Clinical Utility of Imaging Following Peroral Endoscopic Myotomy

Abstract

Introduction: Per-oral endoscopic myotomy (POEM) is a safe and effective endoscopic procedure primarily for treatment of esophageal motility disorders. In recent studies, it has been shown to have similar efficacy when compared to Heller myotomy, and is associated with fewer complications and shorter recovery times. Post-POEM imaging protocols vary from hospital to hospital but are all designed to detect complications of the procedure. At our center, post procedure protocol included a CXR, performed immediately following POEM, as well as gastrograffin swallow study, performed 1 day after POEM. We evaluate the clinical utility of post-POEM imaging with CXR and/or gastrograffin swallow study. Methods: This was a retrospective study performed at a tertiary care university-setting hospital over a period of 3 years from December 2013-April 2017. POEM procedures were performed under general anesthesia using the previously described technique (Figure 1). Indications for POEM included achalasia, esophagogastric junction outlet obstruction, nutcracker esophagus, and epiphrenic diverticulum with or without previous unsuccessful pneumatic dilation, botulinum toxin, and/or Heller myotomy. CXR was performed immediately following POEM and gastrograffin swallow study was performed on post-operative day 1 well as 3-4 weeks following the procedure.Figure: (a) Mucosal incision after submucosal injection, (b) creation of submucosal tunnel via endoscopic submucosal dissection, (c) completed submucosal tunnel (d) circular muscle myotomy, (e) completed myotomy and, (f) closure of mucosal entry with clips.Results: POEM was performed on 79 patients with mean age of 55 years and a total of 46 males (58%). Details of indication for POEM and prior treatment are summarized in Table 1. Of the 79 patients, 65 patients underwent CXR immediately post-op with 36 patients having a normal CXR (46%). None of the patients required intervention based on CXR findings, summarized in Table 2. 68 of the 79 patients underwent gastrograffin swallow study 24 hours after POEM. Findings concerning for contrast leak were identified in 2 patients (Figure 2), both of whom were asymptomatic. The second patient underwent repeat EGD with fluoroscopy within 24 hours of the initial POEM, with no active contrast leak. All patients were discharged w/in 24-48 hours after POEM and were followed up in 4-6 weeks. No early (24-48 hours) or delayed (4-6 weeks) post-op events were noted.Figure: (a) Patient one post-op gastrograffin study with small contained submocosal leak at the site of the surgical clips (b) Patient two post-op gastrograffin study showing a linear tract of contrast coursing towards the right mediastinum.Table: Table. Indication for POEM and Prior TreatmentsTable: Table. Summary of CXR Findings and Interventions Based off of CXR FindingsConclusion: Our findings suggest that CXR as well as gastrograffin swallow study within 24 hours of POEM are of low clinically yield and should only be considered in patients who are symptomatic. Based on our findings, we suggest that if a patient is clinically stable, they can be discharged without any imaging.