Water-jet vs traditional triangular tip knife in peroral endoscopic myotomy for esophageal dysmotility: A systemic review and meta-analysis

Abstract

BACKGROUND

Peroral endoscopic myotomy is an increasingly used less invasive modality to treat esophageal dysmotility. Recently, triangular tip knife with integrated water jet function has been introduced to mitigate multiple instrument exchanges.

AIM

To compare traditional triangular tip knife and water jet knife in terms of procedural success, duration, instrument exchanges, coagulation forceps use, and adverse events.

METHODS

We conducted a systemic review and meta-analysis with two authors independently in electronic databases (PubMed, Embase, and Cochrane Library) from inception through May 2021. In addition, we conducted a relevant search by Reference Citation Analysis (RCA) (https://www.referencecitationanalysis.com). A fixed-effects model was used to calculate weighted mean, odds ratio (OR), and confidence intervals (CI).

RESULTS

We included 7 studies involving 558 patients. Triangular knife and water jet knife were similar in odds of procedural success with ratio of 4.78 (95%CI = 0.22-102.47) and odds of clinical success with ratio of 0.93 (95%CI = 0.29-2.97), respectively. Water jet knife had fewer instrument exchanges compared to triangular knife (2.21, 95%CI = 1.98-2.45 vs 11.9, 95%CI = 11.15-12.70) and usage of coagulation forceps (1.75, 95%CI = 1.52-1.97 vs 2.63, 95%CI = 2.37-2.89). Adverse events were higher in triangular knife group (OR: 2.30, 95%CI = 1.35-3.95).

CONCLUSION

Peroral endoscopic myotomy using water jet knife is comparable in terms of procedural success to triangular tip knife. Water jet knife also required shorter procedural duration, less instrument exchanges, coagulation devices, and overall adverse events.

Keywords: Gastroenterology; Endoscopy gastrointestinal; Esophageal motility disorders; Water jet knife; Dysmotility

Core Tip: Peroral endoscopic myotomy (POEM) has gained traction due to its novel technique of preserving the mucosal layer while working in the submucosa and minimizing risk of leakage of contents into the mediastinum. It hails comparable efficacy and safety data to the standard surgical therapy of laparoscopic Heller myotomy in short term follow up studies. The major steps of POEM are similar among centers, including small mucosal incision, submucosal tunneling, myotomy, and mucosal closure. Within these individual steps, many tools and variations exist to achieve the result. Recently, an innovative water-jet integrated triangular tip knife (WJ) has been devised in order to improve procedural time with less instrument changes, as well as minimize adverse events. There have been several studies comparing the conventional triangular tip knife and WJ and suggesting that WJ can achieve similar clinical and procedural success rate, but with lower adverse effects, instrument changes, and intra-procedural coagulation devices. This is the first meta-analysis to compare the two instruments.