Gastroesophageal Reflux Disease After Peroral Endoscopic Myotomy: Analysis of Clinical Impact and Risk Factors in a Large Series of Patients

Aims Peroral endoscopic myotomy (POEM) is a fascinating procedure for the treatment of patients with esophageal motility disorders, but it is known to be associated with an high risk of post-operative gastroesophageal reflux (GERD). Aims of this study are to evaluate the incidence of iatrogenic GERD and to identify possible associations with preoperative, perioperative and postoperative factors.

Methods All the patients who underwent POEM at a single tertiary referral center since May 2011 until June 2019 and had a complete GERD evaluation, including esophagogastroduodenoscopy, high-resolution manometry and pH-monitoring study after the procedure, were included in the study. Esophagitis was classified according to Los Angeles’. Clinically-relevant GERD was defined by the association of a positive pH-test with heartburn and/or esophagitis. Demographics (gender, age), perioperative (duration of symptoms before treatment, Eckardt score, previous treatments, depth, orientation and length of myotomy), postoperative (4sIRP, esophagitis, deMeester- and Eckardt-score) were collected and analyzed.

Results Seven-hundred patients underwent POEM during the study period and 515 (73,6 %, mean age 48.9 years, 49.1 % males) were included. Altered esophageal acid exposure was confirmed in 198 (38.4 %). One-hundred patients (19.4 %) had heartburn and 184 esophagitis (35.7 %). Interestingly, esophagitis was detected in 56 % of patients with an altered pH-study and 23 % with a normal one. Clinically-relevant GERD was diagnosed in 135 (26.2 %). A trend was observed when examining the relationship between GERD symptoms and severe esophagitis. Previous endoscopic treatments of achalasia were significantly associated with clinically relevant GERD, severe esophagitis or altered esophageal acid exposure (p<0.05). A selective-circular myotomy was associated with a lower incidence of clinically-relevant GERD, altered esophageal acid exposure and esophagitis (p<0.05).

Tab. 1

	Clinically-relevant GERD 135 patients	No clinically-relevant GERD 380 patients	p value
Selective circular myotomy	25.9 % [35]	36.3 % [138]	0.037
Previous endoscopic treatment (Botox – Dilation)	17.8 % [24]	9.7 % [37]	0.0154
Basal LES pressure, mmHg	17 ± 9.8	19.5 ± 10	0.017
4sIRP, mmHg	7.5 ± 4.5	8.7 ± 4.8	0.013

Conclusions Previous achalasia endoscopic therapies and depth-of-myotomy are associated with a high risk of severe GERD. Nevertheless, clinically-relevant GERD was diagnosed in less than one-third of patients, and symptoms were always well-controlled with medical therapy.

Citation: Mangiola F, Familiari P, Landi R et al. OP195 GASTROESOPHAGEAL REFLUX DISEASE AFTER PERORAL ENDOSCOPIC MYOTOMY: ANALYSIS OF CLINICAL IMPACT AND RISK FACTORS IN A LARGE SERIES OF PATIENTS. Endoscopy 2021; 53: S80.

Publication History

Article published online:
19 March 2021