Routine Esophagram Following Peroral Endoscopic Myotomy does Not Reliably Identify Adverse Events

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Post-procedural esophagram may be insufficient to diagnose serious adverse events in patients who underwent peroral endoscopic myotomy (POEM).

Post-procedural esophagram may be insufficient to diagnose serious adverse events in patients who underwent peroral endoscopic myotomy (POEM), according to study results published in Gastrointestinal Endoscopy. In a cohort of patients who underwent POEM, esophagrams conducted on postoperative day (POD) 1 detected only half of all serious adverse events. As such, researchers endorsed the use of endoscopy and other clinical examinations to ensure patient safety following POEM. 

The researchers conducted a retrospective, multicenter cohort study of adult patients who underwent POEM at 3 clinical sites in the United States. Data were collected on procedures performed between 2014 and 2018. Only patients who underwent an esophagram after POEM were included in analyses. The indication for esophagram in all participants was routine POD 1 evaluation, regardless of clinical scenario. Covariates of interest including patient demographics, primary POEM indication, duration of esophageal symptoms, and surgical history prior to POEM. The primary outcome was clinical course after POEM, including adverse events.

The researchers analyzed data from 170 POEM procedures. Approximately half of patients were women (52.9%), and mean age at POEM was 52.5 ± 17.4 years. The most frequent indication for POEM was achalasia (85.3%), followed by nonachalasia esophageal outflow obstructive disorders and esophageal body hypercontractile disorders. In 71.2% of patients, prior procedures had been attempted, including prior POEM. Postoperative symptoms were reported on POD 1 in 75 patients, the most common of which was chest pain (n=50; 67%). POD 1 esophagrams were fluoroscopy-based in 139 patients and computed tomography (CT)-based in 31 patients. Abnormal esophagram findings were noted in 98 (57.6%) cases, though clinically relevant abnormal results were present in just 5 (2.9%). The rate of abnormal findings was significantly higher on CT-based esophagram compared with fluoroscopy-based esophagram (93.5% vs 48.9%; P <.01). There was no association between the rate of POD 1 symptoms and esophagram findings. A total of 4 patients (2.6%) had postoperative dissection or leak, of whom 2 were diagnosed using esophagram. In the remaining 2 patients, no leak was identified during esophagram, which led to repeat endoscopy due to clinical deterioration. In total, only 1 patient displayed a false-positive esophagram finding of esophageal leak.

While the rate of POEM-related adverse events was low, contrast esophagram did not reliably detect postprocedural complications. However, the small number of serious adverse events limits the robustness of these findings. Esophagram also frequently identified clinically abnormal characteristics which were insignificant in treatment course. As such, the researchers advised against relying solely on esophagram to identify post-POEM leaks. “Further large-scale studies aiming to identify accurate predictors of post-POEM leaks are necessary to allow for tailored use of imaging after POEM,” the researchers wrote.

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Reddy CA, Tavakkoli A, Abdul-Hussein M, et al. The clinical impact of routine esophagram after peroral endoscopic myotomy [published online June 2, 2020]. Gastrointest Endosc. doi: 10.1016/j.gie.2020.05.046