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Impedance planimetry during per-oral endoscopic myotomy is associated with decreased inadvertent capnoperitoneum

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Abstract

Background

Per-oral endoscopic myotomy (POEM) has become an accepted minimally invasive alternative to Heller myotomy for the treatment of achalasia and other disorders of esophageal dysmotility. One associated adverse event is the inadvertent creation of capnoperitoneum. A proposed mechanism is that extension of the submucosal tunnel below the esophageal hiatus and onto the gastric wall leads to transmural perforation. We hypothesized that the use of impedance planimetry with the endoscopic functional luminal imaging probe (EndoFLIP) more accurately identifies the esophagogastric junction and helps to better define the myotomy’s ideal limits, thus lowering the incidence of inadvertent capnoperitoneum.

Methods

This is a single-center, retrospective review of consecutive POEM cases from 06/11/2011 to 08/08/2022, with EndoFLIP introduced in 2017. Patient and procedural characteristics, including the incidence of clinically significant capnoperitoneum and decompression, were analyzed using univariate and multivariable linear regression statistics.

Results

There were 140 POEM cases identified, 74 (52.9%) of which used EndoFLIP. Clinically significant capnoperitoneum was encountered in 26 (18.6%) cases, with no differences in patient characteristics between those who had capnoperitoneum and those who did not. There was a decreased incidence of capnoperitoneum in cases using EndoFLIP compared to those without (n = 6, 23% vs n = 20, 77%, p = 0.001), with zero instances in the final 56 cases. After adjusting for potentially confounding factors, EndoFLIP use was associated with a − 15.93% (95% confidence interval − 30.68%, − 1.18%) decrease in procedure duration.

Conclusions

The routine use of EndoFLIP during POEM was associated with decreased incidence of clinically significant capnoperitoneum, potentially due to improved myotomy tailoring and decreased duration of insufflation with shorter procedure times.

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Abbreviations

AE:

Adverse events

CI:

Confidence interval

EGJ:

Esophagogastric junction

EndoFLIP:

Endoluminal functional luminal imaging probe

IQR:

Interquartile range

NAEDD:

Non-achalasia esophageal dysmotility disorders

POEM:

Per-oral endoscopic myotomy

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Authors and Affiliations

  1. Department of Surgery, University of Massachusetts Chan Medical School - Baystate, Springfield, MA, USA

    Matthew F. Mikulski, Timothy J. Morley, Kaitlin P. Debbink & John R. Romanelli

  2. Department of Gastroenterology, University of Massachusetts Chan Medical School - Baystate, Springfield, MA, USA

    David J. Desilets

  3. Baystate Medical Center, Surgery Education Office, 759 Chestnut Street, Springfield, MA, 01199, USA

    Matthew F. Mikulski

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Correspondence to Matthew F. Mikulski.

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John R. Romanelli receives research funding from Davol and consulting fees from New View Surgical. Matthew F. Mikulski, Timothy J. Morley, Kaitlin P. Debbink, and David J. Desilets have no conflict of interest.

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Data from this work was originally presented at the Society of American Gastrointestinal and Endoscopic Surgeons 2022 Annual Meeting, Denver, CO, USA, March 2022.

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Mikulski, M.F., Morley, T.J., Debbink, K.P. et al. Impedance planimetry during per-oral endoscopic myotomy is associated with decreased inadvertent capnoperitoneum. Surg Endosc 38, 280–290 (2024). https://doi.org/10.1007/s00464-023-10526-8

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