Sublingual Nitroglycerine Spray Facilitates Efficient Submucosal Tunneling during Per Oral Endoscopic Myotomy—A Nonrandomized Trial

Abstract

Abstract Introduction In the last one decade, per oral endoscopic myotomy (POEM) has been found to be an effective minimally invasive approach for the treatment of esophageal achalasia cardia and was lately shown to be noninferior to laparoscopic Heller's myotomy in a randomized controlled trial.Here we describe a new method of using sublingual nitroglycerine spray during submucosal tunneling to facilitate the procedure. Materials and Methods This study includes a cohort of 50 patients who were diagnosed with achalasia cardia on high-resolution esophageal manometry. Out of the 50 patients, 27 patients were administered two metered doses of sublingual nitroglycerine spray during submucosal tunneling across the gastroesophageal junction (GEJ), and 23 patients were not administered nitroglycerine. This process was nonrandomized; patients were assigned sublingual nitroglycerine using alternating sequence enrollment number. Results All the procedures were technically feasible and successful without any major complications. Eckhardt's scores of all patients normalized after the procedure. The mean submucosal tunneling time and mean time across GEJ were 36.8 ± 7.9, 14.2 ± 2.9 in intervention group (sublingual nitroglycerine), and 50.2 ± 8.9 and 23.0 ± 3.6 minutes in nonintervention group, respectively. Time for each procedure was significantly less (p < 0.05) in patients who were given sublingual nitroglycerine. Mucosal injury and bleeding during procedure were not significantly different in the two groups. Conclusions This POEM technique with the use of sublingual nitroglycerine spray is simple and renders POEM easier and less time consuming.