A prospective analysis of GERD after POEM on anterior myotomy

• Published in: Surgical endoscopy Vol. 30; no. 6; pp. 2496 - 2504
• Main Authors: Shiwaku, Hironari, Inoue, Haruhiro, Sasaki, Takamitsu, Yamashita, Kanefumi, Ohmiya, Toshihiro, Takeno, Shinsuke, Nimura, Satoshi, Yamashita, Yuichi
• Format: Journal Article
• Language: English
• Published: New York Springer US 01-06-2016; Springer Nature B.V
• Subjects: Abdominal Surgery; Adolescent; Adult; Aged; Aged, 80 and over; Botulinum toxin; Endoscopy; Esophageal Achalasia - surgery; Esophagitis, Peptic - etiology; Esophagoscopy - methods; Esophagus; Female; Follow-Up Studies; Gastroenterology; Gastroesophageal Reflux - etiology; Gynecology; Hepatology; Humans; Male; Manometry; Medicine; Medicine & Public Health; Middle Aged; Muscle Relaxation - physiology; Muscle, Smooth - physiopathology; Natural Orifice Endoscopic Surgery - adverse effects; Natural Orifice Endoscopic Surgery - methods; Performance evaluation; Pressure; Proctology; Prospective Studies; Risk Factors; Surgery; Young Adult; Japan; GERD; Achalasia; POEM
• ISSN: 0930-2794; 1432-2218
• DOI: 10.1007/s00464-015-4507-0

Background
Peroral endoscopic myotomy (POEM) is an emerging, minimally invasive procedure capable of overcoming limitations of achalasia treatments, but gastroesophageal reflux disease (GERD) after POEM is of concern and its risk factors have not been evaluated. This prospective study examined GERD and the association of POEM with reflux esophagitis.
Methods
Achalasia patients were recruited from a single center. The pre- and postoperative assessments included Eckardt scores, manometry, endoscopy, and pH monitoring.
Results
Between September 2011 and November 2014, 105 patients underwent POEM; 70 patients were followed up 3 months after POEM. Postoperatively, significant reductions were observed in lower esophageal sphincter (LES) pressure [from 40.0 ± 22.8 to 20.7 ± 14.0 mmHg (
P
 < 0.05)], LES residual pressure [from 22.1 ± 13.3 to 11.4 ± 6.6 mmHg (
P
 < 0.05)], and Eckardt scores [from 5.7 ± 2.5 to 0.7 ± 0.8 (
P
 < 0.05)]. Symptomatic GERD and moderate reflux esophagitis developed in 5 and 11 patients (grade B,
n
 = 8; grade C,
n
 = 3), respectively, and were well controlled with proton pump inhibitors. Univariate logistic regression analysis revealed integrated relaxation pressure was a predictor of ≥grade B reflux esophagitis. No POEM factors were found to be associated with reflux esophagitis.
Conclusion
POEM is effective and safe in treating achalasia, with no occurrence of clinically significant refractory GERD. Myotomy during POEM, especially of the gastric side, was not associated with ≥grade B (requiring medical intervention) reflux esophagitis. Extended gastric myotomy (2–3 cm) during POEM is recommended to improve outcomes.