DYSPHAGIA ASSOCIATED WITH MOTILITY DISORDERS AFTER ANTI-REFLUX SURGERY: A NEW PROMISING THERAPEUTIC FIELD OF APPLICATION FOR POEM!

Aims Laparoscopic fundoplication (LF) is the gold standard treatment of refractory gastro-esophageal reflux (GERD). However, it may induce dysphagia in 5 to 10% of the cases. LF could induce de novo esophageal motility disorder (EMD) in 20% of the patients, inducing severe dysphagia and impaired quality of life. The management is difficult since 15% require surgical revision. Our objectives were to evaluate the efficacy of POEM on dysphagia, and to document the technical particularities and the complications

Methods Retrospective report of consecutive patients treated by POEM for dysphagia associated to EMD after LF. All patients had normal a high-resolution manometry (HRM) before the surgery. All were suffering from severe and persistent dysphagia, refusing revisional surgery, with abnormal findings at HRM. The procedure was a regular esophageal POEM, including a cardial deep myotomy. The clinical assessment included Eckardt and dysphagia score and weight

Results Eight patients (5 men, 3 women; median age: 67.5 [44-81] years old) were included. The surgery was a Nissen LF in 4 patients and a Toupet LF in 4 patients. HRM showed aperistaltism in 6/8 patients, and an impaired LES relaxations in 6 others, four having both disorders. 4 patients underwent previous endoscopic pneumatic dilation. The median Eckardt and Dysphagia scores were 5/12 [8-11] and 3.5/5[2-4], respectively.

The procedure was completed in 7/8 patients (one complete fibrosis), without complication. The submucosa appeared more fibrotic and vascularized, slightly lengthening the time.

The clinical efficacy rate was 75% (6/8). The median post-operative Eckardt and Dysphagia scores were 1.5/12 [0-9] et 0,5/5 [0-3], respectively, after a median follow-up of 13 months [4-53]. One failure was the technical failure, the other had two pneumatic dilations finally effective.

Conclusions POEM is an interesting and safe option to manage disabling dysphagia associated with EMD after LF, and deserves larger evaluation to confirm these promising outcomes.