Intraprocedural fluoroscopy to determine the extent of the cardiomyotomy during per-oral endoscopic myotomy (with video)

Background An adequate myotomy on the gastric side is considered essential to optimize outcomes in patients undergoing per-oral endoscopic myotomy (POEM). An objective method to measure the length of gastric myotomy has not yet been reported. Objective To evaluate a new method of precisely determining the length of the submucosal tunnel below the esophagogastric junction (EGJ) using intraprocedural fluoroscopy. Design Single-center cohort study. Setting Academic tertiary care center. Patients Twenty-four consecutive patients who underwent POEM for management of achalasia. Interventions A radiopaque marker (endoscopic clip placed at the EGJ or fluoroscopically guided placement of a 19-gauge needle on the skin) was used to mark the EGJ. The endoscope was inserted to the most distal aspect of the submucosal tunnel and, using fluoroscopy, the distance between the radiopaque marker and the tip of the endoscope was measured. Main Outcome Measurements Technical success, procedural impact, duration of technique, and adverse events. Results Technical success was achieved in 100% of patients. The submucosal tunnel was extended in 5 patients (20.8%) with a mean extension of 1.4 ±.5 cm. The mean increase in procedure time was 4 minutes with the endoscopic clip and 2 minutes with the 19-gauge needle. There were no adverse events associated with this technique. Limitations Need for fluoroscopy. Absence of available criterion standard. Conclusions Intraprocedural fluoroscopy was an efficient and safe method of objectively documenting the extent of gastric myotomy during POEM. This may benefit those investigating the anatomic and physiologic changes that occur during the myotomy and those early in their experience performing POEM.