Recent progress of gastroesophageal reflux after endoscopic myotomy

Abstract

Per-oral endoscopic myotomy (POEM) is an innovative minimally invasive technique and has emerged as the preferred modality for treating achalasia and spastic esophageal disorders in numerous specialized centers worldwide. Gastroesophageal reflux (GER) is a common complication following POEM procedures. Recently, an article in the World Journal of Gastroenterology, providing a comprehensive update on post-POEM GER. In this article, the authors present novel insights and strategies that offer valuable implications for endoscopy.

Key Words: Per-oral endoscopic myotomy; Gastroesophageal reflux; Progress; Treatment; Update

Core Tip: The article highlighted the significance of predictive methods in identifying patients at risk of developing gastroesophageal reflux (GER) following per-oral endoscopic myotomy (POEM) surgery. By evaluating novel technologies and refined clinical indicators, clinicians could anticipate the likelihood of postoperative reflux and tailor treatment strategies accordingly. Overall, the core tip of the article served as a comprehensive guide for clinicians involved in the management of patients undergoing POEM procedures. By emphasizing the importance of predictive, preventive, and management strategies, the article aimed to enhance treatment outcomes, reduce complications, and optimize patient care standards in the context of post-POEM GER.

TO THE EDITOR

Achalasia is a rare esophageal motility disorder characterized by the loss of peristalsis and inadequate relaxation of the lower esophageal sphincter, particularly during swallowing[1-3]. Treatment options aim to improve the passage of food through the gastroesophageal junction and include standard therapies such as botulinum toxin injection, pneumatic balloon dilation, laparoscopic Heller myotomy, and newer treatment modalities such as per-oral endoscopic myotomy (POEM)[4]. The article “Prediction, prevention and management of gastroesophageal reflux after per-oral endoscopic myotomy: An update” published in the World Journal of Gastroenterology[1], provides a comprehensive review of the latest advances in the prediction, prevention, and management of gastroesophageal reflux (GER) following POEM. The study highlighted significant improvements in prediction methods, including the introduction of novel technologies and clinical indicators. Furthermore, it explored various preventive strategies aimed at reducing the incidence of post-POEM GER, such as advancements in preoperative preparation and postoperative management. Additionally, the article outlined updated treatment methods, offering insights into new treatment modalities and surgical interventions for addressing reflux symptoms post-POEM. These findings are pivotal as they contribute to enhancing treatment outcomes, reducing complication rates, and help physicians optimize patient care. Overall, this study sheds light on the evolving landscape of GER management post-POEM, with potential implications for clinical practice and patient care.

POEM is a minimally invasive surgical technique used to treat achalasia, a condition characterized by impaired esophageal motility. During POEM, an endoscope is inserted through the mouth and into the esophagus, where a myotomy, or surgical incision, is made in the inner lining of the esophagus to relieve the obstruction caused by dysfunctional lower esophageal sphincter muscles. While POEM effectively alleviates symptoms of achalasia, such as dysphagia, it has been associated with an increased risk of postoperative GER. This reflux can lead to complications such as esophagitis, Barrett’s esophagus, and even esophageal adenocarcinoma if left untreated. Therefore, understanding and managing GER after POEM is crucial for optimizing patient outcomes and preventing long-term complications. The clinical significance of addressing post-POEM GER lies in ensuring the success and safety of this therapeutic intervention for patients with achalasia.

In their comprehensive review titled “Prediction, prevention and management of GER after per-oral endoscopic myotomy: An update”, Nabi et al[1] assessed the strategic interventions aimed at addressing GER following POEM. The authors emphasized the urgent need for advanced methods to predict the occurrence of post-POEM GER. These predictive methods incorporated cutting-edge technologies and refined clinical indicators, providing clinicians with valuable insights to anticipate and preempt potential reflux complications. Moreover, the study underscored the significance of implementing multifaceted preventive strategies to mitigate the incidence of post-POEM GER. Enhanced preoperative assessments, tailored patient selection criteria, and meticulous intraoperative techniques are advocated to minimize disruptions to esophageal anatomy and optimize surgical outcomes. The meticulous attention to detail in these preoperative and intraoperative phases aimed to reduce the risk of GER-related complications, thereby enhancing patient safety and satisfaction. In addition, the authors discussed comprehensive postoperative management protocols aimed at effectively reducing GER-related complications and optimizing long-term outcomes for patients undergoing POEM. These management strategies include close monitoring of symptoms, timely pharmacologic interventions, and judicious dietary changes. By addressing GER symptoms promptly and proactively, clinicians can minimize the risk of complications and improve overall patient outcomes[5]. In response to these findings, the authors advocated for the use of a dual-scope technique to precisely control the length of the gastric myotomy. This refined surgical approach not only assists in determining the optimal myotomy length but also facilitates the assessment of myotomy direction, thereby reducing the likelihood of reflux-related complications[6]. In addition, studies have shown that patients who retain sling fibers post-POEM have a significantly lower incidence of grade B or higher reflux esophagitis than those who do not (31.3% vs 58.1%)[7]. Although the overall incidence of reflux esophagitis was similar between the conventional group and the sling fiber retention group, the latter group exhibited a significantly lower frequency of severe esophagitis (Los Angeles grade C/D) (44.1% vs 18.5%)[8]. Furthermore, the study suggested that post-POEM reflux esophagitis responds well to proton pump inhibitors, with refractory GER disease being significantly less common after POEM. These findings highlighted the importance of proactive management strategies in mitigating GER-related complications and optimizing long-term outcomes for patients undergoing POEM[9]. In summary, the meticulous exploration of predictive, preventive, and management strategies in this study offered valuable insights into the evolving landscape of GER management post-POEM. By advocating for refined surgical techniques and comprehensive management protocols, the authors aimed to empower clinicians to make informed decisions and enhance patient care standards in this specialized domain.

In conclusion, the study by Nabi et al[1] provides a comprehensive update on post-POEM GER, offering new insights and strategies for clinical practice. Future research endeavors are anticipated to further refine management strategies in this field, contributing to the health and well-being of patients.