Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case–control study

Abstract

Background and study aims The variables associated with gastroesophageal reflux (GER) after peroral endoscopic myotomy (POEM) are largely unknown. This study aimed to: 1) identify the prevalence of reflux esophagitis and asymptomatic GER in patients who underwent POEM, and 2) evaluate patient and intraprocedural variables associated with post-POEM GER.

Patients and methods All patients who underwent POEM and subsequent objective testing for GER (pH study with or without upper gastrointestinal [GI] endoscopy) at seven tertiary academic centers (one Asian, two US, four European) were included. Patients were divided into two groups: 1) DeMeester score ≥ 14.72 (cases) and 2) DeMeester score of < 14.72 (controls). Asymptomatic GER was defined as a patient with a DeMeester score ≥ 14.72 who was not consuming proton pump inhibitor (PPI).

Results A total of 282 patients (female 48.2 %, Caucasian 84.8 %; mean body mass index 24.1 kg/m²) were included. Clinical success was achieved in 94.3 % of patients. GER evaluation was completed after a median follow-up of 12 months (interquartile range 10 – 24 months). A DeMeester score of ≥ 14.72 was seen in 57.8 % of patients. Multivariable analysis revealed female sex to be the only independent association (odds ratio 1.69, 95 % confidence interval 1.04 – 2.74) with post-POEM GER. No intraprocedural variables were associated with GER. Upper GI endoscopy was available in 233 patients, 54 (23.2 %) of whom were noted to have reflux esophagitis (majority Los Angeles Grade A or B). GER was asymptomatic in 60.1 %.

Conclusion Post-POEM GER was seen in the majority of patients. No intraprocedural variables were identified to allow for potential alteration in procedural technique.

^* Co-first authors

• References

• 1 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
• 2 NOSCAR POEM White Paper Committee, Stavropoulos SN, Desilets DJ et al. Per-oral endoscopic myotomy white paper summary. Gastrointest Endosc 2014; 80: 1-15
• 3 Talukdar R, Inoue H, Nageshwar Reddy D. Efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia: a systematic review and meta-analysis. Surg Endosc 2015; 29: 3030-3046
• 4 Von Renteln D, Fuchs KH, Fockens P. et al. Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology 2013; 145: 309-311 .e1-3
• 5 Werner YB, Costamagna G, Swanstrom LL. et al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut 2016; 65: 899-906
• 6 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
• 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
• 8 Shiwaku H, Inoue H, Sasaki T. et al. A prospective analysis of GERD after POEM on anterior myotomy. Surg Endosc 2016; 30: 2496-2504
• 9 Khashab MA, El Zein M, Kumbhari V. et al. Comprehensive analysis of efficacy and safety of peroral endoscopic myotomy performed by a gastroenterologist in the endoscopy unit: a single-center experience. Gastrointest Endosc 2016; 83: 117-125
• 10 Campos GM, Vittinghoff E, Rabl C. et al. Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg 2009; 249: 45-57
• 11 Richards WO, Torquati A, Holzman MD. et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg 2004; 240: 405-415
• 12 Torquati A, Lutfi R, Khaitan L. et al. Heller myotomy vs Heller myotomy plus Dor fundoplication: cost-utility analysis of a randomized trial. Surg Endosc 2006; 20: 389-393
• 13 Inoue H, Tianle KM, Ikeda H. et al. Peroral endoscopic myotomy for esophageal achalasia: technique, indication, and outcomes. Thorac Surg Clin 2011; 21: 519-525
• 14 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
• 15 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
• 16 Kumta NA, Kedia P, Sethi A. et al. Transoral incisionless fundoplication for treatment of refractory GERD after peroral endoscopic myotomy. Gastrointest Endosc 2015; 81: 224-225
• 17 Bhayani NH, Kurian AA, Dunst CM. et al. A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia. Ann Surg 2014; 259: 1098-1103
• 18 Marano L, Pallabazzer G, Solito B. et al. Surgery or peroral esophageal myotomy for achalasia: a systematic review and meta-analysis. Medicine (Baltimore) 2016; 95: e3001
• 19 Wei M, Yang T, Yang X. et al. Peroral esophageal myotomy versus laparoscopic Heller’s myotomy for achalasia: a meta-analysis. J Laparoendosc Adv Surg Tech A 2015; 25: 123-129
• 20 Ujiki MB, Yetasook AK, Zapf M. et al. Peroral endoscopic myotomy: a short-term comparison with the standard laparoscopic approach. Surgery 2013; 154: 893-900
• 21 Teitelbaum EN, Rajeswaran S, Zhang R. et al. Peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy produce a similar short-term anatomic and functional effect. Surgery 2013; 154: 885-892
• 22 Bechara R, Ikeda H, Onimaru M. et al. Peroral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations. Gastrointest Endosc 2016; 84: 330-338
• 23 Yang D, Pannu D, Zhang Q. et al. Evaluation of anesthesia management, feasibility and efficacy of peroral endoscopic myotomy (POEM) for achalasia performed in the endoscopy unit. Endosc Int Open 2015; 3: E289-E295
• 24 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
• 25 Zerbib F. The prevalence of oesophagitis in “silent” gastro-oesophageal reflux disease: higher than expected?. Dig Liver Dis 2015; 47: 12-13
• 26 Gerson LB, Shetler K, Triadafilopoulos G. Prevalence of Barrett’s esophagus in asymptomatic individuals. Gastroenterology 2002; 123: 461-467
• 27 Lagergren J, Bergstrom R, Lindgren A. et al. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. N Engl J Med 1999; 340: 825-831
• 28 Choi JY, Jung HK, Song EM. et al. Determinants of symptoms in gastroesophageal reflux disease: nonerosive reflux disease, symptomatic, and silent erosive reflux disease. Eur J Gastroenterol Hepatol 2013; 25: 764-771
• 29 Cook MB, Corley DA, Murray LJ. et al. Gastroesophageal reflux in relation to adenocarcinomas of the esophagus: a pooled analysis from the Barrett’s and Esophageal Adenocarcinoma Consortium (BEACON). PLoS One 2014; 9: e103508
• 30 Rutegard M, Nordenstedt H, Lu Y. et al. Sex-specific exposure prevalence of established risk factors for oesophageal adenocarcinoma. Br J Cancer 2010; 103: 735-740
• 31 Lofdahl HE, Lu Y, Lagergren J. Sex-specific risk factor profile in oesophageal adenocarcinoma. Br J Cancer 2008; 99: 1506-1510
• 32 Salvador R, Caruso V, Costantini M. et al. Shorter myotomy on the gastric site ((2.5 cm) provides adequate relief of dysphagia in achalasia patients. Dis Esophagus 2015; 28: 412-417
• 33 Oelschlager BK, Chang L, Pellegrini CA. Improved outcome after extended gastric myotomy for achalasia. Arch Surg 2003; 138: 490-497