Reflux after peroral endoscopic myotomy: The dilemma and the options

Abstract

Per oral endoscopic myotomy (POEM) is rapidly emerging as the treatment of choice for achalasia cardia, but its success is marred by problematic reflux. Although symptomatic reflux rates are low and often comparable to that after laparoscopic Hellers myotomy (LHM), a high incidence of pathologic reflux has been noted after POEM. This poses a dilemma as to what is true reflux, and in determining the indications and optimal endpoints for managing post-POEM reflux. The two pertinent reasons for the difference in reflux rates between LHM and POEM are the variation in length and location of myotomy and the absence of an anti-reflux procedure in POEM. Proton pump inhibitor remains the most sought-after treatment of POEM derived reflux. Nevertheless, modifications in the procedural technique of POEM and the addition of endoscopic fundoplication can probably emerge as a game changer. This article briefly reviews the incidence, causes, controversies, predictive factors, and management strategies related to post-POEM reflux.

Keywords: Achalasia; Per oral endoscopic myotomy; Laparoscopic Heller myotomy; Transoral incisionless fundoplication; Gastroesophageal reflux disease; Pathologic reflux; Proton pump inhibitor; Endoscopic fundoplication; Endoluminal functional lumen imaging planimetry tailored myotomy; Sling-fiber preserving myotomy

Core Tip: The incidence of symptomatic gastroesophageal reflux disease differs from that of pathologic reflux, as observed in endoscopy and potential of hydrogen studies after per oral endoscopic myotomy (POEM). Pathologic reflux is more common after POEM than laparoscopic Hellers myotomy. It is attributed to difference in the technique used or because an anti-reflux procedure is not routinely added to POEM. Post-POEM reflux can be managed with proton pump inhibitors or surgically with new emerging operative techniques.