Kiosov O. The optimization of endoscopic treatment for various degrees of esophageal achalasia

The dissertation is devoted to solving an urgent issue in modern medicine, which involves improving the surgical treatment of esophageal achalasia of stages II - III by the choice of modified intervention methodology and myotomy location. Scientific novelty of the results. The expanded scientific concept regarding the prevalence and clinical-instrumental semiotics of esophageal achalasia. For the first time, the technique of POEM with preservation of the anti-reflux barrier will be improved by correcting the access and volume of myotomy in the form of performing a complete myotomy of the lower esophageal sphincter while preserving the sliding fibers in the stomach (as an anti-reflux mechanism) with a gastric myotomy length of up to 2 cm. The advantages of the proposed surgical technique of POEM in reducing the risk of intra- and postoperative complications and the frequency of recurrence of stage II - III esophageal achalasia have been identified and proven. Based on the study of the impact of the developed surgery on the motor and evacuatory functions of the esophagus in the early and late postoperative periods, as well as the quality of life of patients, it has been proven that the proposed modified technique of POEM is a highly effective method for treating stage II - III esophageal achalasia. It significantly reduces the number of postoperative complications such as reflux esophagitis, peptic esophageal strictures, and recurrence of the primary disease, thereby improving the quality of life of patients operated on for this pathology. Additionally, new data have been obtained regarding the results of a comparative analysis of the dynamics of achalasia symptoms after POEM and video laparoscopic esophagocardiomyotomy according to Heller with Dor/Toupet fundoplication, based on the cumulative score of the Eckardt scale. The observed difference of 4.07 times (p < 0.001) indicates the significantly greater effectiveness of the proposed modified POEM technique. Practical significance of the obtained results. The results of the study have proven that in cases of achalasia of the cardia stage II - III, surgical treatment using the proposed method of POEM with modification in the form of complete myotomy of the lower esophageal sphincter with preservation of the sliding fibers in the stomach (as an anti-reflux mechanism) with a gastric myotomy length of up to 2 cm is recommended. This improved technique helps prevent damage to the esophageal wall and postoperative complications associated with either insufficient or excessive narrowing of the esophageal opening. It has been demonstrated that the proposed method of esophagocardiomyotomy is characterized by sufficient technical simplicity, reduced trauma, and high safety compared to the traditional Heller's operation. It eliminates several of its inherent disadvantages, which, together with a good anti-reflux effect, allows recommending the technique for widespread use in clinical practice. The feasibility of determining the quality of life status using specialized questionnaires (ASQ, QLQ-C30, and QLQ-OES18 (esophageal module)) within the framework of comprehensive examination has been substantiated. This approach makes it possible to assess not only the subjective well-being of patients and the severity of esophageal dysfunction but also to use these indicators as potential markers for evaluating clinical effectiveness over time under different treatment strategies and timelines for achalasia of the cardia stage II - III. It has been shown that the indications for performing POEM should include: a confirmed diagnosis of achalasia of the cardia stage II - III, inefficacy of conservative therapy courses or previous endoscopic minimally invasive treatment methods, signs of scar changes in the esophagus, and recurrences more frequently than one case per quarter. The study results have proven that the newly proposed personalized surgical treatment method for achalasia of the cardia stage II - III in the form of a modified POEM is a clinically effective and safer alternative to Heller's esophagocardiomyotomy. It not only reduces hospitalization periods but also significantly improves treatment outcomes, reduces the number of postoperative complications, ensures anti-reflux function without dysphagia, and enhances patients' quality of life.