Post‐per‐oral endoscopic myotomy heartburn: It’s not always reflux: Expert review

Abstract

Patients with achalasia frequently develop gastroesophageal reflux (GER)-related symptoms and complications after per-oral endoscopic myotomy (POEM). Reflux symptoms are thought to be due to GER and the current treatment of post-POEM GER focuses on acid suppression with proton pump inhibitors (PPI). However, reflux symptoms in achalasia patients post-POEM can be due to true reflux, nonreflux esophageal acidification due to stasis or acid fermentation, or esophageal hypersensitivity to chemical or mechanical stimuli. True acidic reflux is not always the cause of reflux symptoms. Twenty-four-hour pH monitoring with impedance is essential to differentiate causes of esophageal acidification. PPI is useful only in true acidic reflux. Detection of acid fermentation requires manual review of a 24-h pH study, as automated review often overestimates acid exposure time due to its inability to differentiate true reflux from fermentation. Stasis of ingested acidic food warrants evaluation of esophageal emptying by timed barium esophagogram. In cases of inadequate emptying, esophagogastric junction (EGJ) distensibility can be evaluated by a functional lumen imaging probe. Impaired distensibility with inadequate esophageal emptying suggests treatment failure and may require retreatment. In treatment-refractory patients, esophageal hypersensitivity should be considered and treated with neuromodulators. Thus, the diagnostic approach to post-POEM reflux symptoms should evolve to identify various patterns of esophageal acidification, esophageal emptying patterns, EGJ distensibility, and hypersensitivity. Consequently, the treatment of GER post-POEM should not be limited to treating esophageal acidification by reflux, but should encompass other causes of acidification and esophageal hypersensitivity.

Gastroesophageal Reflux Waning Over Time in Endoscopic Versus Surgical Myotomy for the Treatment of Achalasia: A Systematic Review and Meta-Analysis

“…The only way to use this method as a solid criterion for GERD is to review a 24-hour pHmetry manually. In contrast, an automated review overestimated acid exposure time by not differentiating actual reflux from fermentation [ 48 ]. Therefore, we decided to discard this examination for further analysis.…”

Breaking the Barrier in Endoscopy

“…41 Post POEM heartburn can occur due to acid fermentation, delayed esophageal clearance, stasis, and esophageal hypersensitivity other than true acidic reflux. 42 Third Space Endoscopy beyond POEM Large (>3 cm), submucosal tumors arising from muscularis propria can have malignant potential and can be resected endoscopically by submucosal tunneling and endoscopic resection (STER). The steps are similar to POEM except for tumor dissection and en bloc removal by snare instead of the myotomy.…”

One step forward in resolving the controversies around post‐peroral endoscopic myotomy gastroesophageal reflux

“…Various studies show female sex, the presence of a hiatus hernia, body mass index >35 kg/m 2 , low integrated relaxation pressure, and full-thickness myotomy have been reported as reflux risks. 2 Recently, a multicenter cohort study involving 14 high-volume centers in Japan analyzed 2905 patients with achalasia-related esophageal motility disorders. 8 Severe reflux esophagitis (Los Angeles grade C or D) was diagnosed in 219 patients (7.5%).…”

“…In a recent issue of Digestive Endoscopy, Ramchandani et al proposed a diagnostic and treatment approach to identify causes of reflux symptoms differentiating various patterns of esophageal acidification, esophageal emptying patterns, esophagogastric junction distensibility, and hypersensitivity to chemical or mechanical stimuli. 2 Acid fermentation, acid reflux with delayed clearance, and stasis of ingested acidic food are the common acidification patterns whereas acid reflux alone with normal esophageal clearance is the least common acidification pattern. The authors proposed a workup with 24-h pH impedance monitoring with manual review to characterize acidification patterns, and the following treatment should be based on the diagnosis.…”

“…Previous studies have failed to identify predictors of reflux after POEM. Various studies show female sex, the presence of a hiatus hernia, body mass index >35 kg/m 2 , low integrated relaxation pressure, and full‐thickness myotomy have been reported as reflux risks 2 . Recently, a multicenter cohort study involving 14 high‐volume centers in Japan analyzed 2905 patients with achalasia‐related esophageal motility disorders 8 .…”