Evaluation of the need for routine esophagram after peroral endoscopic myotomy (POEM)

Khoury, Rym El; Teitelbaum, Ezra N.; Sternbach, Joel M.; Soper, Nathaniel J.; Harmath, Carla; Pandolfino, John E.; Kahrilas, Peter J.; Hungness, Eric S.

doi:10.1007/s00464-015-4585-z

Cited by 34 publications

(20 citation statements)

References 22 publications

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“…Mucosal defects may cause life‐threatening AE such as mediastinitis or peritonitis. Although contrast esophagram is done by approximately 88% of facilities to detect esophageal leaks after POEM, 10 this technique is known to have a suboptimal diagnostic yield to detect clinically significant complications 16 . Esophageal leaks on esophagram may not be detected on POD 1 because dehiscence or mucosal breakdown can take several days to occur 17 .…”

Section: Discussionmentioning

confidence: 99%

“…Although contrast esophagram is done by approximately 88% of facilities to detect esophageal leaks after POEM, 10 this technique is known to have a suboptimal diagnostic yield to detect clinically significant complications. 16 Esophageal leaks on esophagram may not be detected on POD 1 because dehiscence or mucosal breakdown can take several days to occur. 17 Although a recent study reported that POEM could be done as an outpatient procedure with same-day discharge without conducting post-POEM esophagram nor endoscopy, it showed two out of 101 patients with elevated temperature and white blood cell, which consequently revealed mucosal perforation.…”

Section: Discussionmentioning

confidence: 99%

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Importance of second‐look endoscopy after per‐oral endoscopic myotomy for safe postoperative management

Fujiyoshi

Inoue

Abad

et al. 2020

Digestive Endoscopy

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Objectives Per‐oral endoscopic myotomy (POEM) is a safe and effective treatment for achalasia and esophageal motility disorders. The role of second‐look endoscopy (SE) on postoperative day 1 has not been examined. This study aimed to evaluate the findings and need of SE after POEM. Methods This is a single‐center, retrospective study. All consecutive patients who underwent POEM and SE on postoperative day 1 between December 2017 and September 2019 were included. The primary endpoint was the rate of newly‐detected adverse events (nAE) during SE that required endoscopic intervention or deviation from the normal postoperative course. Multivariate logistic regression was used to identify predictors of nAE. Results Four‐hundred‐ninety‐seven patients (mean age, 50.3 years; female, 49.9%) were included. SE identified abnormal findings in a total of 71 patients (14.3%). nAE which required endoscopic intervention or deviation from the normal postoperative course were identified in 12 patients (2.4%): eight (1.6%) entry site dehiscence; two (0.4%) submucosal hemorrhage or hematoma; and two (0.4%) dehiscence of an intraoperative perforation site after endoclip closure. Other findings such as mucosal thermal damage without perforation and small submucosal hematoma were found in 54 patients (10.9%) and five patients (1.0%), respectively. Multivariate analysis showed that longer operation time and intraoperative adverse events (AE) were associated with clinically significant nAE during SE. Conclusions Second‐look endoscopy can detect and treat nAE that may lead to severe AE. Thus, SE should be highly considered before starting oral ingestion in all cases, and especially in those who present an intraoperative AE and longer operation time.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Importance of second‐look endoscopy after per‐oral endoscopic myotomy for safe postoperative management

Fujiyoshi

Inoue

Abad

et al. 2020

Digestive Endoscopy

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“…Patients are given clear liquids on the evening of surgery if they are not experiencing significant nausea. We no longer perform a routine esophagram in the immediate post-operative period, as we’ve previously demonstrated its low specificity for clinically relevant complications 42 . However, we recommend that novice practitioners obtain routine esophagography during their early POEM experience.…”

Section: Methodsmentioning

confidence: 99%

Treatment of idiopathic achalasia with per-oral esophageal myotomy

Campagna

Hungness

2018

Techniques in Gastrointestinal Endoscopy

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Achalasia is a rare esophageal motility disorder that necessitates the disruption of the lower esophageal sphincter. Patients with achalasia should be evaluated in a systematic, multidisciplinary fashion. Workup should include upper endoscopy, esophagography, and high-resolution manometry. The gold standard for surgical treatment is laparoscopic Heller myotomy with partial fundoplication. Per-oral esophageal myotomy is a novel endoscopic technique that has gained considerable traction over the past decade. The procedure includes the creation of a submucosal tunnel and a selective circular myotomy of the lower esophageal sphincter. Common intra-operative hazards include bleeding within the submucosal tunnel and capnoperitoneum. Significant complications are rare. Patients experience excellent dysphagia relief that is on par with laparoscopic Heller myotomy at moderate-term follow up. Post-operative gastroesophageal reflux disease occurs in greater than one-third of patients, and the vast majority of cases are readily controlled with an anti-secretory medication. Although data is sparse, there is a growing body of literature that supports the long-term durability of per-oral esophageal myotomy.

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“…Botulinum toxin injection will last only for a few months, and commonly requires repeated therapy[ 86 , 87 ]. Surgical myotomy can result in durable improvement, whilst POEM may offer a less invasive approach, although long-term data is currently unavailable[ 88 , 89 ]. Medications such as oral nitrates or calcium channel blockers lack efficacy but can be used as a holding measure while definitive therapy is being considered[ 87 ].…”

Section: Treatmentmentioning

confidence: 99%

Dysphagia: Thinking outside the box

Philpott

Garg

Tomic

et al. 2017

WJG

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Dysphagia is a common symptom that is important to recognise and appropriately manage, given that causes include life threatening oesophageal neoplasia, oropharyngeal dysfunction, the risk of aspiration, as well as chronic disabling gastroesophageal reflux (GORD). The predominant causes of dysphagia varies between cohorts depending on the interplay between genetic predisposition and environmental risk factors, and is changing with time. Currently in white Caucasian societies adopting a western lifestyle, obesity is common and thus associated gastroesophageal reflux disease is increasingly diagnosed. Similarly, food allergies are increasing in the west, and eosinophilic oesophagitis is increasingly found as a cause. Other regions where cigarette smoking is still prevalent, or where access to medical care and antisecretory agents such as proton pump inhibitors are less available, benign oesophageal peptic strictures, Barrett’s oesophagus, adeno- as well as squamous cell carcinoma are endemic. The evaluation should consider the severity of symptoms, as well as the pre-test probability of a given condition. In young white Caucasian males who are atopic or describe heartburn, eosinophilic esophagitis and gastroesophageal reflux disease will predominate and a proton pump inhibitor could be commenced prior to further investigation. Upper gastrointestinal endoscopy remains a valid first line investigation for patients with suspected oesophageal dysphagia. Barium swallow is particularly useful for oropharyngeal dysphagia, and oesophageal manometry mandatory to diagnose motility disorders.

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Evaluation of the need for routine esophagram after peroral endoscopic myotomy (POEM)

Abstract: In this series, we found routine esophagram to have a high sensitivity but a very low specificity in detecting clinically significant complications. Routine esophagram after POEM may not be necessary.

Cited by 34 publications

References 22 publications

Importance of second‐look endoscopy after per‐oral endoscopic myotomy for safe postoperative management

Importance of second‐look endoscopy after per‐oral endoscopic myotomy for safe postoperative management

Treatment of idiopathic achalasia with per-oral esophageal myotomy

Dysphagia: Thinking outside the box

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