PreciseSECT Mode versus Spray Coag Mode for Submucosal Tunneling in Peroral Endoscopic Esophageal Myotomy: A Randomized Trial

Abstract Peroral endoscopic esophageal myotomy (POEM) has become a primary therapeutic modality for Achalasia. PreciseSECT is a newly developed electrosurgical current mode with proposed advantages over standard modes in the POEM procedure. A total of 52 patients diagnosed with achalasia were randomized to undergo POEM performed using either PreciseSECT mode or Spray coag mode for submucosal tunneling. An ERBE VIO3 generator and Hybridknife were used in all procedures. The primary outcome was submucosal dissection duration, while secondary outcomes included total procedure duration, adverse events, and clinical success. Technical success occurred in all patients. Submucosal tunneling duration (17 min [8–41] vs. 15.5 [7–76], p = 0.5), submucosal tunneling speed (0.64 cm/min [0.21–1.5] vs. 0.73 [0.2–1.43], p = 0.34), and total procedure duration (44 min [27–77] vs. 38.5 [21–130], p = 0.19) were similar in PreciseSECT and Spray coag groups, respectively. Bleeding requiring change to a coagrasper (1 [0–3] vs. 0 [0–1], p = 0.01) and the need to change the electrosurgical mode to coagulate non-bleeding vessels (3 [0–9] vs. 1 [0–5], p = 0.002) were higher in the PreciseSECT group. However, the occurrence of type 1 mucosal injury was higher in the Spray coag group (7.7 vs. 34.6%, p = 0.05). Using a hybrid knife, Spray coag mode is associated with a higher incidence of mucosal injury. In contrast, PreciseSECT mode is associated with a more frequent need to switch accessories to coagulate bleeding vessels, as well as a more frequent need to change to another mode to coagulate non-bleeding vessels. Both modes seem to have similar submucosal dissection speeds. (clinicaltrials.gov registration NCT06189859).