Different Surgical Procedures of Peroral Endoscopic Myotomy(POEM) for Esophageal Achalasia

Esophageal Achalasia Clinical Trial

Official title:

Different Surgical Procedures of Peroral Endoscopic Myotomy(POEM) for Esophageal Achalasia: a Multicenter Prospective Randomized Controlled Trial

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT03012854
• Other study ID #: NFEC-2016-186
• Status: Recruiting
• Phase: N/A
• First received: January 5, 2017
• Last updated: May 11, 2017
• Start date: December 2016
• Est. completion date: December 2021

Study information

• Verified date: May 2017
• Source: Nanfang Hospital of Southern Medical University
• Contact: Wei Gong, Doctor
• Phone: 86-15820290385
• Email: drgwei[@]foxmail.com
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

This study compares the clinical efficacy of safety of circular myotomy and full-thickness myotomy guided by peroral endoscopic in treatment of incision length of ≤7cm and of ≥7cm in achalasia patients.

Description:

Esophageal achalasia is an esophageal motor disorder, which is characterized by the absence of esophageal peristalsis combined with a defective relaxation of the lower esophageal sphincter (LES). The major symptoms of esophageal achalasia are dysphagia, chest pain, and regurgitation of undigested food.

Currently, treatment options mainly focus on relief of the symptoms by reducing the LES pressure. Pneumatic dilation is the main endoscopic therapies for esophageal achalasia. However, the patients need repeat treatment to maintain therapeutic success and there is a risk of perforation (1%-3%). For surgery approaches, the laparoscopic Heller's myotomy (LHM) combined with Dor's antireflux procedure has gained considerable interest. The LHM can sustain therapeutic effects for long-term in approximately 80% of patients.

Recently, Inoue et al. succeeded in treating achalasia endoscopically with a method called peroral endoscopic myotomy (POEM) and achieved promising results in short-term. Technically, POEM derived from natural orifice transluminal endoscopic surgery (NOTES) and endoscopic submucosal dissection (ESD), in which a submucosal tunnel is created after submucosal injection, and then an endoscopic myotomy was made at the gastroesophageal junction.

However, the clinical efficacy of safety of circular myotomy and full-thickness myotomy guided by peroral endoscopic in treatment of incision length of ≤7cm and of ≥7cm in achalasia patients were not determined, and there was no prospective study that compared different surgical procedures of POEM for esophageal achalasia. Therefore, we aim to compare the clinical efficacy of safety of circular myotomy and full-thickness myotomy guided by peroral endoscopic in treatment of incision length of ≤7cm and of ≥7cm in achalasia patients.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 400
• Est. completion date: December 2021
• Est. primary completion date: December 2021
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 75 Years

Eligibility

Inclusion Criteria:

1. Between 18 and 75 years of age;

2. Patient with esophageal achalasia;

3. Eckardt score > 3;

4. Signed informed consent.

Exclusion Criteria:

1. Severe cardio-pulmonary disease or other serious disease leading to unacceptable surgical risk;

2. Pseudo-achalasia, Mega-oesophagus (greater than 7 cm), or Oesophageal diverticula in the distal oesophagus;

3. Previous endoscopic Botox injection;

4. Previous oesophageal or gastric surgery;

5. Pregnancy or lactation women, or ready to pregnant women;

6. Not capable of filling out questionnaires.

Related Conditions & MeSH terms

• Esophageal Achalasia
• Esophageal Motility Disorders
• Esophageal Spasm, Diffuse

