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Gastro-esophageal reflux disease (GERD) after peroral endoscopic myotomy (POEM)

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Abstract

Background

Peroral endoscopic myotomy (POEM) is gaining traction as a minimally invasive treatment of achalasia. Increased reflux is reported after POEM but the incidence, type and severity of reflux are not fully understood. We aimed to study the prevalence and nature of reflux after POEM and correlate reflux with endoscopy and pH-impedance findings.

Methods

This is a prospective cohort study of achalasia patients undergoing POEM since 2014. Data from Eckardt and GERD symptom scores, high-resolution oesophageal manometry (HRM) and gastroscopy were performed pre-procedure and repeated at 1-year follow-up. Data from 24-h pH-impedance, if performed, were also recorded. A standardized questionnaire was used to determine the severity and frequency of heartburn symptoms and the composite score for each patient was calculated.

Results

58 patients underwent POEM between January 2014 and October 2018. The efficacy of POEM at 1 year was 93.0%. We observed reduction of median Integrated Relaxation Pressure (IRP) from 23.5 ± 33.1 mmHg to 13.4 ± 7.71 mmHg (p = 0.005) and mean Eckardt score improved from 6.09 ± 2.43 points to 1.16 ± 1.70 points (p < 0.001). At 1 year, 43.1% (n = 25) had symptomatic reflux. Of the 40 patients who underwent repeated gastroscopy, 60.0% (n = 24) had endoscopic evidence of oesophagitis with seven patients (18%) diagnosed with Grade C or D oesophagitis. 43.1% (n = 25) of patients had pH-impedance done post-POEM off PPIs. 14 patients (56%) had increased acid exposure. Sixteen percent of reflux episodes were acidic and 77.3% were weakly acidic.

Conclusion

POEM was an effective treatment for achalasia. However, GERD was common after POEM with incidence of 43% on symptom score, 60% on endoscopy and 56% on pH-impedance test. Post-POEM reflux appeared to be predominantly acidic in nature. Routine surveillance for GERD after POEM is recommended.

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Authors and Affiliations

  1. Department of Surgery, National University Hospital, National University Health System, Level 8 Tower Block, 1 E Kent Ridge Road, Singapore, 119 228, Singapore

    Jun Liang Teh, Hui Yu Tham, Corrisa Chee, Guowei Kim, Asim Shabbir & Jimmy Bok Yan So

  2. Department of Surgery, JurongHealth Campus, National University Health System, Singapore, Singapore

    Jun Liang Teh

  3. Division of Gastroenterology and Hepatology, University Medicine Cluster, National University Health System, Singapore, Singapore

    Alex Yu Sen Soh

  4. Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Reuben Kong Min Wong

  5. gutCARE Digestive Liver Endoscopy Associates, Singapore, Singapore

    Reuben Kong Min Wong

  6. Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Jimmy Bok Yan So

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  1. Jun Liang Teh
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Correspondence to Jimmy Bok Yan So.

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Drs. JL Teh, HY Tham, A Soh, A Shabbir, GW Kim, R Wong and JBY So have no conflict of interest or financial ties to disclose.

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Teh, J.L., Tham, H.Y., Soh, A.Y.S. et al. Gastro-esophageal reflux disease (GERD) after peroral endoscopic myotomy (POEM). Surg Endosc 36, 3308–3316 (2022). https://doi.org/10.1007/s00464-021-08644-2

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  • DOI: https://doi.org/10.1007/s00464-021-08644-2

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