Published online Jun 21, 2024. doi: 10.3748/wjg.v30.i23.2947
Revised: May 6, 2024
Accepted: May 20, 2024
Published online: June 21, 2024
Processing time: 99 Days and 14.9 Hours
In this editorial, we respond to a review article by Nabi et al, in which the authors discussed gastroesophageal reflux (GER) following peroral endoscopic myotomy (POEM). POEM is presently the primary therapeutic option for achalasia, which is both safe and effective. A few adverse effects were documented after POEM, incl
Core Tip: In this editorial, we discuss the current objective measures for diagnosing gastroesophageal reflux (GER) after peroral endoscopic myotomy (POEM). We also review the factors that contribute to this adverse event, including patient and technique-related characteristics. Furthermore, we provide a list of all published studies on the various treatment options available for post-POEM GER, such as proton pump inhibitors, peroral endoscopic fundoplication, and transoral incisionless fundoplication.
- Citation: Tawheed A, Bahcecioglu IH, Yalniz M, El-Kassas M. Gastroesophageal reflux after per-oral endoscopic myotomy: Management literature. World J Gastroenterol 2024; 30(23): 2947-2953
- URL: https://www.wjgnet.com/1007-9327/full/v30/i23/2947.htm
- DOI: https://dx.doi.org/10.3748/wjg.v30.i23.2947
Achalasia is a disorder of esophageal motility. Its defining characteristics are the lower esophageal sphincter’s (LES) ineffective relaxation and the absence of esophageal peristalsis[1]. Peroral endoscopic myotomy (POEM) is considered the gold standard for managing achalasia[2]. After being introduced 16 years ago, we gained a better understanding of the procedure, its long-term sequence, and its outcomes[3]. Despite the high safety profile of POEM procedures done by third-space endoscopy experts, adverse events (AEs) are still reported. One of the notable AEs after POEM is gastroesophageal reflux (GER)[4]. In a meta-analysis, Repici et al[5] found that the incidence of GER was significantly higher following POEM than laparoscopic Heller myotomy. In this editorial, we briefly discuss the predictors of post-POEM GER and the different diagnostic and therapeutic strategies.
The Lyon consensus in 2018 determined that clinical history, questionnaire data, and response to antisecretory medication are inadequate on their own to definitively diagnose GER disease (GERD)[6]. A definitive diagnosis could be made based on the findings of objective tests. Endoscopic findings include grade C and D erosive esophagitis according to Los Angeles classification (LA), a long segment of Barret’s esophagus, or strictures. At the same time, an acid exposure time (AET) of > 6% is considered diagnostic along with the subjective methods. The consensus did not include recommendations for diagnosing post-POEM GER, despite multiple studies indicating a high prevalence of GER after POEM, with rates as high as 60% in some instances[1,7,8]. Further clarification is needed regarding the term GER when describing the sequelae in patients who have undergone POEM. Several post-POEM investigations characterize GER as having a DeMeester score over 14.7 or an esophageal pH below 4 for over 5% of the observation period, similar to diagnosing GER unrelated to POEM[1,9]. According to objective testing using 24-h pH monitoring, almost 50% of those individuals have a high AET[10]. Despite the high incidence rate, only 10% of patients are symptomatic[9]. In those patients, a high AET can be attributed to either real GER, characterized by an acute decrease in pH below 3 with sluggish clearance during pH monitoring, or to fermentation of residual food due to long-standing achalasia, resulting in a gradual reduction in pH usually above 3.7[11]. Diagnosis of GER using pH monitoring should be postponed for more than 1 mo following POEM to prevent inaccurate results due to mucosal edema and damage[10].
