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World J Gastroenterol. Mar 7, 2024; 30(9): 1096-1107
Published online Mar 7, 2024. doi: 10.3748/wjg.v30.i9.1096
Prediction, prevention and management of gastroesophageal reflux after per-oral endoscopic myotomy: An update
Zaheer Nabi, Pradev Inavolu, Nageshwar Reddy Duvvuru
Zaheer Nabi, Pradev Inavolu, Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad 500082, Telangana, India
Nageshwar Reddy Duvvuru, Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad 500032, Telangana, India
Author contributions: Nabi Z and Inavolu P wrote the manuscript; Duvvuru NR provided critical inputs to the manuscript.
Conflict-of-interest statement: Authors declare no conflict of interests for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Zaheer Nabi, FASGE, MBBS, MD, Consultant Physician-Scientist, Department of Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500082, Telangana, India. zaheernabi1978@gmail.com
Received: December 17, 2023
Peer-review started: December 17, 2023
First decision: January 16, 2024
Revised: January 26, 2024
Accepted: February 18, 2024
Article in press: February 18, 2024
Published online: March 7, 2024
Processing time: 79 Days and 9.6 Hours
Abstract

Achalasia cardia, the most prevalent primary esophageal motility disorder, is predominantly characterized by symptoms of dysphagia and regurgitation. The principal therapeutic approaches for achalasia encompass pneumatic dilatation (PD), Heller's myotomy, and the more recent per-oral endoscopic myotomy (POEM). POEM has been substantiated as a safe and efficacious modality for the management of achalasia. Although POEM demonstrates superior efficacy compared to PD and an efficacy parallel to Heller's myotomy, the incidence of gastroesophageal reflux disease (GERD) following POEM is notably higher than with the aforementioned techniques. While symptomatic reflux post-POEM is relatively infrequent, the significant occurrence of erosive esophagitis and heightened esophageal acid exposure necessitates vigilant monitoring to preclude long-term GERD-related complications. Contemporary advancements in the field have enhanced our comprehension of the risk factors, diagnostic methodologies, preventative strategies, and therapeutic management of GERD subsequent to POEM. This review focuses on the limitations inherent in the 24-h pH study for evaluating post-POEM reflux, potential modifications in the POEM technique to mitigate GERD risk, and the strategies for managing reflux following POEM.

Keywords: Achalasia cardia; Per-oral endoscopic myotomy; Gastroesophageal reflux; Esophagitis; Gastroesophageal reflux disease

Core Tip: Per-oral endoscopic myotomy (POEM) has gained recognition as a primary therapeutic intervention for achalasia cardia. POEM is distinguished by its effectiveness and a commendable safety profile. However, gastroesophageal reflux disease (GERD) has emerged as an important long term adverse event after POEM. Notably, the incidence of GERD is higher after POEM when compared to the other leading treatment modalities including pneumatic dilatation and Heller’s myotomy with fundoplication. Since the introduction of POEM in 2010, there has been considerable advancement in our understanding of GERD after POEM. This article aims to elucidate the recent developments in predicting, preventing, assessing, and managing GERD subsequent to POEM intervention.