Peroral endoscopic esophageal myotomy (POEM) has become a primary therapeutic modality for Achalasia. Precisect is a newly developed electrosurgical current mode with proposed advantages over standard modes in POEM procedure. The aim of this study was to evaluate the performance of precisect mode vs spray coag mode in submucosal tunneling during POEM.

52 patients diagnosed with Achalasia were randomized to have POEM procedure performed with either Precisect mode or Spray coag mode for submucosal tunneling using an ERBE VIO3 generator and Hybrid knife. 

Technical success occurred in all patients. Submucosal tunneling duration (17 minutes (8-41) vs 15.5 (7-76), p:0.5 ), submucosal tunneling speed ( 0.64 cm/minute (0.21-1.5) vs 0.73 (0.2-1.43), p:0.34) and whole procedure duration ( 44 minutes (27-77) vs 38.5 (21-130), p:0.19 ) were similar in Precisect and Spray coag groups respectively. Bleeding requiring change to a coagrasper ( 1 (0-3) vs 0 (0-1), p:0.01  ) and need to change electrosurgical mode to coagulate non-bleeding vessels ( 3 (0-9) vs 1 (0-5), p:0.002 ) were higher in the Precisect group. However, the occurrence of mucosal injury was higher in the Spray coag group ( 7.7% vs 34.6%, p: 0.05 ).

Using a hybrid knife, Precisect mode is associated with more frequent switching to coagrasper to coagulate bleeding vessels as well as a more frequent need to shift to another mode to coagulate non-bleeding vessels in comparison to Spray coag mode. On the other hand, Spray coag mode is associated with a higher incidence of mucosal injury. Both modes seem to have the similar speed of submucosal dissection.

(clinicaltrials.gov registration NCT06189859)