Gas Leak and Mucosal Injury During Endoscopic Esophageal Myotomy After Previous Myotomy: A Single-Center Experience

Abstract

Salih Samo,1,2 Falak Hamo,2 Anand S Jain,1 Rushikesh H Shah,1 Vaishali Patel,1 Lucie F Calderon,1 Mengdan Xie,1 Parit Mekaroonkamol,1 Steven A Keilin,1 Qiang Cai1 1Division of Digestive Diseases-Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; 2Division of Gastroenterology, Hepatology and Motility-Department of Medicine, The University of Kansas School of Medicine, Kansas City, KS, USACorrespondence: Qiang CaiEmory University School of Medicine, 1365 Clifton Road, B1262, Atlanta, GA, 30322, USATel [phone]Fax [phone]Email [email protected]: Peroral endoscopic myotomy (POEM) after prior myotomy (PM-POEM) can be technically challenging with possible increased adverse events. We aimed to assess gas leak and mucosal injury incidence during PM-POEM, compared to an index POEM (iPOEM), and post-procedure extubation time.Patients and Methods: A retrospective study comparing PM-POEM to iPOEM from March 2016 to August 2018.Results: There were 21 subjects in the PM-POEM and 56 subjects in the iPOEM. The PM-POEM group was younger (average age 44.33 vs 57.57 years, p=0.0082). Gas leak incidence did not differ between groups (28.6% in PM-POEM vs 14.3% in iPOEM, p=0.148). For cases with imaging available postoperatively, there was a trend towards higher incidence of gas leak in the PM-POEM, but it was not statistically significant (60% vs 42.1%, p=0.359). The post-procedure extubation time was not different between PM-POEM and iPOEM (11.38 vs 9.46 minutes, p=0.93), but it was longer when gas leak occurred (15.92 vs 8.67 minutes, p=0.027). The odds of mucosal injury were four-fold higher (OR, 4.31; 95% CI, 1.32– 14.08), and more clips were used to close mucosal injuries (0.62 vs 0.14 clips, p=0.0053) in the PM-POEM group. More procedures were deemed difficult or challenging in the PM-POEM (33.3% vs 7.1%, p=0.007). The number of clips used to close the mucosotomy was not different between groups (4.05 vs 3.84 clips, p=0.498). Although the myotomy was shorter in PM-POEM, it was not statistically significant (6.38 vs 7.14 cm, p=0.074). However, the procedure was longer in PM-POEM (61.28 vs 45.39 minutes, p=0.0017). There was no intervention or ICU admission required pertinent to the procedure.Conclusion: Performing PM-POEM can be more difficult with more mucosal injuries. Gas leak was associated with a slightly longer post-procedure extubation time, but clinical relevance is unclear given incidence of gas leak was unknown at time of extubation.Keywords: peroral endoscopic myotomy, Heller’s myotomy, achalasia, gas leak, mucosal injury

Keywords

• peroral endoscopic myotomy
• heller’s myotomy
• achalasia
• gas leak
• mucosal injury.