Post-POEM reflux: who’s at risk?

Arevalo, Gabriel; Sippey, Megan; Martín-del-Campo, Luis A.; He, Jack C.; Ali, Ahmed M.; Marks, Jeffrey M.

doi:10.1007/s00464-019-07086-1

Cited by 15 publications

(6 citation statements)

References 27 publications

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“…Patients who underwent POEM for alternative indications, including diffuse esophageal spasm, esophagogastric junction outflow obstruction, and jackhammer esophagus, were also excluded. The majority of patients in this cohort were included in previously published studies on shorter-term outcomes, incidence of gastroesophageal reflux disease, and adverse events (AEs) after POEM however clinical outcomes have never been reported beyond 4 years 6 17 18 19 20 21 .…”

Section: Methodsmentioning

confidence: 99%

Durability of per-oral endoscopic myotomy beyond 6 years

et al. 2021

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Background and study aims The aim of this study was to assess long-term clinical outcomes beyond 6 years in patients who underwent per-oral endoscopic myotomy (POEM) for the treatment of achalasia. Patients and methods Patients with achalasia who underwent POEM between 2010 and 2012 and had follow-up of at least 6 years were retrospectively identified at eight tertiary care centers. The primary outcome evaluated was clinical success defined by an Eckardt symptom score (ESS) ≤ 3 for the duration of the follow-up period. The clinical success cohort was compared to failure (ESS > 3 at any time during follow-up) in order to identify characteristics associated with symptom relapse. The incidence of patient-reported gastroesophageal reflux (GER) was also evaluated. Results Seventy-three patients with 6-year follow-up data were identified. Sustained clinical remission was noted in 89 % (65/73) at 6-years. Mean ESS decreased from 7.1 ± 2.3 pre-procedure to 1.1 ± 1.1 at 6 years (P < 0.001). Symptomatic reflux was reported by 27 of 72 patients (37.5 %). Type I achalasia (OR 10.8, P = 0.04) was found to be associated with clinical failure on logistic regression analysis. Conclusions In patients with achalasia, POEM provides high initial clinical success with excellent long-term outcomes. There are high rates of patient-reported gastroesophageal reflux post-procedure which persist at long-term follow-up.

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Section: Methodsmentioning

confidence: 99%

Durability of per-oral endoscopic myotomy beyond 6 years

et al. 2021

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“…16 Similar incidence has been reported in other studies. 9,10,13,17,[19][20][21][22][23][25][26][27] A large single-center study of over 200 consecutive patients reported a high DeMeester score (>14.72), endoscopy-confirmed reflux esophagitis, and symptomatic GERD in 47.9, 41.9, and 29.3% of patients, respectively. 26 In an extensive meta-analysis comparing LHM to POEM that included 74 studies involving more than 7,000 patients, it was found that patients undergoing POEM were more likely to develop GERD symptoms (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.33-2.14; p < 0.0001), erosive esophagitis (OR, 9.31; 95% CI, 4.71-18.85; p < 0.0001), and abnormal esophageal acid exposure (EAE) (OR, 4.30; 95% CI, 2.96-6.27; p < 0.0001) as compared with those undergoing LHM.…”

Section: The Issue Of Post-poem Germentioning

confidence: 99%

“…18 Early studies on POEM reported modest postprocedure gastrointestinal reflux disease (GERD) in 12 to 21% of patients, 3,4,8 possibly due to the limited follow-up included. Recent studies have focused on post-POEM GERD in greater detail and have reported an alarming 40 to 60% incidence of post-POEM GERD, 9,10,13,[17][18][19][20][21][22][23] so much so that it prompted an editorial addressing this concern. 24 Given the fact that all three modalities are primarily directed toward LES relaxation, some element of increased GER may be considered as a natural outcome of these therapies.…”

Section: Introductionmentioning

confidence: 99%

Gastroesophageal Reflux after Peroral Endoscopic Myotomy: Myth or Reality?

