Post-POEM and Gastrografin Swallow: What to Look For?

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Introduction: Peroral endoscopic myotomy (POEM) recently has gained popularity for treatment of medically resistant achalasia. No long term data are available; however, the preliminary safety and efficacy data show encouraging results. Most centers perform gastrografin swallow on day 1 post-procedure for evaluation of mucosal integrity and confirmation of smooth passage of contrast media through the GE junction. Herein, we report the gastrografin swallow findings as they pertain to the evaluation of POEM-related complications and lumen patency. Methods: This is a single centre case series of 8 patients who underwent POEM for endoscopic, manometric, and radiologically confirmed achalasia. Each patient underwent a single gastrografin swallow on day 1 post-procedure for evaluation by an experienced radiologist. Results: Normal post-surgical radiologic findings were usually unremarkable, with the exception of radio-opaque clips in the mid to distal esophagus used for closure of the mucosal entry site. In 1 patient, no clips were visualized as endoscopic suturing via overstitch Apollo device (Texas) was performed. In 3 patients, the presence of radio-opaque clips were also seen in gastric cardia/lesser curvature corresponding to endoclips used, during the procedure, to close small mucosal defects created secondary to dissection. In 2 of our 8 patients, submucosal edema was manifested as smooth, rounded filling defects around the esophageal clips. However, in 1 of our patients, mucosal integrity was compromised and pooling of contrast was seen in the submucosal tunnel. This appeared as an extra-luminal linear fluid collection along the esophageal contour between the mucosal and outer longitudinal muscle layer. The mucosal leak was successfully managed by use of endoclip application. On subsequent studies, this collection was noted to decrease in size. There were no incidences of leakage into the mediastinum or peritoneum. Conclusion: From our limited study, the gastrografin swallow appears to be a safe and sensitive modality for evaluation of mucosal leaks. The post-surgical appearance of the esophagus is essentially normal except for the presence of endoclips. The esophageal contour should be smooth and without evidence of distal tapering or delayed passage of contrast. The standard gastrografin swallow, which includes AP and left posterior oblique views at our institution, appears to be sufficient in determining post-operative complications.