Evaluation of timed barium esophagram after per-oral endoscopic myotomy to predict clinical response

Abstract

Background and study aims The aim of this study was to evaluate whether timed barium esophagram within 24 hours post-per-oral endoscopic myotomy (POEM) (TBE-PP) could predict clinical outcomes. Patients and methods This was a single-center retrospective study of prospectively collected data on consecutive patients with ≥ 6-month follow-up who underwent POEM followed by TBE-PP. Esophageal contrast retention 2 minutes after TBE-PP was assessed as Grade 1 (< 10 %), 2 (10 %–49 %), 3 (50 %–89 %) or 4 (> 90 %). Eckardt score, esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM) and function lumen imaging probe (FLIP) of the esophagogastric junction (EGJ) were obtained at baseline. These tests along with pH testing of antisecretory therapy were repeated 6 and 24 months after POEM. Clinical response by Eckardt score ≤ 3, EGJ-distensibility index (EGJ-DI) > 2.8 mm2/mm Hg, and integrated relaxation pressure (IRP) < 15 mm Hg and incidence of gastroesophageal reflux disease (GERD) were compared by transit time. Results Of 181 patients (58 % male, mean 53 ± 17 yr), TBE-PP was classified as Grade 1 in 122 (67.4 %), Grade 2 in 41 (22.7 %), Grade 3 in 14 (7.7 %) and Grade 4 in 4 (2.2 %). At 6 months, overall clinical response by ES (91.7 %), IRP (86.6 %), EGJ-DI (95.7 %) and the diagnosis of GERD (68.6 %) was similar between Grade 1 and Grade 2–4 TBE-PP. At 24 months, Grade 1 had a higher frequency of a normal IRP compared to Grades 2–4 (95.7 % vs. 60 %, P = 0.021) but overall response by ES (91.2 %), EGJ-DI (92.3 %) and the diagnosis of GERD (74.3 %) were similar. Conclusions Contrast emptying rate by esophagram after POEM has limited utility to predict clinical response or risk of post-procedure GERD.

Routine esophagram to detect early esophageal leakage after peroral endoscopic myotomy

“…Therefore, findings for which intervention is not necessary should not be regarded as AEs Original article [19,33]. Performing routine esophagram 1 day post-POEM to assess delay in passage of contrast does not predict long-term efficacy of POEM, and thus, is not useful for that purpose either [34,35]. This is the first study comparing AEs after POEM in patients with and without routine esophagram 1 day post-POEM.…”

“…POEM appeared to be safe when performed by experienced endoscopists [4,7,8,9,10,11,12]. However, the definition and classification of adverse events (AEs) varies between studies, and therefore, the number of AEs are wide-ranging from 0% to 35.8% [9,10,12,13,14,15,16,17,18]. Initially, all types of mucosal injury and gas-related events such as pneumoperitoneum and pneumomediastinum were reported as AEs.…”

Symptom Association for Gastroesophageal Reflux Disease by pH Monitoring After Peroral Endoscopic Myotomy

“…These findings add to recent literature about follow-up and testing after POEM. An esophagram <24 hours after POEM does not predict clinical response or risk of GERD (11). Furthermore, normal FLIP metrics by EGJ-DI are equivalent to a normal IRP by HRM to predict clinical response (12).…”

Failure of Per-Oral Endoscopic Myotomy (POEM) for Achalasia Cardia—LES-Directed Therapy or Esophageal Body Therapy-Directed Therapy?: A Pictorial High-Resolution Esophageal Manometry (HREM) Case-Based Analysis

“…In another paper by DeWitt et al 8 in 2021, which evaluated the use of TBE after POEM, it was reported that contrast emptying rate by esophagogram after POEM has limited utility to predict clinical response or risk of postprocedure gastroesophageal reflux disease.…”