Bapaye

Gandhi

Bapaye

2021

Journal of Digestive Endoscopy

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Peroral endoscopic myotomy (POEM) is an accepted treatment for achalasia cardia (AC), and results are comparable to those of laparoscopic Heller myotomy (LHM). In recent years, several reports have confirmed higher incidence of gastroesophageal reflux (GER) following POEM. This review evaluates the current evidence regarding post-POEM GER, critically examines the potential contributing factors responsible for GER, limitations of the current available functional testing, and precautions and preventive measures, and provides future directions for research. Factors conclusively contributing to increased post-POEM GER include injury to the sling fibers of the lower esophageal sphincter, length of gastric myotomy > 2 cm, and others. Historically, these same factors have been implicated for development of GER after surgical (laparoscopic) myotomy. Although less invasive, optimal technique of POEM may be important to control post-POEM GER. Most post-POEM GER occurs during the immediate post-POEM period, is mild, and is easily treatable using proton-pump inhibitors. GER incidence plateaus at 2 years and is comparable to that after LHM. Patients should therefore be prescribed proton-pump inhibitors for at least 2 years. Antireflux procedures (ARPs) are infrequently required in these patients as the incidence of refractory GER is low. Novel ARPs have been recently described and are currently under evaluation. Conclusive diagnosis of GER is a clinical challenge. Most patients are asymptomatic, and GER is diagnosed only on abnormal esophageal acid exposure (EAE). Studies have demonstrated that current measures to diagnose GER are inadequate, inaccurate, and cannot differentiate between true GER and abnormal EAE due to food fermentation in the distal esophagus. The Lyon Consensus criteria should be implemented for confirmation of diagnosis of GER. Finally, the review recommends an evidence-based clinical algorithm for evaluation and management of post-POEM GER and provides guidelines for future research in this field.

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“…The incidence at 24 months was 44 % and 29 %, respectively [10]. While several studies have identified risk factors for post-POEM reflux such as female sex, presence of preoperative esophagitis, as well as high preoperative Eckardt score, the effect of procedural factors such as overall length of myotomy on post-procedure reflux is debatable [11,12]. Based on the available evidence and following the tenets of LHM, the actual myotomy length is recommended to be at least 6 cm (2 cm in the esophagus, 2-3 cm lower esophageal sphincter, 2 cm cardia) and on average between 8 and 10 cm [13].…”

Section: Introductionmentioning

confidence: 99%

Short versus standard esophageal myotomy in achalasia patients: a systematic review and meta-analysis of comparative studies

et al. 2021

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Background and study aims Despite the clinical efficacy of peroral endoscopic myotomy (POEM), postoperative symptomatic gastroesophageal reflux disease (GERD) remains a major concern. While it is known that length of the gastric myotomy affects postoperative GERD, the clinical relevance of variation in esophageal myotomy length is not well known. We performed a systematic review and meta-analysis of studies comparing outcomes of short versus standard myotomy length in patients with achalasia. Patients and methods We searched multiple databases from inception through November 2020 to identify studies that reported on outcomes of achalasia patients who underwent short compared with standard esophageal myotomy. Meta-analysis was performed to determine pooled odds ratio (OR) of clinical success, GERD outcomes, and adverse events with the two techniques. Results 5 studies with 474 patients were included in the final analysis (short myotomy group 214, standard myotomy group 260). There was no difference in clinical success (OR 1.17, 95 % confidence interval [CI] 0.54–2.52; I2 0 %; P = 0.69), postoperative symptomatic GERD (OR 0.87, 95 %CI 0.44–1.74; I2 29 %; P = 0.70), and overall adverse events (OR 0.52, 95 %CI 0.19–1.38; I2 40 %; P = 0.19), between the two groups. Incidence of postoperative erosive esophagitis as determined by endoscopy was lower in the short myotomy group (OR 0.50, 95 %CI 0.24–1.03; I2 0 %; P = 0.06). Conclusion Our analysis showed that performing POEM with short esophageal myotomy in achalasia was as safe and effective as standard myotomy, with lower incidence of postoperative erosive esophagitis.

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Post-POEM reflux: who’s at risk?

Cited by 15 publications

References 27 publications

Durability of per-oral endoscopic myotomy beyond 6 years

Durability of per-oral endoscopic myotomy beyond 6 years

Gastroesophageal Reflux after Peroral Endoscopic Myotomy: Myth or Reality?

Short versus standard esophageal myotomy in achalasia patients: a systematic review and meta-analysis of comparative studies

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