Gastroesophageal reflux disease after peroral endoscopic myotomy: Analysis of clinical, procedural and functional factors, associated with gastroesophageal reflux disease and esophagitis

Abstract It has been 10 years since peroral endoscopic myotomy (POEM) was reported for the first time, and POEM has currently become the standard treatment for achalasia and related disorders globally because it is less invasive and has a higher curative effect than conventional therapeutic methods. However, there are limited studies comparing the long-term outcomes of POEM with those of conventional therapeutic methods, particularly in the occurrence of gastroesophageal reflux disease (GERD) after therapy. With this background, we held a consensus meeting to discuss the pathophysiology and management of GERD after POEM based on published papers and experiences of each expert and to discuss the prevention of GERD and dealing with anti-acid drug refractory GERD. This meeting was held on April 27, 2018 in Tokyo to establish statements and finalize the recommendations using the modified Delphi method. This manuscript presents eight statements regarding GERD after POEM.

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Peroral endoscopic myotomy outcomes: Efficacy and gastroesophageal reflux disease

Techniques in Gastrointestinal Endoscopy ◽

10.1016/j.tgie.2013.05.002 ◽

2013 ◽

Vol 15 (3) ◽

pp. 140-143 ◽

Cited By ~ 1

Author(s):

Ashwin A. Kurian ◽

Lee L. Swanström

Keyword(s):

Gastroesophageal Reflux Disease ◽

Gastroesophageal Reflux ◽

Reflux Disease ◽

Peroral Endoscopic Myotomy ◽

Endoscopic Myotomy

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Gastroesophageal reflux disease after peroral endoscopic myotomy: lest we forget what we already know

Diseases of the Esophagus ◽

10.1093/dote/doz106 ◽

2019 ◽

Vol 32 (12) ◽

Cited By ~ 1

Author(s):

Robert Bechara ◽

Haruhiro Inoue ◽

Yuto Shimamura ◽

David Reed

Keyword(s):

Gastroesophageal Reflux Disease ◽

Gastroesophageal Reflux ◽

Reflux Disease ◽

Esophageal Acid Exposure ◽

Acid Exposure ◽

Peroral Endoscopic Myotomy ◽

First Line ◽

Endoscopic Myotomy ◽

Definition Of ◽

Acid Exposure Time

Summary After the performance of the first peroral endoscopic myotomy (POEM) in 2008, POEM has now spread worldwide and has arguably become a first-line treatment option for achalasia. Recently, there is increasing debate regarding post-POEM gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD). The reported incidences of GERD vary widely, owing to the variability in the definitions used. The literature regarding GERD and achalasia patients with a focus on 24-hour pH testing, esophageal acid exposure, and fermentation and the definitions of GERD used in the POEM literature are examined. 24-hour pH testing in achalasia patients may be abnormal due to fermentation both pre- and post-treatment. It is vital that POEM operators ensure that fermentation is recognized during 24-hour pH testing and excluded in the analysis of acid exposure time (AET) used in the diagnosis of GERD. In untreated achalasia, 24-hour pH testing may suggest abnormal AET in over a third of patients. However, most abnormal AETs in untreated achalasia patients are due to fermentation rather than GER. In treated achalasia, up to half of the patients with abnormal AET may be attributable to fermentation. To have a candid discussion and appropriately address the questions surrounding post-POEM GERD, consistent definitions need to be applied. We suggest the recent definition of GERD from the Lyon Consensus to be utilized when diagnosing GERD in post-POEM patients. Further studies are required in establishing ideal parameters for 24-hour pH testing in achalasia patients.

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Gastroesophageal reflux disease after peroral endoscopic myotomy is unpredictable, but responsive to proton pump inhibitor therapy: a large, single-center study

Endoscopy ◽

10.1055/a-1133-4354 ◽

2020 ◽

Vol 52 (08) ◽

pp. 643-651

Author(s):

Zaheer Nabi ◽

Mohan Ramchandani ◽

Rama Kotla ◽

Manu Tandan ◽

Rajesh Goud ◽

...

