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Endoscopy 2020; 52(08): 643-651
DOI: 10.1055/a-1133-4354
Original article

Gastroesophageal reflux disease after peroral endoscopic myotomy is unpredictable, but responsive to proton pump inhibitor therapy: a large, single-center study

Zaheer Nabi
1   Department of Gastroenterologist, Asian Institute of Gastroenterology, Hyderabad, India
,
Mohan Ramchandani
1   Department of Gastroenterologist, Asian Institute of Gastroenterology, Hyderabad, India
,
Rama Kotla
2   Department of Anaesthesia, Asian Institute of Gastroenterology, Hyderabad, India
,
Manu Tandan
1   Department of Gastroenterologist, Asian Institute of Gastroenterology, Hyderabad, India
,
Rajesh Goud
1   Department of Gastroenterologist, Asian Institute of Gastroenterology, Hyderabad, India
,
Santosh Darisetty
2   Department of Anaesthesia, Asian Institute of Gastroenterology, Hyderabad, India
,
G. Venkat Rao
3   Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
,
D. Nageshwar Reddy
1   Department of Gastroenterologist, Asian Institute of Gastroenterology, Hyderabad, India
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Author commentary on Zaheer Nabi et al.Endoscopy 2020; 52(08): v28-v28
DOI: 10.1055/a-1147-7138

Abstract

Background Gastroesophageal reflux disease (GERD) is an important concern after peroral endoscopic myotomy (POEM). However, there are limited data on the risk factors for post-POEM GERD and its responsiveness to proton pump inhibitors (PPIs). In this study, we aimed to analyze the variables affecting the occurrence of GERD and its response to PPI therapy.

Methods Consecutive patients with idiopathic achalasia who underwent POEM (December 2016 to January 2018) were evaluated for GERD using 24-hour pH impedance, esophagogastroduodenoscopy (EGD), and symptoms. Multivariate analysis was performed to identify the variables affecting the incidence of post-POEM GERD.

Results A total of 209 patients with esophageal motility disorders, including 194 patients with non-sigmoid achalasia, underwent POEM during the study period. Comprehensive evaluation of GERD was completed on 167 patients (86.1 %): 47.3 % women with a mean (standard deviation) age of 41 (14.42) years and body mass index of 22.2 (3.89) kg/m2; the majority (70.7 %) were treatment naïve. A high DeMeester score (> 14.72), reflux esophagitis, and symptomatic GERD were identified in 47.9 %, 41.9 %, and 29.3 % of patients, respectively. On logistic regression analysis, type of achalasia, technique of POEM (anterior vs. posterior), pre- or post-POEM esophageal manometry variables, and patient characteristics were not associated with post-POEM GERD. Erosive esophagitis responded to PPI therapy in the majority of patients (81.4 %).

Conclusion The incidence of GERD is high after POEM. Most of the reflux esophagitis is mild and responsive to PPI therapy. There are no procedural or patient-related variables that appear to affect the incidence of post-POEM GERD.



Publication History

Received: 05 October 2019

Accepted: 17 February 2020

Article published online:
24 March 2020

© Georg Thieme Verlag KG
Stuttgart · New York

Refers to:

Is gastroesophageal reflux disease after peroral endoscopic myotomy a clinical problem?Endoscopy 2020; 52(08): 652-653
DOI: 10.1055/a-1185-9739

 

