Original article Clinical endoscopy| Volume 84, ISSUE 3, P408-415, September 2016

Prospective evaluation of CT esophagram findings after peroral endoscopic myotomy

Published:February 21, 2016DOI:

      Background and Aims

      Peroral endoscopic myotomy (POEM) is a procedure with potential for serious adverse events. Postprocedure imaging is routinely done, yet there is no consensus on the optimal imaging protocol. We describe a novel and simple CT esophagram protocol for evaluation after POEM and for reporting the full spectrum of radiographic findings and subsequent interventions.


      This was a single-center prospective study of consecutive patients treated with POEM evaluated with CT esophagram.


      Eighty-four consecutive patients who had POEM performed underwent CT esophagrams. The most common findings were pneumomediastinum (85.7%), pneumoperitoneum (66.7%), subcutaneous emphysema (52.4%), and pleural effusion (46.4%). Other findings included retroperitoneal air (38.1%), pneumothorax (19%), atelectasis (14.3%), intramural air in the esophagus and/or stomach (13.1%), pericardial effusion (2.4%), and pneumopericardium (2.4%). Five patients required intervention based on CT findings. In 1 patient, a leak was detected on CT esophagram before any clinical manifestation, facilitating prompt intervention and avoiding potential serious outcomes. Four patients were diagnosed with pneumonia and were treated with antibiotics. There was frequent postprocedural atelectasis, which prompted the introduction of routine incentive spirometry in all postoperative POEM cases.


      CT esophagram is a simple and accessible imaging test for routine postoperative POEM evaluation. Numerous and dramatic postprocedure radiographic findings may be expected and demonstrated with this imaging modality. Although most of these findings may not require intervention, some are of potential significance, and early identification may help modify postprocedure management. (Clinical trial registration number: NCT01832779.)


