Transoral Incisionless fundoplication for reflux after peroral endoscopic myotomy: a crucial addition to our arsenal

Abstract

Introduction Increased esophageal acid exposure is seen in a large percentage of patients with achalasia who undergo peroral endoscopic myotomy (POEM). Endoscopic transoral fundoplication (TIF) is a novel endoscopic technique for the management of patients with chronic gastroesophageal reflux (GERD). We present the first case series evaluating the role of TIF post-POEM. Methods Consecutive patients 18 years or older from our academic institution who underwent a POEM procedure and subsequently underwent TIF for symptomatic reflux or regurgitation between December 2014 and June 2017 were included. The primary outcome was discontinuation of proton-pump inhibitor (PPI) use and healing of esophagitis (when initially present) on post-procedure esophagogastroduodenoscopy (EGD). Technical success was defined as successful completion of the endoscopic fundoplication. Adverse events (AEs) were recorded for all patients. Results Five patients were included (60 % male, average age 55 ± 14 years). Technical success was achieved in 100 % of patients. Discontinuation of PPI use was achieved in 5/5 patients (100 %). Three patients had esophagitis pre-procedure and all were noted to have resolution of inflammation on post-procedure EGD. No adverse events were noted. Mean follow-up time was 27 months (range 5 – 34 months). Conclusion TIF post-POEM appears feasible, safe, and efficacious in improving symptoms and esophagitis, decreasing long-term risks of acid exposure, and decreasing risks of long-term PPI use in patients post-POEM in this small cohort of patients. Larger studies are needed to confirm these initial findings.

Long-term outcomes of per-oral endoscopic myotomy in achalasia patients with a minimum follow-up of 4 years: a multicenter study

“…Regarding long-term management of postmyotomy reflux, the ability to perform a simultaneous fundoplication at the time of LHM has been an advantage of this approach over POEM [30] However, the introduction of transoral fundoplication to the arsenal of tools used to manage reflux is putting that advantage to test. It has been shown by Tyberg et al [31], on a small cohort of patients that TIF after POEM is a feasible, safe, and efficacious technique for management of post-POEM reflux. There are other ongoing efforts [32,33] to report the efficacy and safety of transoral fundoplication on larger cohorts of post-POEM patients with reflux.…”

Statement for gastroesophageal reflux disease after peroral endoscopic myotomy from an international multicenter experience

“…Commentary: currently, there are a few reports which describe additional fundoplication for GERD after POEM [7][8][9]. Swanström states that the need for an antireflux procedure after POEM is exceedingly rare in his and other Western experiences [10].…”

“…Therefore, when POEM was first introduced, the development of GERD was a huge concern. However, to date, there have been few reports on the occurrence of GERD requiring surgical intervention with fundoplication [7][8][9][10].…”

Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey

“…If a substantial number of patients require anti-reflux surgery after POEM, then it could tip the balance back towards LHM plus partial fundoplication as the preferred first line option. Fortunately, there may be an endoscopic solution to post-POEM GERD - namely the TIF procedure[44]. In our experience of over 60 consecutive POEM procedures, only 3 patients were refractory to PPI medications and the TIF procedure was able to control GERD symptoms and esophagitis in all 3 patients.…”