Clinical impact of routine esophagram after peroral endoscopic myotomy: a systematic review and meta-analysis

Peroral endoscopic myotomy (POEM) has become a major treatment for esophageal motility disorders. Early routine post-POEM esophagram is frequently performed to assess for adverse events (AEs), although the clinical benefit remains questionable. We conducted a systematic review and meta-analysis to evaluate the clinical impact of a routine esophagram after POEM in asymptomatic patients.

PubMed was searched from inception to November 2024. The primary outcome was to evaluate the incidence of intramural and extramural esophageal leaks after POEM. Secondary outcomes included radiographic findings on routine esophagram after POEM and the rate in which radiographic findings resulted in a change in management. A random-effects model was used, and outcomes were represented as pooled rates, along with 95% confidence intervals (CIs).

Fourteen studies with 2153 patients were included. Most patients (mean age ranged from 39.4 to 59.3 years) had achalasia (90.6%) with a mean baseline Eckardt score ranging between 3.0 and 12. Patients underwent a routine esophagram within 24 to 72 hours after POEM. The pooled rates of intramural and extramural esophageal leaks were 2.3% (95% CI, 0.8-6.1; I² = 79.4) and 1.4% (95% CI, 0.8-2.5; I² = 81.6), respectively. Pneumoperitoneum and pneumomediastinum were the 2 most common findings on imaging, with pooled rates of 42.0% (95% CI, 26.5-59.2) and 33.7% (95% CI, 12.4-64.6), respectively. Collectively, the frequency in which routine imaging findings resulted in a change in management was 3.4% (95% CI, 1.7-6.8; I² = 81.6).

Esophageal leakage is a very uncommon AE after POEM. Routine esophagram rarely impacted immediate postprocedural care in asymptomatic patients. Selective imaging may result in higher diagnostic yield and improved cost-efficiency, and mitigate the risk of unwarranted additional testing due to incidental radiographic findings.