Effects of Antibiotic Flush into the Submucosal Tunnel During Peroral Endoscopic Myotomy

Abstract

Introduction: Per-Oral Endoscopic Myotomy (POEM) is a relatively novel endoscopic treatment option for management of esophageal motility disorders. Antibiotics such as bacitracin (6% solution) is often flushed in to the submucosal tunnel during the procedure and the usefulness of this is unclear. Our aim was to evaluate the effect and outcomes of antibiotic flush in to the submucosal tunnel during the POEM. Methods: This was a retrospective cohort study performed at a tertiary care university-setting over a period of 3 years. POEM was performed in patients diagnosed with achalasia, esophagogastric junction (EGJ) outlet obstruction, nutcracker esophagus, or epiphrenic diverticulum with or without previous unsuccessful pneumatic dilation, botulinum toxin, and/or Heller myotomy. All patients who received antibiotic flush in to the submucosal tunnel during the POEM were compared with those who did not receive the antibiotic flush. The outcomes were compared based on the Eckardt scores (pre and 4-6 weeks after POEM), symptomatology immediately after POEM (< 24 hours), and any adverse events post POEM. Fisher's exact test and Student t-test were used for statistical analysis. Results: POEM was performed on a total of 79 patients with a mean age of 55 years. Of the 79 patients, 46 (58%) were males. Three patients were excluded as one patient developed cardiac arrest with return of spontaneous circulation during the POEM, and there was no documentation regarding antibiotic flush in 2 patients. Of the 79 patients, initial 35 received antibiotic flush during POEM (cases). Pre-POEM Eckardt scores for the cases and control were 4.66 and 5.84 respectively. The post POEM Eckardt scores for those exposed to antibiotics and not were 0.58 and 0.48 respectively (p=0.59). Severe chest pain requiring narcotics immediately after the POEM was noted in 6 (17.1%) patients from the antibiotic group however, only one patient (2%) experienced severe chest pain in the control group (p=0.11). No major immediate post-op symptoms or complications were noted in either group. None of the patients in either group required any intervention including repeat POEM after the initial POEM procedure. There were no cases of infection. Conclusion: Antibiotic flush into the submucosal tunnel during POEM does not seem to be of any benefit. Although patients with antibiotic flush seem to experience severe chest pain requiring narcotics more often immediately following POEM, statistical significance was not observed.