  • References

  • 1 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Inoue H, Sato H, Ikeda H. et al. Per-oral endoscopic myotomy: a series of 500 patients. J Am Coll Surg 2015; 221: 256-264
    CrossrefPubMedGoogle Scholar
  • 3 Nabi Z, Ramchandani M, Chavan R. et al. Per-oral endoscopic myotomy for achalasia cardia: outcomes in over 400 consecutive patients. Endosc Int Open 2017; 5: E331-E339
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Swanstrom LL, Rieder E, Dunst CM. A stepwise approach and early clinical experience in peroral endoscopic myotomy for the treatment of achalasia and esophageal motility disorders. J Am Coll Surg 2011; 213: 751-756
    CrossrefPubMedGoogle Scholar
  • 5 Costamagna G, Marchese M, Familiari P. et al. Peroral endoscopic myotomy (POEM) for oesophageal achalasia: preliminary results in humans. Dig Liver Dis 2012; 44: 827-832
    CrossrefPubMedGoogle Scholar
  • 6 Kumbhari V, Familiari P, Bjerregaard NC. et al. Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case-control study. Endoscopy 2017; 49: 634-642
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Familiari P, Greco S, Gigante G. et al. Gastroesophageal reflux disease after peroral endoscopic myotomy: Analysis of clinical, procedural and functional factors, associated with gastroesophageal reflux disease and esophagitis. Dig Endosc 2016; 28: 33-41
    PubMedGoogle Scholar
  • 8 Jones EL, Meara MP, Schwartz JS. et al. Gastroesophageal reflux symptoms do not correlate with objective pH testing after peroral endoscopic myotomy. Surg Endosc 2016; 30: 947-952
    CrossrefPubMedGoogle Scholar
  • 9 Shiwaku H, Inoue H, Sasaki T. et al. A prospective analysis of GERD after POEM on anterior myotomy. Surg Endosc 2016; 30: 2496-2504
    CrossrefPubMedGoogle Scholar
  • 10 Wang XH, Tan YY, Zhu HY. et al. Full-thickness myotomy is associated with higher rate of postoperative gastroesophageal reflux disease. World J Gastroenterol 2016; 22: 9419-9426
    CrossrefPubMedGoogle Scholar
  • 11 Sharata AM, Dunst CM, Pescarus R. et al. Peroral endoscopic myotomy (POEM) for esophageal primary motility disorders: analysis of 100 consecutive patients. J Gastrointest Surg 2015; 19: 161-170; discussion 170
    CrossrefPubMedGoogle Scholar
  • 12 Hungness ES, Sternbach JM, Teitelbaum EN. et al. Per-oral endoscopic myotomy (poem) after the learning curve: durable long-term results with a low complication rate. Ann Surg 2016; 264: 508-517
    CrossrefPubMedGoogle Scholar
  • 13 Nabi Z, Ramchandani M, Chavan R. et al. Peroral endoscopic myotomy in treatment-naive achalasia patients versus prior treatment failure cases. Endoscopy 2018; 50: 358-370
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Ramchandani M, Nabi Z, Reddy DN. et al. Outcomes of anterior myotomy versus posterior myotomy during POEM: a randomized pilot study. Endosc Int Open 2018; 6: E190-E198
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Lundell LR, Dent J, Bennett JR. et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification. Gut 1999; 45: 172-180
    CrossrefPubMedGoogle Scholar
  • 16 Ngamruengphong S, Inoue H, Chiu PW. et al. Long-term outcomes of per-oral endoscopic myotomy in patients with achalasia with a minimum follow-up of 2 years: an international multicenter study. Gastrointest Endosc 2017; 85: 927-933 e922
    CrossrefPubMedGoogle Scholar
  • 17 Repici A, Fuccio L, Maselli R. et al. GERD after per-oral endoscopic myotomy as compared with Heller's myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc 2018; 87: 934-943 e918
    CrossrefPubMedGoogle Scholar
  • 18 Ponds FA, Fockens P, Lei A. et al. Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: a randomized clinical trial. JAMA 2019; 322: 134-144
