Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case–control study

Abstract

The variables associated with gastroesophageal reflux (GER) after peroral endoscopic myotomy (POEM) are largely unknown. This study aimed to: 1) identify the prevalence of reflux esophagitis and asymptomatic GER in patients who underwent POEM, and 2) evaluate patient and intraprocedural variables associated with post-POEM GER. All patients who underwent POEM and subsequent objective testing for GER (pH study with or without upper gastrointestinal [GI] endoscopy) at seven tertiary academic centers (one Asian, two US, four European) were included. Patients were divided into two groups: 1) DeMeester score ≥ 14.72 (cases) and 2) DeMeester score of< 14.72 (controls). Asymptomatic GER was defined as a patient with a DeMeester score ≥ 14.72 who was not consuming proton pump inhibitor (PPI). A total of 282 patients (female 48.2 %, Caucasian 84.8 %; mean body mass index 24.1 kg/m) were included. Clinical success was achieved in 94.3 % of patients. GER evaluation was completed after a median follow-up of 12 months (interquartile range 10 - 24 months). A DeMeester score of ≥ 14.72 was seen in 57.8 % of patients. Multivariable analysis revealed female sex to be the only independent association (odds ratio 1.69, 95 % confidence interval 1.04 - 2.74) with post-POEM GER. No intraprocedural variables were associated with GER. Upper GI endoscopy was available in 233 patients, 54 (23.2 %) of whom were noted to have reflux esophagitis (majority Los Angeles Grade A or B). GER was asymptomatic in 60.1 %. Post-POEM GER was seen in the majority of patients. No intraprocedural variables were identified to allow for potential alteration in procedural technique.

Clinical Practice Update: The Use of Per-Oral Endoscopic Myotomy in Achalasia: Expert Review and Best Practice Advice From the AGA Institute

“…As a result, routine endoscopy to screen for erosive disease or Barrett’s esophagus at some point post-POEM is advocated by several leading experts. 42,49,50 Consistent with this, patients considering POEM should be advised beforehand that they might require lifelong proton pump inhibitor therapy for symptomatic reflux or erosive esophagitis. Clearly, more treatment data are needed to determine the long-term efficacy and complications of POEM.…”

“…47 One of the greatest concerns after POEM is reflux, evidence of which is observed in up to 58% of patients (Table 2). 42 …”

“…Similarly, a multicenter case-control series studying 282 patients found endoscopic or pH-metry evidence of post-POEM gastroesophageal reflux disease in 58% of the patients, including endoscopic esophagitis in 23% (proton pump inhibitor use was uncontrolled). 42 Furthermore, a substantial percentage of these patients are asymptomatic, despite the presence of erosive esophagitis.…”

Fair reliability of eckardt scores in achalasia and non‐achalasia patients: Psychometric properties of the eckardt spanish version in a multicentric study

“…Regurgitation is also a frequent achalasia complain, but it is widely non‐specific. This could be relevant as an achalasia patient can have a post‐treatment ESS = 3 only due to gastro‐esophageal reflux disease (GERD), which is a frequent treatment complication . Weight loss is referred by a minority of achalasia patients .…”

Endoscopic Intramural Surgery Part II: Muscular Division

“…In some ways, these new techniques are replacing surgical interventions. 47,48 IMS EMD procedures do have limitations that prevent more widespread adoption including limited access to the technology and availability of endoscopic instruments required, advanced training opportunities for operators, and the relative rareity of diseases that are effectively treated by these approaches. 49,50 Additionally, appropriate support and infrastructure are needed for successful training and adoption of these techniques by a multidisciplinary team.…”