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Clinical impact of routine esophagram after peroral endoscopic myotomy

      Background and Aims

      It is unclear whether the common practice of postoperative day (POD) 1 esophagram impacts clinical care or reliably identifies significant adverse events (AEs) related to peroral endoscopic myotomy (POEM). Therefore, we aimed to correlate the most clinically relevant esophagram findings with postoperative outcomes after POEM.

      Methods

      Patients were retrospectively reviewed and included if they underwent POEM at 1 of the 3 study institutions between 2014 and 2018. Patient outcomes were assessed in relation to relevant POD 1 esophagram findings such as esophageal dissection or leak.

      Results

      One hundred seventy post-POEM contrast esophagrams (139 fluoroscopy-based vs 31 CT-based) performed on POD 1 were included. Most esophagrams (n = 98) contained abnormal findings but only 5 showed esophageal leak or dissection. Confirmed postoperative AEs of leak or dissection occurred in 4 patients. In 2 patients, POD 1 esophagram appropriately identified the leak or dissection, but in the other 2 patients the initial esophagram was negative, and the AEs were not recognized before clinical deterioration. One patient had a false-positive leak and dissection noted on esophagram leading to an unremarkable endoscopy.

      Conclusions

      Despite the low AE rate after POEM, follow-up esophagram on POD 1 frequently shows expected, unremarkable postprocedural findings and occasionally fails to diagnose serious AEs. This results in pitfalls in accuracy regarding agreement between esophagram versus clinical and endoscopic findings. Relying exclusively on esophagram for post-POEM clinical decision-making can lead to unnecessary additional testing or missed AEs.

      Abbreviations:

      AE (adverse event), POEM (peroral endoscopic myotomy), POD (postoperative day)
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      Linked Article

      • Clinical utility of routine post-peroral endoscopic myotomy imaging: Does clinical decision making outweigh the protocol?
        Gastrointestinal EndoscopyVol. 93Issue 1
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          Achalasia is a motor disorder of the esophagus characterized by inability of the lower esophageal sphincter to relax, along with absence of peristalsis in the esophagus. The annual incidence is reported to be 1 in 100,000 individuals.1 On the basis of high-resolution manometry findings, achalasia is further characterized into 3 types: type I (classic) with minimal contractility in the esophageal body, type II with intermittent periods of panesophageal pressurization, and type III (spastic) with premature or spastic distal esophageal contractions.
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