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

Abstract

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.

Second‐look endoscopy after POEM for all, some or none… More you see, the more you find!

“…In this study, mucosal barrier failure (MBF) was the most common nAE in 10 (83%) patients 1 . Mucosal inflammation in long‐standing disease may pose difficulty in closure using endoclips and predispose to MBF 4 .…”

“…We read this article entitled “Importance of second‐look endoscopy after per‐oral endoscopic myotomy for safe postoperative management” with great interest 1 . In this retrospective study n = 497), second‐look endoscopy (SE) detected abnormal findings in 71 (14.3%) patients.…”

“…2,3 In this study, mucosal barrier failure (MBF) was the most common nAE in 10 (83%) patients. 1 Mucosal inflammation in long-standing disease may pose difficulty in closure using endoclips and predispose to MBF. 4 In the current study, the majority of the patients with nAE group had type I achalasia (67%) and dilated (≥35 mm) esophagus (75%) suggesting advanced achalasia.…”

“…4 In the current study, the majority of the patients with nAE group had type I achalasia (67%) and dilated (≥35 mm) esophagus (75%) suggesting advanced achalasia. 1 In addition, the majority of the procedures were performed by non-expert operators. The rate of intraoperative mucosal injury is likely to be lower with experienced operators.…”

What are the factors for detecting adverse events in second‐look endoscopy after per‐oral endoscopic myotomy (POEM)? A reply to “Second‐look endoscopy after POEM for all, some or none… More you see, the more you find!”

“…However, there have been no previous reports of EUSguided intrahepatic bile duct fistulation from a reconstructed gastric tube. [1][2][3][4] We report a patient with recurrent esophageal cancer that caused hilar obstruction (Bismuth type I) in whom endoscopic retrograde cholangiopancreatography was not possible. We performed EUS-guided hepatico-gastrictubestomy (EUS-HGTS).…”