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Endoscopy versus radiology in post-procedural monitoring after peroral endoscopic myotomy (POEM)

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Abstract

Background

The newly developed technique of peroral endoscopic myotomy (POEM) has been shown to be effective in several short- and mid-term studies. Limited information is available about the adequacy of immediate post-POEM monitoring tests.

Methods

POEM was performed under general anesthesia in 228 patients (59.6% male, mean age 45.6 ± 15.5 years). Post-procedural checks comprised clinical and laboratory examination, and, during post-procedure days 1–5, endoscopy and—in the first 114 cases—radiologic examination using water-soluble contrast (1st group); the remaining patients underwent post-procedure controls without radiology (2nd group). Main outcome was value of endoscopic compared to radiologic control for recognition of early adverse events.

Results

In the first group, routine fluoroscopic contrast swallow suggested minor leakages at the mucosal entry site in two cases which was confirmed endoscopically in only one. Endoscopy revealed two minor entry site leakages and, in six additional cases, dislocated clips without leakage (overall 5.3%). All eight patients underwent reclipping and healed without clinical sequelae. In the 2nd group, endoscopy showed 5 clip dislocations (all reclipped) and one ischemic cardiac perforation in a patient with clinical deterioration on post-POEM day 1 who had to undergo surgery after confirmation of leakage by CT.

Conclusions

Radiologic monitoring (contrast swallow) after POEM is not useful and can be omitted. Even routine endoscopic monitoring for detection and closure of minor defects of the mucosal entry site yields limited information with regards to final outcome; major complications are very rare and probably associated with clinical deterioration.

Clinical Trials Gov Registration number of the main study: NCT01405417.

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Abbreviations

CI:

Confidence interval

CrP:

C-reactive protein

ESD:

Endoscopic submucosal dissection

EGJ:

Esophagogastric junction

LES:

Lower esophageal sphincter

POEM:

Peroral endoscopic myotomy

PPI:

Proton pump inhibitor

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Acknowledgements

The study was also supported by the following Foundations for manometry equipment and study personnel: G. and J. Rickertsen-, Agnes-Graefe-, Reinhard-Frank-, Dr. C.A. Skroeder-, F.-G. und B. von Gaertner-, J.M. Boettcher-, Dr. G. Buechtemann-, and Hamburgische Stiftung für Wissenschaften, Entwicklung und Kultur Helmut und Hannelore Greve.

Author information

Author notes

  1. Daniel von Renteln

    Present address: Department of Gastroenterology, Centre Hospitalier de l´Université de Montreal, Montreal, Canada

  2. Jan Friso Nast and Christoph Berliner have contributed equally to this work.

Authors and Affiliations

  1. Department of Gastroenterology, University Hospital Hamburg-Eppendorf, Hamburg, Germany

    Jan Friso Nast

  2. Department of Diagnostic and Interventional Radiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany

    Christoph Berliner, Harald Ittrich & Gerhard Adam

  3. Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany

    Thomas Rösch, Daniel von Renteln, Tania Noder, Guido Schachschal, Stefan Groth & Yuki B. Werner

  4. Department of Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany

    Jan F. Kersten

  5. Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany

    Thomas Rösch

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  1. Jan Friso Nast
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Contributions

Jan-Friso Nast und Yuki Werner were responsible for designing and conducting the analysis, data collection, and performance of study manometry. Christoph Berliner reviewed the radiologic images and contributed to data analysis and writing the paper. Daniel von Renteln, Guido Schachschal, Ulrike Denzer, and Stefan Groth carried out POEM procedures and/or monitoring examinations and contributed to writing the paper. Tanja Noder was responsible for patient inclusion, data collection, and monitoring. Harald Ittrich and Gerhard Adam reviewed the manuscript and contributed to the Discussion section. Jan Kersten was responsible for the statistical analysis. Thomas Rösch was responsible for designing and conducting the study, data collection, data analysis, and writing and revising the manuscript. All authors revised and approved the final manuscript. The authors would also like to thank H. Inoue and H. Minami for training and helping to introduce the POEM procedure of this study.

Corresponding author

Correspondence to Thomas Rösch.

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Disclosures

Thomas Rösch and Yuki Werner received support from Olympus in the form of a grant; they would like to thank the Euro-NOTES foundation for supporting this study including data collection. Jan Friso Nast, Christoph Berliner, Daniel von Renteln, Tania Noder, Guido Schachschal, Stefan Groth, Harald Ittrich, J.F. Kersten, and Gerhard Adam have no conflict of interest or financial ties relevant to this study to disclose.

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Nast, J.F., Berliner, C., Rösch, T. et al. Endoscopy versus radiology in post-procedural monitoring after peroral endoscopic myotomy (POEM). Surg Endosc 32, 3956–3963 (2018). https://doi.org/10.1007/s00464-018-6137-9

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  • DOI: https://doi.org/10.1007/s00464-018-6137-9

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