PLA General Hospital from December 2014 to May 2022 were reviewed. Patients with recurrent achalasia who experienced initial POEM clinical failure were retrospectively included in this study. The primary endpoint was retreatment clinical success, defined as an Eckardt score ≤ 3 during the postretreatment follow-up and no need for additional treatment. Procedure-related adverse events, changes in manometric lower esophageal sphincter (LES) pressure and reflux complications, as well as procedure-related parameters, were recorded.

RESULTS

Sixteen patients underwent Re-POEM (9 patients) or Re-POEM-SSMD (7 patients) successfully at a median of 45.5 mo (range, 4-95 mo) after initial POEM. During a median follow-up period of 31 mo (range, 7-96 mo), clinical success (Eckardt score ≤ 3) was achieved in 8 (88.9%) and 6 (85.7%) patients after Re-POEM and Re-POEM-SSMD, respectively (P = 0.849). The median Eckardt score dropped from 4 (range, 3-8) at preretreatment to 1 (range, 0-5) at postretreatment in the Re-POEM group (P = 0.025) and from 5 (range, 2-8) to 2 (range, 0-4) in the Re-POEM-SSMD group (P < 0.001). The mean manometric LES pressure decreased from 23.78 ± 9.04 mmHg to 11.45 ± 5.37 mmHg after Re-POEM (P < 0.001) and from 26.80 ± 7.48 mmHg to 11.05 ± 4.38 mmHg after Re-POEM-SSMD (P < 0.001). No serious adverse events were recorded in both groups.

CONCLUSION

In conclusion, Re-POEM-SSMD appears to be a safe and effective salvage therapy for recurrent achalasia with severe interlayer adhesions.

Keywords: Esophageal achalasia, Recurrence, Peroral endoscopic myotomy, Simultaneous submucosal and muscle dissection, Interlayer adhesion, Salvage therapy

Core Tip: For recurrent achalasia after initial peroral endoscopic myotomy (POEM) failure, repeat POEM (Re-POEM) has been reported as a potential treatment option. However, severe interlayer adhesions caused by previous procedures impede the successful establishment of a submucosal tunnel. In this study, we retrospectively analyzed the data of patients who had persistent or recurrent symptoms after initial POEM and underwent Re-POEM or Re-POEM with simultaneous submucosal and muscle dissection (Re-POEM-SSMD). The results show that Re-POEM-SSMD could serve as an effective and safe salvage option for patients with recurrent achalasia when conventional POEM procedures are impeded by severe interlayer adhesions.