Intervention

Procedure:
• short-myotomy
Entry to submucosal space. After submucosal injection, a 2-cm longitudinal mucosal incision is made at approximately 8-10 cm proximal to the gastroesophageal junction (GEJ). Submucosal tunnelling. A long submucosal tunnel is created to 3 cm distal to the GEJ. Endoscopic myotomy is carried out in a proximal to distal direction to a total length less than 7 cm. The expected end point of myotomy is 2 cm distal to the GEJ. Myotomy of inner circular muscle bundles and outer longitudinal muscle layer is done. Closure of mucosal entry: the mucosal incision is closed using hemostatic clips.
• long-myotomy
Entry to submucosal space. After submucosal injection, a 2-cm longitudinal mucosal incision is made at approximately 8-10 cm proximal to the gastroesophageal junction (GEJ). Submucosal tunnelling. A long submucosal tunnel is created to 3 cm distal to the GEJ. Endoscopic myotomy is carried out in a proximal to distal direction to a total length more than 7 cm. The expected end point of myotomy is 2 cm distal to the GEJ. Myotomy of inner circular muscle bundles and outer longitudinal muscle layer is done. Closure of mucosal entry: the mucosal incision is closed using hemostatic clips.
• full-thickness myotomy
Entry to submucosal space. After submucosal injection, a 2-cm longitudinal mucosal incision is made at approximately 8-10 cm proximal to the gastroesophageal junction (GEJ). Submucosal tunnelling. A long submucosal tunnel is created to 3 cm distal to the GEJ. Endoscopic myotomy is carried out in a proximal to distal direction to a total length more than 7 cm. The expected end point of myotomy is 2 cm distal to the GEJ. Myotomy of inner circular muscle bundles and outer longitudinal muscle layer is done. Closure of mucosal entry: the mucosal incision is closed using hemostatic clips.
• circular myotomy
Entry to submucosal space. After submucosal injection, a 2-cm longitudinal mucosal incision is made at approximately 8-10 cm proximal to the gastroesophageal junction (GEJ). Submucosal tunnelling. A long submucosal tunnel is created to 3 cm distal to the GEJ. Endoscopic myotomy is carried out in a proximal to distal direction to a total length more than 7 cm. The expected end point of myotomy is 2 cm distal to the GEJ. Myotomy of inner circular muscle bundles is done, leaving the outer longitudinal muscle layer intact. Closure of mucosal entry: the mucosal incision is closed using hemostatic clips.

Locations

Country	Name	City	State
China	Nanfang Hospital of Southern Medical University	Guanzhou	Guangdong

Sponsors (1)

Lead Sponsor	Collaborator
Nanfang Hospital of Southern Medical University

Country where clinical trial is conducted

China, 

References & Publications (2)

Boeckxstaens GE, Annese V, des Varannes SB, Chaussade S, Costantini M, Cuttitta A, Elizalde JI, Fumagalli U, Gaudric M, Rohof WO, Smout AJ, Tack J, Zwinderman AH, Zaninotto G, Busch OR; European Achalasia Trial Investigators.. Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia. N Engl J Med. 2011 May 12;364(19):1807-16. doi: 10.1056/NEJMoa1010502. — View Citation

Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M, Satodate H, Odaka N, Itoh H, Kudo S. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010 Apr;42(4):265-71. doi: 10.1055/s-0029-1244080. Epub 2010 Mar 30. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Therapeutic success	Therapeutic success is defined as a symptom control to an Eckardt score of 3 or less. The Eckardt score is the sum of the symptom scores for dysphagia, regurgitation, and chest pain (with a score of 0 indicating the absence of symptoms, 1 indicating occasional symptoms, 2 indicating daily symptoms, and 3 indicating symptoms at each meal) and weight loss (with 0 indicating no weight loss, 1 indicating a loss of <5 kg, 2 indicating a loss of 5 to 10 kg, and 3 indicating a loss of >10 kg) (Eckardt, V. Gastroenterology, 1992. 103(6): p. 1732-8.)	From date of randomization until the follow-up ended, assessed up to 5 years
Secondary	Procedure related complication	Perforation, Delayed bleeding, Pneumothorax, Subcutaneous emphysema, Anastomotic leak etc.	From date of randomization until the follow-up ended, assessed up to 5 years
Secondary	Time of treatment failure	Time of treatment failure is defined as when the Eckardt score of patients are more than 3.	From date of randomization until the follow-up ended, assessed up to 5 years
Secondary	Pressure at the lower esophageal sphincter	From date of randomization until the follow-up ended, assessed up to 5 years	From date of randomization until the follow-up ended, assessed up to 5 years
Secondary	Quality of life	Patients will complete the quality-of-life questionnaires (the Medical Outcomes Study 36-Item Short-Form Health Survey, SF-36) for assessing quality of life.	From date of randomization until the follow-up ended, assessed up to 5 years

External Links

•   Homepage of Department of Gastroenterology, Nanfang Hospital of Southern Medical University
•   Homepage of Nanfang Hospital of Southern Medical University