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

Background and Aims: 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). Methods: 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. Results: 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). Conclusions: 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.