Predicting GER after POEM has been challenging due to the lack of a standardized diagnostic approach, making it difficult to rely on previous data. In 2021, a meta-analysis was conducted by Mota et al[12] on the published studies in the literature discussing the risk factors for predicting the occurrence of GER after POEM. The study found that full-thickness myotomy, using a posterior myotomy approach, endoscopic findings, pH monitoring, and symptoms were more com
The risk of post-POEM GER could be minimized during the procedure by some measures, including performing a short esophageal myotomy[10]. In surgical myotomy procedures, myotomies shorter than 1 cm can reduce the occurrence of GER, while myotomies longer than 2 cm have been shown to be more effective in relieving the symptoms of achalasia[16]. A recent meta-analysis found that for patients who underwent POEM, the safety and effectiveness of short esop
Multiple studies have discussed the treatment strategies for post-POEM GER (Table 1). In a consensus, Inoue et al[22] reported that proton pump inhibitors (PPIs) are the first line for treating post-POEM GER. The role of PPIs in patients who underwent POEM is a bit controversial since most cases with high AET are asymptomatic[22]. According to studies, the majority of patients who experienced symptoms of GER after POEM were effectively treated with PPIs, and the response was confirmed using objective tests[23,24]. Although numerous algorithms have been suggested for treating post-POEM GERD, Maydeo and Patil[10] presented the most comprehensive algorithm (Figure 1).
Ref. | n | Treatment | Follow-up GER assessment method | Results and conclusion |
Inoue et al[26], 2019 | 21 | POEM + F | Not assessed | Technical success: 100%. Maintaining wrap at 2 mo: 95%. AE: 0% |
Shrigiriwar et al[33], 2023 | 6 | POEM + F + PPI | GERD-HRQL; RSI | Technical success: 100%. AE: 0%. GERD-HRQL score: 2.3 ± 3.7. RSI Score: 2.2 ± 2.5 |
Patil et al[35], 2021 | 20 | POEM + F + PPI | 24 h pHmetry; endoscopy | Technical success: 85%. Subcutaneous emphysema: 47%. Capnothorax: 17%. At 1 mo follow-up grade B esophagitis: 23.5%. At 3 mo pHmetry: High AET in those with loosening of wrap 100%. At 3 mo pHmetry: Normal AET in those who maintained wrap 100%. Maintaining wrap at 3 mo: 58.8%. Patient off PPI after 3 mo: 58.8% |
Toshimori et al[36], 2020 | 1 | POEF for refractory GERD with erosive esophagitis after POEM | Endoscopy | Technical success without notable AE with maintaining the wrap at a 10-mo follow-up endoscopy. Improved symptoms. No erosive esophagitis |
Maydeo et al[37], 2023 | 30 | EFTP | GERDQ; endoscopy. 24 pHmetry | Maintaining flap at 3 mo: 89.6%. AE: 13.8% “mild symptoms”. Symptoms resolution and PPI stoppage after 6 mo: 72.4%. Improvement (> 50% from baseline) in AET: 96.6%. GERDQ improvement by > 50% at 6 mo: 55.2% |
Bapaye et al[32], 2021 | 25 | POEM + F | GERDQ; endoscopy; 24 pHmetry | Technical success: 92%. Maintaining wrap at 12 mo: 82.6%. AE: 12%. Abnormal AET at 2 mo: 11.1%. Erosive esophagitis at 2 mo: 18.2% |
Ayoub et al[38], 2024 | 4 | TIF + PPI | GERD-HRQL | 75% of patients achieved either dose reduction or discontinuation of PPI. Pre-TIF GERD-HRQL: 20 ± 18.5. Post-TIF GERD-HRQL: 3.75 ± 6.2 |
Hoerter et al[39], 2022 | 1 | TIF | Endoscopy | Technical success without notable AE. Absence of esophagitis at a 9-mo follow-up endoscopy |
Kumta et al[40], 2015 | 1 | TIF | Not assessed | Technical success without notable AE |
DeWitt et al[41], 2024 | 17 | TIF, cTIF | GERD-HRQL; endoscopy; 24 pHmetry | At 9 mo follow-up: Stopped PPI: 80%. Pre-TIF esophagitis: 88%. Post-TIF esophagitis: 50%. Pre-TIF total time reflux episode: 90.5 ± 46.9. Post-TIF total time reflux episode: 49.3 ± 32.3 |
Tyberg et al[25], 2018 | 5 | PPI + TIF | Endoscopy | Technical success: 100%. Complete resolution of symptoms: 100% |
Shiwaku et al[15], 2022 | 1886 | PPI | Endoscopy | Complete resolution of symptoms: 100% at 5-yr follow up |
Nabi et al[42], 2020 | 167 | PPI | Endoscopy | Complete resolution of esophagitis: 81.4% |
Brewer Gutierrez et al[43], 2020 | 67 | PPI | Endoscopy; pHmetry | At 48 mo follow-up erosive esophagitis: 16%. 47.5 % had AET despite being on PPI |