      POEM (peroral endoscopic myotomy)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Pasricha P.J.
        • Hawari R.
        • Ahmed I.
        • et al.
        Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia.
        Endoscopy. 2007; 39: 761-764
        • Inoue H.
        • Minami H.
        • Kobayashi Y.
        • et al.
        Peroral endoscopic myotomy (POEM) for esophageal achalasia.
        Endoscopy. 2010; 42: 265-271
        • Swanström L.L.
        • Rieder E.
        • Dunst C.M.
        A stepwise approach and early clinical experience in peroral endoscopic myotomy for the treatment of achalasia and esophageal motility disorders.
        J Am Coll Surg. 2011; 213: 751-756
        • von Renteln D.
        • Inoue H.
        • Minami H.
        • et al.
        Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study.
        Am J Gastroenterol. 2012; 107: 411-417
        • Costamagna G.
        • Marchese M.
        • Familiari P.
        • et al.
        Peroral endoscopic myotomy (POEM) for oesophageal achalasia: preliminary results in humans.
        Dig Liver Dis. 2012; 44: 827-832
        • Chiu P.W.
        • Wu J.C.
        • Teoh A.Y.
        • et al.
        Peroral endoscopic myotomy for treatment of achalasia: from bench to bedside (with video).
        Gastrointest Endosc. 2013; 77: 29-38
        • Verlaan T.
        • Rohof W.O.
        • Bredenoord A.J.
        • et al.
        Effect of peroral endoscopic myotomy on esophagogastric junction physiology in patients with achalasia.
        Gastrointest Endosc. 2013; 78: 39-44
        • Lee B.H.
        • Shim K.Y.
        • Hong S.J.
        • et al.
        Peroral endoscopic myotomy for treatment of achalasia: initial results of a Korean study.
        Clin Endosc. 2013; 46: 161-167
        • Minami H.
        • Isomoto H.
        • Yamaguchi N.
        • et al.
        Peroral endoscopic myotomy for esophageal achalasia: clinical impact of 28 cases.
        Dig Endosc. 2014; 26: 43-51
        • Hungness E.S.
        • Teitelbaum E.N.
        • Santos B.F.
        • et al.
        Comparison of perioperative outcomes between peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy.
        J Gastrointest Surg. 2013; 17: 228-235
        • Von Renteln D.
        • Fuchs K.H.
        • Fockens P.
        • et al.
        Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study.
        Gastroenterology. 2013; 145: 309-311.e1-3
        • Inoue H.
        • Sato H.
        • Ikeda H.
        • et al.
        Per-oral endoscopic myotomy: a series of 500 patients.
        J Am Coll Surg. 2015; 221: 256-264
        • Cai M.Y.
        • Zhou P.H.
        • Yao L.Q.
        • et al.
        Thoracic CT after peroral endoscopic myotomy for the treatment of achalasia.
        Gastrointest Endosc. 2014; 80: 1046-1055
        • Li Q.L.
        • Zhou P.H.
        Perspective on peroral endoscopic myotomy for achalasia: Zhongshan experience.
        Gut Liver. 2015; 9: 152-158
        • Yang S.
        • Zeng M.S.
        • Zhang Z.Y.
        • et al.
        Pneumomediastinum and pneumoperitoneum on computed tomography after peroral endoscopic myotomy (POEM): postoperative changes or complications?.
        Acta Radiol. 2015; 56: 1216-1221
        • Eckardt V.F.
        • Aignherr C.
        • Bernhard G.
        Predictors of outcome in patients with achalasia treated by pneumatic dilation.
        Gastroenterology. 1992; 103: 1732-1738
        • Pandolfino J.E.
        • Kwiatek M.A.
        • Nealis T.
        • et al.
        Achalasia: a new clinically relevant classification by high-resolution manometry.
        Gastroenterology. 2008; 135: 1526-1533
        • Mellow M.H.
        • Pinkas H.
        Endoscopic laser therapy for malignancies affecting the esophagus and gastroesophageal junction. Analysis of technical and functional efficacy.
        Arch Intern Med. 1985; 145: 1443-1446
        • Yang D.
        • Wagh M.S.
        Peroral endoscopic myotomy for the treatment of achalasia: an analysis.
        Diagn Ther Endosc. 2013; 2013: 389596
        • Anderson M.A.
        • Ben-Menachem T.
        • Gan S.I.
        • et al.
        Management of antithrombotic agents for endoscopic procedures.
        Gastrointest Endosc. 2009; 70: 1060-1070
        • Yang D.
        • Pannu D.
        • Zhang Q.
        • et al.
        Evaluation of anesthesia management, feasibility and efficacy of peroral endoscopic myotomy (POEM) for achalasia performed in the endoscopy unit.
        Endosc Int Open. 2015; 3: E289-E295
        • Stavropoulos S.N.
        • Modayil R.J.
        • Friedel D.
        • et al.
        The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience.
        Surg Endosc. 2013; 27: 3322-3338
        • Khashab M.A.
        • Messallam A.A.
        • Onimaru M.
        • et al.
        International multicenter experience with peroral endoscopic myotomy for the treatment of spastic esophageal disorders refractory to medical therapy (with video).
        Gastrointest Endosc. 2015; 81: 1170-1177
        • Cools-Lartigue J.
        • Andalib A.
        • Abo-Alsaud A.
        • et al.
        Routine contrast esophagram has minimal impact on the postoperative management of patients undergoing esophagectomy for esophageal cancer.
        Ann Surg Oncol. 2014; 21: 2573-2579
        • Bingham J.
        • Shawhan R.
        • Parker R.
        • et al.
        Computed tomography scan versus upper gastrointestinal fluoroscopy for diagnosis of staple line leak following bariatric surgery.
        Am J Surg. 2015; 209: 810-814
        • Onogi F.
        • Araki H.
        • Ibuka T.
        • et al.
        Transmural air leak: a computed tomographic finding following endoscopic submucosal dissection of gastric tumors.
        Endoscopy. 2010; 42: 441-447
        • Lantos J.E.
        • Levine M.S.
        • Rubesin S.E.
        • et al.
        Comparison between esophagography and chest computed tomography for evaluation of leaks after esophagectomy and gastric pull-through.
        J Thorac Imaging. 2013; 28: 121-128