Introduction
Per-oral endoscopic myotomy (POEM) is an established treatment modality for achalasia cardia. Submucosal fibrosis (SMF) is rare, but the most important reason for technical failure during POEM. Prediction of SMF may be crucial to improve technical outcomes with POEM.
Aims & Methods
In this study we aim to evaluate the predictors for SMF in cases with achalasia cardia.Consecutive patients with achalasia cardia who underwent POEM (Aug 2021 to October 2022) were included in the study, prospectively. Various factors were analysed for prediction of SMF including age, gender, stasis esophagitis, type of achalasia, duration of disease, lower esophageal sphincter pressure (LESP), height of barium column on barium esophagogram and severity of symptoms (Eckardt score). Esophageal mucosa was graded for the severity of stasis esophagitis (grade I to grade III) based on vascular pattern, mucosal thickening, ulceration and nodularity. SMF was graded (I minimal, II moderate, III severe) according to mucosal lift, difficulty in entry, density of SM fibers, separation of mucosa and muscle.
Results
240 patients (males 139, mean age 44.4±14.7 years) underwent POEM during the study period. The subtypes of achalasia included type I in 29, type II in 201, type III in 10. Median symptom duration was 24 (1-240) months and mean pre-POEM Eckardt score was 7.6±1.8. Majority (93.3%) of the patients were treatment naïve and underwent POEM via posterior route (91.2%). Stasis esophagitis was evident in 122 (50.8%) patients including grade I in 99 (41.3%), grade II in 16 (6.7%) and grade III in 7 (2.9%) patients. SMF was detected in 87 (36.3%) patients including grade I in 52 (21.7%), grade II in 30 (12.5%) and grade III in 5 (2.1%) patients. Mean age, duration of symptoms, width of esophagus and procedure duration were significantly higher in cases with submucosal fibrosis. (Table 1) Significantly higher proportion of patients with type I achalasia (62.1%) had SMF as compared to type II (33.8%) and type III achalasia (10%) [p=0.013]. On multivariate analysis, the presence of stasis esophagitis and width of esophagus on timed barium were predictors of significant (≥grade II) SMF.
| Multivarient analysis | SMF (no or grade 1) | Significant SMF (grade 2 or 3) | p value |
Age, mean+/-SD
| 44.5+/-14.5
| 44.0+/-15.9
| 0.859
|
Disease duration, months
| 36.3+/-43.9
| 43.9+/-53.1
| 0.035
|
Mean Eckardt score
| 7.8+/-1.9
| 7.1+/-1.4
| 0.060
|
Mean TBS height in cm
| 13.8+/-5.1
| 13.4+/-5.4
| 0.619
|
Mean TBS width in cm
| 4.6+/-1.7
| 6.1+/-3.5
| 0.001
|
Mean LES pressure, mmHg
| 24.3+/-10 3
| 26.9+/-15.1
| 0.198
|
Mean Integrated relaxation pressure, mmHg
| 26.6+/-13.7
| 27.2+/-13 9
| 0.791
|
Mean Myotomy length, cm
| 9.2+/-2.6
| 9.9+/-2.9
| 0.114
|
Mean Procedure time, min
| 40.8+/-17.7
| 58.2+/-24.1
| 0.001
|
Conclusion
Severe SMF (grade III) is uncommon in cases with achalasia cardia. The presence of stasis esophagitis and width of esophagus are predictors of SMF during POEM.
References
1. Wu QN, Xu XY, Zhang XC, Xu MD, Zhang YQ, Chen WF, Cai MY, Qin WZ, Hu JW, Yao LQ, Li QL. Submucosal fibrosis in achalasia patients is a rare cause of aborted peroral endoscopic myotomy procedures. Endoscopy. 2017 Aug;49(08):736-44.
2. Feng X, Linghu E, Chai N, Ding H. New endoscopic classification of esophageal mucosa in achalasia: A predictor for submucosal fibrosis. Saudi journal of gastroenterology: official journal of the Saudi Gastroenterology Association. 2018 Mar;24(2):122.
Disclosure
Nothing to disclose