Use of intraoperative fluoroscopy to reduce post–peroral endoscopic myotomy reflux: a proof-of-concept study

TL;DR

This study explores using intraoperative fluoroscopy during a specific endoscopic procedure to reduce post-surgery acid reflux by adjusting the myotomy angle.

Contribution

The study introduces intraoperative fluoroscopy as a potential tool to tailor myotomy and reduce post-POEM reflux.

Findings

Patients with a wider fluoroscopic angle showed a trend toward increased reflux symptoms at 3 and 12 months.

Intraoperative fluoroscopy may help preserve sling fibers and reduce post-POEM gastroesophageal reflux disease.

Results suggest a need for prospective studies to confirm the observed trends.

Abstract

Post–peroral endoscopic myotomy (POEM) gastroesophageal reflux is a common adverse event. Intraoperative fluoroscopy (IOF) can help identify the gastroesophageal junction (GEJ) during submucosal tunneling and evaluate the extent of myotomy into the stomach during POEM. In this study, we investigated the use of IOF to predict and prevent post-POEM GERD (PPG).

This was a retrospective review of all patients who underwent POEM with IOF at our institution. A blinded gastroenterologist measured the fluoroscopic angle (FA) between the endoscope tip at the GEJ, before submucosal tunneling, and at the distal extent of the submucosal tunnel into the cardia. The FA was compared in patients with and without PPG at 3 and 12 months.

Sixty-seven patients were included. The median FA was wider in patients on a proton pump inhibitor at 3 months (10.30 vs –1.35 degrees, P = .28) and 12 months (6.20 vs –1.05 degrees, P = .46) and in patients with presence of heartburn symptoms at 3 months (6.20 vs 2.35 degrees, P = .49) and 12 months (15.10 vs 0.15 degrees, P = .16).

Our study suggests that IOF could be used to tailor the myotomy to preserve sling fibers and in turn reduce PPG. Although our findings did not show statistical significance, the trend toward increased PPG in patients with a wider FA warrants a prospective controlled study to further test this hypothesis.

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