    CrossrefPubMedGoogle Scholar
  • 19 Sanaka MR, Thota PN, Parikh MP. et al. Peroral endoscopic myotomy leads to higher rates of abnormal esophageal acid exposure than laparoscopic Heller myotomy in achalasia. Surg Endosc 2019; 33: 2284-2292
    CrossrefPubMedGoogle Scholar
  • 20 Werner YB, Hakanson B, Martinek J. et al. Endoscopic or surgical myotomy in patients with idiopathic achalasia. NEJM 2019; 381: 2219-2229
    CrossrefPubMedGoogle Scholar
  • 21 Ichkhanian Y, Benias P, Khashab MA. Case of early Barrett cancer following peroral endoscopic myotomy. Gut 2019; 68: 2107-2110
    CrossrefPubMedGoogle Scholar
  • 22 Tan Y, Lv L, Wang X. et al. Efficacy of anterior versus posterior per-oral endoscopic myotomy for treating achalasia: a randomized, prospective study. Gastrointest Endosc 2018; 88: 46-54
    CrossrefPubMedGoogle Scholar
  • 23 Stavropoulos SN, Modayil RJ, Zhang X. et al. Is there a difference in outcomes between anterior and posterior peroral endoscopic myotomy (POEM)? A randomized study from an experienced high-volume operator. Gastrointest Endosc 2018; 87: AB121-AB122
    PubMedGoogle Scholar
  • 24 Khashab MA, Sanaei O, Ponchon T. et al. Peroral endoscopic myotomy (POEM): Anterior versus posterior approach, a randomized single-blinded clinical trial. Gastrointest Endosc 2018; 87: AB119
    PubMedGoogle Scholar
  • 25 Sanaka MR, Parikh MP, Subramanium S. et al. Obesity does not impact outcomes or rates of gastroesophageal reflux after peroral endoscopic myotomy in achalasia. J Clin Gastroenterol 2019; DOI: 10.1097/MCG.0000000000001235.
    CrossrefPubMedGoogle Scholar
  • 26 Tanaka S, Toyonaga T, Kawara F. et al. Novel per-oral endoscopic myotomy method preserving oblique muscle using two penetrating vessels as anatomic landmarks reduces postoperative gastroesophageal reflux. J Gastroenterol Hepatol 2019; 34: 2158-2163
    CrossrefPubMedGoogle Scholar
  • 27 El-Serag HB, Sweet S, Winchester CC. et al. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut 2014; 63: 871-880
    CrossrefPubMedGoogle Scholar
  • 28 Inoue H, Ueno A, Shimamura Y. et al. Peroral endoscopic myotomy and fundoplication: a novel NOTES procedure. Endoscopy 2019; 51: 161-164
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Tyberg A, Choi A, Gaidhane M. et al. Transoral incisional fundoplication for reflux after peroral endoscopic myotomy: a crucial addition to our arsenal. Endosc Int Open 2018; 6: E549-E552
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Nabi Z, Ramchandani M, Darisetty S. et al. Peroral endoscopic myotomy with endoscopic fundoplication in a patient with idiopathic achalasia. Endoscopy 2020; 52: 74-75
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Tanaka S, Toyonaga T, Kawara F. et al. The novel per-oral endoscopic myotomy method preserving oblique muscle using two penetrating vessels as anatomic landmarks reduces postoperative gastroesophageal reflux. J Gastroenterol Hepatol 2019; 34: 2158-2163
    CrossrefPubMedGoogle Scholar
  • 32 Inoue H, Shiwaku H, Kobayashi Y. et al. Statement for gastroesophageal reflux disease after peroral endoscopic myotomy from an international multicenter experience. Esophagus 2020; 17: 3-10
    CrossrefPubMedGoogle Scholar
  • 33 Kumbhari V, Besharati S, Abdelgelil A. et al. Intraprocedural fluoroscopy to determine the extent of the cardiomyotomy during per-oral endoscopic myotomy (with video). Gastrointest Endosc 2015; 81: 1451-1456
    CrossrefPubMedGoogle Scholar
  • 34 Tanaka S, Kawara F, Toyonaga T. et al. Two penetrating vessels as a novel indicator of the appropriate distal end of peroral endoscopic myotomy. Dig Endosc 2018; 30: 206-211
    CrossrefPubMedGoogle Scholar