Routine X-ray contrast study after peroral endoscopic myotomy does not improve patient outcomes

Study Background and Aim: Peroral endoscopic myotomy (POEM) is a primary treatment for achalasia. Traditionally, oral feeding is initiated after an X-ray contrast study excludes the post-procedure leak. However, since major adverse events (AEs) are rare and typically symptomatic, the need for routine postprocedural X-ray studies is uncertain. Our center initially used routine X-raycontrast studies, but from late 2018 we adopted a clinical decision-based approach, starting oral feeding on postoperative day 2 unless complications were suspected. This study compares both strategies regarding complication rates and hospital stay. METHODS: We performed a retrospective analysis of POEM procedures between 2015 and 2023 in our tertiary center. Patients were divided into an "X-ray subgroup" (feeding after negative X-ray contrast study on the 1st postoperative day) and a "clinical decision subgroup (feeding on the 1st or 2nd postoperative day based on a clinical judgment). Primary outcomes were the rate of major and minor AEs and length of hospital stay. MAJOR RESULTS: A total of 271 POEM procedures were analyzed (129 males, 142 females; mean age 52.6 ± 16.1 years). X-ray contrast was performed in 106 (39.1%) patients (March 2015 - December 2018), while in 165 (60.9%) patients (December 2018 - December 2023) the initiation of oral intake was based on a clinical evaluation. Adverse events occurred in 16 patients (15.1%) and 25 patients (15.2%) in the X-ray group and in the clinical decision group, respectively (p=NS). Major adverse events occurred in 4 (3.8%) and 2 (1.2%) in X-ray subgroup and clinical decision subgroup, respectively (p=NS). Hospital stay was shorter in the clinical decision group. (6.6 ± 1.5 vs. 7.2 ± 2.9 days, p=0.05 95% CI [0.0, 1.2]). CONCLUSIONS: Severe complications after POEM are rare. Routine X-ray contrast study after POEM does not lead to decreased rate of adverse events.