Clinical impact of routine CT esophagogram after peroral endoscopic myotomy (POEM) for esophageal motility disorders

Abstract

Background and study aims Per oral endoscopic myotomy (POEM) of the lower esophageal sphincter has become a major treatment for esophageal motility disorders, especially achalasia. POEM can result in esophageal bleeding or perforation and pleural and mediastinal effusion. Early routine computed tomography (CT) esophagogram is frequently performed to assess these adverse events (AEs) before resuming oral food intake. We sought to evaluate the value of routine CT esophagogram on postoperative day (POD) 1 after POEM.

Patients and methods This single-center retrospective study was performed in a tertiary referral center for interventional digestive endoscopy. We included consecutive patients with POEM and routine CT esophagogram on POD 1 between July 2018 and July 2019.

Results Fifty-eight patients were included in the study, 79 % of whom had achalasia. Twenty patients (34 %) presented post-endoscopic AEs, including two patients with severe AEs requiring intensive care admission (one compressive pneumothorax and one mediastinitis); no deaths occurred. Of the 58 CT esophagograms performed, only one was normal. The 57 others (98 %) showed at least one abnormal finding: pneumoperitoneum or retroperitoneal air (91 %), pneumomediastinum (78 %), pleural effusion (34 %), pneumothorax (14 %), pneumonia (7 %), pericardial effusion (2 %), and mediastinal collection (2 %). CT esophagograms revealed AEs and modified therapeutic management in eight patients of 58 (14 %), all of whom had clinical symptoms prior to CT.

Conclusions POD 1 CT esophagogram after POEM for esophageal motility disorders diagnosed clinically meaningful AEs in 14 % of patients, all associated with persistent clinical symptoms. Routine use of CT esophagogram after POEM in asymptomatic patients is questionable.

• References

• 1 Kahrilas PJ, Katzka D, Richter JE. Clinical Practice Update: The use of per-oral endoscopic myotomy in achalasia: expert review and best practice advice from the AGA Institute. Gastroenterology 2017; 153: 1205-1211
• 2 Ponds FA, Fockens P, Lei A. et al. Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: a randomized clinical trial. JAMA 2019; 322: 134-144
• 3 Werner YB, Hakanson B, Martinek J. et al. Endoscopic or surgical myotomy in patients with idiopathic achalasia. N Engl J Med 2019; 381: 2219-2229
• 4 Barret M, Dohan A, Oudjit A. et al. Meglumine diatrizoate esophagogram after peroral endoscopic myotomy (POEM): identification of imaging findings associated with clinical complications and longer hospital stay. Eur Radiol 2020; 30: 4175-4181
• 5 Pannu D, Yang D, Abbitt PL. et al. Prospective evaluation of CT esophagram findings after peroral endoscopic myotomy. Gastrointest Endosc 2016; 84: 408-415
• 6 Yang S, Zeng M-S, Zhang Z-Y. et al. Pneumomediastinum and pneumoperitoneum on computed tomography after peroral endoscopic myotomy (POEM): postoperative changes or complications?. Acta Radiol 2015; 56: 1216-1221
• 7 Cai M-Y, Zhou P-H, Yao L-Q. et al. Thoracic CT after peroral endoscopic myotomy for the treatment of achalasia. Gastrointest Endosc 2014; 80: 1046-1055
• 8 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 9 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
• 10 Greffier J, Pereira F, Hamard A. et al. Effect of tin filter-based spectral shaping CT on image quality and radiation dose for routine use on ultralow-dose CT protocols: A phantom study. Diagn Interv Imaging 2020; 101: 373-381
• 11 Haito-Chavez Y, Inoue H, Beard KW. et al. Comprehensive Analysis of adverse events associated with per oral endoscopic myotomy in 1826 patients: an international multicenter study. Am J Gastroenterol 2017; 112: 1267-1276
• 12 Inoue H, Sato H, Ikeda H. et al. Per-oral endoscopic myotomy: a series of 500 patients. J Am Coll Surg 2015; 221: 256-264
• 13 Levy JL, Levine MS, Rubesin SE. et al. Findings of esophagography for 25 patients after peroral endoscopic myotomy for achalasia. AJR Am J Roentgenol 2016; 207: 1185-1193
• 14 Nast JF, Berliner C, Rösch T. et al. Endoscopy versus radiology in post-procedural monitoring after peroral endoscopic myotomy (POEM). Surg Endosc 2018; 32: 3956-3963
• 15 Reddy CA, Tavakkoli A, Abdul-Hussein M. et al. Clinical impact of routine esophagram after peroral endoscopic myotomy. Gastrointest Endosc 2021; 93: 102-106
• 16 Harmath C, Horowitz J, Berggruen S. et al. Fluoroscopic findings post-peroral esophageal myotomy. Abdom Imaging 2015; 40: 237-245