Diagnostic value of X-ray contrast study in preventing postprocedural complications after POEM is limited – retrospective analysis from the high volume centre

Aims Peroral endoscopic myotomy has become the mainstay of treatment of achalasia. As major adverse events are rare and are rarely asymptomatic, there is ongoing debate whether routine X-ray contrast study after POEM is necessary. In our center we have been performing POEM procedures since 2015 and initially performed X-ray contrast study routinely, however, after it has become unavailable so we adopted initiating oral liquids on the 2^nd postoperative day in the absence of complications. We compared these two strategies in terms of early complications rate and the length of the hospital stay.

Methods This is a single-centre retrospective analysis. We evaluated the rate of peri- and postprocedural complications and length of the hospital stay in patients hospitalized for POEM for esophageal achalasia in 2015-2023. We separately evaluated the “X-ray subgroup” (oral feeding was initiated after X-ray the following day after POEM) and the “clinical decision subgroup” (oral feeding on the 2^nd postoperative day).

Results We analyzed a 271 POEM procedures, mean age of patients was 52.3±16 years. 102 patients (37.2%) received X-ray contrast study, in 169 patients (62.8%) the initiation of oral feeding was based on clinical decision. The mean time of the hospital stay was 7.2±2.9 vs. 6.5±1.4 days in the X-ray group and in the clinical decision group, resp. (p<0.004). In the X-ray group there were complications in 8 patients (7.7%). Of them, 5 were periprocedural, were solved during the procedure and did not lead to the extension of the hospital stay. There were postprocedural complications in 3 patients: 1. submucosal leak on X-ray contrast study the following day after POEM was solved by placing endoscopic clips, 2. bleeding from the mucosal entry after discharge and 3. mediastinitis requiring prolonged ATB therapy. In the clinical decision group there were complications in 10 patients (5.9%), 9 were periprocedural, 8 of which were solved during the procedure/not extending hospital stay, 1 required surgery due to inability to endoscopically solve the mucosal perforation. In one case perforation with pleural effusion was detected on CT scan on the 3^rd postoperative day and required surgical intervention that led to the extension of the hospital stay.

Conclusions Our analysis shows that severe complications after POEM are rare. In each subgroup there was only single postprocedural event in which X-ray was helpful in its early detection. The length of the hospital stay in the clinical descision group was significantly shorter than in the X-ray group. That could be attributed to the improvement of the endoscopic experience. Supported by: VEGA 1/0060/23

Publication History

Article published online:
27 March 2025