Post written by Chanakyaram A. Reddy, MD, from the Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA.

The focus of the study was to provide clarification for the role in obtaining routine postoperative day (POD) 1 esophagram following peroral endoscopic myotomy (POEM).

POEM is a technique that has rapidly evolved over the last decade as an effective treatment modality for achalasia and some cases of spastic esophageal motility disorders. POEM can occasionally result in serious adverse events with the most notable being esophageal leak. Thus, obtaining a routine contrast esophagram on the day after POEM has become a common practice at many centers. However, there is a paucity in data evaluating whether this practice is impactful in patients’ clinical courses after POEM.

We studied a total of 170 patients who had undergone POEM among our 3 study sites (University of Michigan, Medical University of South Carolina, and Johns Hopkins University). Intraoperative adverse events occurred in 24.1% of cases. Most of these were self-limited or resolved intraoperatively and did not prevent completion of POEM or alter the post-operative clinical course. Abnormal esophagram findings were present in 98 studies (57.6%), but more relevant results of leak and/or dissection were present in a small fraction (5 studies, 2.9%). Postoperative symptoms were reported on POD 1 in 75 patients. When comparing patients with symptoms on POD 1, 41.1% had a normal esophagram and 46.4% had an abnormal esophagram, which illustrates a lack of significant difference when stratifying based on the combination of symptoms and imaging findings (P=0.5).

Four patients had postoperative adverse events of dissection or leak. In 2 of 4 patients, the leak or dissection was not discovered until time of clinical deterioration because postoperative esophagram did not reveal significant abnormalities. In contrast, 1 patient who was doing clinically well, underwent postoperative endoscopy where no abnormalities were found based on the preceding esophagram being suspicious for leak. Our data illustrates the pitfalls of POD 1 esophagram by providing examples of false negative and false positive significant imaging findings. We favor using a combination of factors such as intraoperative events and postoperative clinical course, rather than heavy reliance on esophagram when making clinical decisions. Future large-scale studies can build upon our findings by aiming to discover accurate predictors of post-POEM leaks in order to more accurately tailor the ordering of postoperative imaging.

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