Intraprocedural fluoroscopy with POEM

Dr. KumbhariVivek Kumbhari, MD, from the Department of Medicine and Division of Gastroenterology and Hepatology at The Johns Hopkins Medical Institutions in Baltimore, Maryland, USA shares this New Methods article “Intraprocedural fluoroscopy to determine the extent of the cardiomyotomy during per-oral endoscopic myotomy (with video).”

One of the major technical challenges in performing per-oral endoscopic myotomy (POEM) is identification of the esophagogastric junction (EGJ) because this guides the termination of the submucosal tunnel and extent of subsequent myotomy. By extrapolating from the Heller myotomy literature, we presume that it is necessary to perform a 2-3cm myotomy of the gastric cardia to eradicate the clasp and sling fibers that are considered essential to maintain lower esophageal sphincter (LES) continence.

There was a need for an objective, efficient, and reproducible method to determine the length of the submucosal tunnel beyond the LES. Although several subjective landmarks have been described to detect the adequacy of the gastric myotomy, they often rely on the experience of the operator and hence may not be useful for those new to performing POEM. We also believe that objective measurements of the gastric myotomy during POEM will be of benefit to those investigating the anatomic and physiologic changes that occur during the myotomy. For example, physiologic changes that occur at the LES after each centimeter of gastric myotomy may be investigated using the combination of intraprocedural fluoroscopy and EndoFLIP. This may allow a ‘personalized medicine’ type approach to the length of gastric myotomy.

POEM operators have not been able to determine the effect of the length of gastric myotomy on reflux, presumably because a method of accurately determining the length of gastric myotomy has not been identified. By using intraprocedural fluoroscopy, the right balance between an adequate myotomy and reducing the propensity of reflux may be ascertained. This may obviate the need for an antireflux procedure to be performed in patients undergoing POEM.

Figure 4. The endoscope has a diameter of 1 cm, and therefore the endoscope tip is measured to be 3 cm below the needle marking the EGJ (arrow).

This study demonstrates 2 efficient and safe methods of objectively determining the length of the submucosal tunnel below the EGJ. Both methods described were successful in all cases and consumed minimal time. The use of intraprocedural fluoroscopy led to further submucosal dissection in 20.8% of patients. No adverse events were associated with this technique. We particularly preferred the use of a 19-gauge needle to mark the EGJ as this incurred less cost and was faster to perform than using an endoscopic clip.

We do not believe that the use of intraprocedural fluoroscopy is mandatory for all operators during each POEM procedure. However, it can be considered in cases where uncertainty exists and in the setting of clinical trials, particularly multicenter trials where subjective measures may be less reliable.

Read the abstract of this article here.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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