Keyword(s):

Gastroesophageal Reflux Disease ◽

Gastroesophageal Reflux ◽

Proton Pump ◽

Reflux Esophagitis ◽

Reflux Disease ◽

Comprehensive Evaluation ◽

Erosive Esophagitis ◽

Peroral Endoscopic Myotomy ◽

Demeester Score ◽

Endoscopic Myotomy

Abstract Background Gastroesophageal reflux disease (GERD) is an important concern after peroral endoscopic myotomy (POEM). However, there are limited data on the risk factors for post-POEM GERD and its responsiveness to proton pump inhibitors (PPIs). In this study, we aimed to analyze the variables affecting the occurrence of GERD and its response to PPI therapy. Methods Consecutive patients with idiopathic achalasia who underwent POEM (December 2016 to January 2018) were evaluated for GERD using 24-hour pH impedance, esophagogastroduodenoscopy (EGD), and symptoms. Multivariate analysis was performed to identify the variables affecting the incidence of post-POEM GERD. Results A total of 209 patients with esophageal motility disorders, including 194 patients with non-sigmoid achalasia, underwent POEM during the study period. Comprehensive evaluation of GERD was completed on 167 patients (86.1 %): 47.3 % women with a mean (standard deviation) age of 41 (14.42) years and body mass index of 22.2 (3.89) kg/m2; the majority (70.7 %) were treatment naïve. A high DeMeester score (> 14.72), reflux esophagitis, and symptomatic GERD were identified in 47.9 %, 41.9 %, and 29.3 % of patients, respectively. On logistic regression analysis, type of achalasia, technique of POEM (anterior vs. posterior), pre- or post-POEM esophageal manometry variables, and patient characteristics were not associated with post-POEM GERD. Erosive esophagitis responded to PPI therapy in the majority of patients (81.4 %). Conclusion The incidence of GERD is high after POEM. Most of the reflux esophagitis is mild and responsive to PPI therapy. There are no procedural or patient-related variables that appear to affect the incidence of post-POEM GERD.

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203 RISK AND PROTECTIVE FACTORS OF GASTROESOPHAGEAL REFLUX DISEASE AFTER PERORAL ENDOSCOPIC MYOTOMY

Diseases of the Esophagus ◽

10.1093/dote/doaa087.38 ◽

2020 ◽

Vol 33 (Supplement_1) ◽

Author(s):

N Fukushima ◽

T Masuda ◽

F Yano ◽

K Tsuboi ◽

M Hoshino ◽

...

Keyword(s):

Gastroesophageal Reflux Disease ◽

Gastroesophageal Reflux ◽

Protective Factors ◽

Reflux Disease ◽

Preoperative Evaluation ◽

Peroral Endoscopic Myotomy ◽

Limiting Current ◽

Upper Gastrointestinal Endoscopy ◽

Study Cohort ◽

Endoscopic Myotomy

Abstract Peroral endoscopic myotomy(POEM)has been reported as safe and effective treatment for achalasia. This procedure is proposed to be a less invasive alternative to conventional laparoscopic Heller-myotomy with Dor-fundoplicatin(LHD), previous studies have shown that POEM may result in a higher incidence of gastroesophageal reflux disease(GERD)compared with LHD. However, certain predictors of GERD after POEM remain unstudied limiting current treatment strategy of achalasia. The aim of this study is to clarify the protective factors of GERD post-POEM. Methods Fifty-one patients who underwent POEM at our institution between January 2016 and December 2019 were included. We performed esophagogram and high-resolution esophageal manometry (HRM) as a part of preoperative evaluation. Upper gastrointestinal endoscopy has been assessed 3 months, 1 year, and then yearly after POEM. Patients were divided into two groups based on post-POEM endoscopic findings: GERD group (patients who had esophagitis [n = 28; median age 53 years with 18 male]) and non-GERD group (patients who did not have GERD [n = 23; median age 50 years with 14 male]). We compared preoperative foregut tests between the two groups. Results Twenty-eight out of 51 patients (54.9%) developed esophagitis. There were no differences in age, sex, BMI, and findings of esophagogram between the groups. Based on HRM test, greater overall lower esophageal sphincter (LES) length was noted in the non-GERD group compared with the GERD group (3.0 vs. 2.6 cm, p = 0.034). Length of gastric myotomy was comparable between the GERD and non-GERD groups (2.0 vs. 3.0 cm, p = 0.477). Similar incidence of esophagitis was evident in patients who had a history of prior LHD and those who underwent POEM as a primary intervention (60% [9/15 patients] vs. 52.8% [19/36 patients], p = 0.437). Conclusion Shorter overall LES length appears to be associated with esophagitis post-POEM. Length of gastric myotomy did not correlate to GERD in the study cohort. Prior Dor fundoplication may not avert development of GERD after POEM. Further study is warranted.

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