title: Peroral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy.
abstract: BACKGROUND
  A circular muscle myotomy preserving the longitudinal outer esophageal muscular layer is often recommended during peroral endoscopic myotomy (POEM) for achalasia. However, because the longitudinal muscle fibers of the esophagus are extremely thin and fragile, and completeness of myotomy is the basis for the excellent results of conventional surgical myotomy, this modification needs to be further debated. Here, we retrospectively analyzed our prospectively maintained POEM database to compare the outcomes of endoscopic full-thickness and circular muscle myotomy.
  
  
  METHODS
  According to the myotomy depth, 103 patients with full-thickness myotomy were assigned to group A, while 131 patients with circular muscle myotomy were assigned to group B. Symptom relief, procedure-related parameters and adverse events, manometry outcomes, and reflux complications were compared between groups.
  
  
  RESULTS
  The mean operation times were significantly shorter in group A compared with group B (p = 0.02). There was no increase in any procedure-related adverse event after full-thickness myotomy (all p < 0.05). During follow-up, treatment success (Eckardt score ≤ 3) persisted for 96.0% (95 of 99) of patients in group A and for 95.0% (115 of 121) of patients in group B (p = 0.75). There were no statistically significant differences in pre- and post-treatment D-value of symptom scores and lower esophageal sphincter pressures between groups (both p > 0.05). The overall clinical reflux complication rates were also similar (21.2% vs 16.5%, p = 0.38).
  
  
  CONCLUSIONS
  Short-term symptom relief and manometry outcomes of each method were comparable. Full-thickness myotomy significantly reduced the procedure time but did not increase the procedure-related adverse events or clinical reflux complications.
authors.affiliation: Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
authors.forename: Quan-Lin
authors.initials: QL
authors.lastname: Li
authors.forename: Wei-Feng
authors.initials: WF
authors.lastname: Chen
authors.forename: Ping-Hong
authors.initials: PH
authors.lastname: Zhou
authors.forename: Li-Qing
authors.initials: LQ
authors.lastname: Yao
authors.forename: Mei-Dong
authors.initials: MD
authors.lastname: Xu
authors.forename: Jian-Wei
authors.initials: JW
authors.lastname: Hu
authors.forename: Ming-Yan
authors.initials: MY
authors.lastname: Cai
authors.forename: Yi-Qun
authors.initials: YQ
authors.lastname: Zhang
authors.forename: Wen-Zheng
authors.initials: WZ
authors.lastname: Qin
authors.forename: Zhong
authors.initials: Z
authors.lastname: Ren
mesh_terms: D000328:Adult; D016009:Chi-Square Distribution; D004931:Esophageal Achalasia / Q000601:surgery*; D004945:Esophagoscopy / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008365:Manometry; D009130:Muscle, Smooth / Q000601:surgery*; D061646:Operative Time; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: EGD; EGJ; GER; HRM; LES; POEM; PPI; esophagogastric junction; esophagogastroduodenoscopy; gastroesophageal reflux; high-resolution manometry; lower esophageal sphincter; peroral endoscopic myotomy; proton pump inhibitor