There is a debate surrounding the incorporation of endoscopic fundoplication as a standard procedure alongside POEM. Multiple fundoplication approaches are being examined, either separate from POEM, such as transoral inci
The alternative fundoplication option is POEM + F. Inoue et al[26] introduced a novel endoscopic fundoplication to reduce post-POEM GER. The authors documented a reduction in the incidence of reflux symptoms with an intact wrap at 1-mofollow-up after the procedure. In a single-center study, 25 patients underwent POEM + F, in which 23 patients (92%) had a technically successful procedure. Follow-up endoscopy showed that 19 patients (82.6%) had an intact wrap, whereas only 3 patients (12%) experienced delayed complications due to endoloop or endoclip erosion of the mucosa, which resolved spontaneously. Only 2 patients (11%) in this group developed GER after POEM[32]. In the United States, Shrigiriwar et al[33] conducted the first United States study with 6 patients and achieved a technical success rate of 100%. However, they did encounter some technical difficulties that need to be addressed in future research. These included the off-label use of endoscopic accessories in POEM + F and the need for surgical anatomy awareness before performing such a procedure.
In the Nabi et al[34] review article titled “Prediction, prevention, and management of gastroesophageal reflux after per-oral endoscopic myotomy: An update” and published in the World Journal of Gastroenterology, the authors provided a well-organized, comprehensive review of post-POEM GER in terms of risk factors, diagnosis, prevention, and management. They provided an algorithm for the evaluation and management of post-POEM GER. Also, they summarized the conclusions of the published papers with a simple and clear figure of the current understanding of post-POEM GER.
In our opinion, the diagnosis of GER after POEM should be determined using both objective and subjective approaches. Questionnaires and other subjective approaches for diagnosing GER can be used in conjunction with objective procedures or to evaluate the quality of life of individuals suspected of having post-POEM GER. It has been reported that nearly 60% of patients undergoing POEM may experience AET. Therefore, performing pHmetry, especially in symptomatic patients, can prove to be helpful in assessing the need for an endoscopic anti-reflux procedure. However, delaying this testing for at least 1 mo after the POEM procedure is important to avoid inaccurate results due to mucosal edema and damage. Existing data on myotomy techniques indicate certain techniques that decrease the risk of developing GER. However, these data were inconclusive. Therefore, when performing the POEM procedure, the choice of myotomy technique should not be influenced by concerns about the development of post-POEM GER. Instead, the decision should be based on the specific circumstances of the procedure, such as the difficulty level, the complexity of using the double-scope technique, and the experience and preference of the endoscopist. However, a trial should be conducted to minimize the length of the myotomy and lower the risk of prolonged post-POEM erosive esophagitis. The first line of management for patients at risk of developing GER should always be PPIs, which are effective in treating esophagitis in most patients. POEM + F is promising yet in the early stages of development. However, this procedure needs the endoscopist to have a surgical background or be an expert in POEM and third-space endoscopic procedures, with a proficient surgical team available as a backup. Long-term studies are necessary to validate the substantial risk associated with the procedure and the long-term efficacy. In addition, accessories manufacturing companies should collaborate with endoscopists to design necessary accessories to prevent off-label use of items such as endoloop, which may lead to various risks such as tool change delays and losing position during the procedure.
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