Peroral endoscopic myotomy with fundoplication: are we there yet!

Peroral endoscopic myotomy (POEM) has revolutionized the endoscopic management of achalasia cardia. After almost a decade of “poetry,” there is ample evidence to suggest that POEM is a safe and effective treatment modality for esophageal achalasia. Major adverse events are rare, and the procedure can be safely accomplished in an endoscopy suit.

The management of achalasia involves disruption of lower esophageal sphincter muscle fibers, and therefore gastroesophageal reflux (GER) is not infrequent. Heller myotomy is usually accompanied by a partial fundoplication, which significantly reduces the incidence of pathological GER [1]. However, there is no antireflux procedure performed with POEM. As a result, symptoms as well as objective evidence of GER are significantly higher after POEM compared with after laparoscopic Heller myotomy, as highlighted by two recent systematic reviews and meta-analysis [2] [3]. A recent editorial entitled “Will reflux kill POEM?” raised substantial concerns on the issue of GER after POEM [4]. In the current era, although the efficacy of POEM is established, the high incidence of GER is certainly worrisome. GER can have potentially serious consequences, such as Barrett’s esophagus and esophageal adenocarcinoma.

In this issue of Endoscopy, Inoue et al. describe a novel technique in which the principles of natural orifice transluminal endoscopic surgery (NOTES) are exploited to create an endoscopic fundoplication during the POEM procedure [5]. After completing the endoscopic myotomy, the peritoneal cavity was entered with the endoscope. An appropriate site was chosen along the anterior wall of the stomach for placement of distal anchoring clips. Another gastroscope in the stomach served as a guide for the optimal site of distal anchors along the anterior gastric wall. Several clips were placed over the loop along the anterior wall of the stomach (distal anchor) and the distal edge of the myotomy site (proximal anchor). Subsequently, closure of the loop resulted in the formation of a fundoplication wrap. The wrap fashioned in such a way mimicked the one created by surgeons (i. e. Dor fundoplication). The procedure added a median of 44 minutes to POEM and there were no major adverse events.

“The concept of adding NOTES fundoplication to the POEM procedure is appealing and may prove to be valuable for the primary prophylaxis of gastroesophageal reflux in these patients.”

The authors of this study, who are also the pioneers of POEM, should be congratulated for their commendable work and insightful thinking. The technique offers a potential solution to the key problem of GER and is the prime need of the hour. Combining fundoplication with the POEM procedure can have several possible advantages, including completion of the entire procedure endoscopically during the primary POEM procedure and no requirement for any special equipment or accessories.

Although appealing, POEM-F may have several potential limitations. First, it will be prudent to perform POEM via an anterior approach in order to fashion an anterior fundoplication. However, in the recent past there has been an inclination of endoscopic surgeons to perform POEM via a posterior approach. This is due to the technical ease of performing POEM, as the accessories emerge from the endoscope at roughly the 6 o’clock position. Second, it may not be possible to perform POEM-F in patients who have previously undergone POEM via an anterior approach owing to the presence of submucosal fibrosis. Third, the durability of the fundoplication wrap created during POEM-F is uncertain. The protective effect of Dor fundoplication reduces with time, and GER can be detected in nearly half of the patients on long-term (> 20 years) follow-up after Heller – Dor surgery [6]. In the present study, the fundoplication wrap maintained its physical appearance on follow-up. However, the follow-up duration was not long enough to make conclusions regarding the durability of the wrap. Finally, an increase in the procedure duration and the requirement for additional endoclips and an endoloop are likely to escalate the overall cost of the POEM procedure. Therefore, a cost – benefit analysis will have to be conducted and taken into account as well. It is important to note that the present study intended to evaluate the feasibility of fundoplication along with POEM. In other words, it was a proof-of-concept pilot trial and needs further evaluation before transferring the technique from “bench to bedside.”

• References

• 1 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: 405-412
• 2 Repici A, Fuccio L, Maselli R. et al. GERD after per-oral endoscopic myotomy as compared with Heller’s myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc 2018; 87: 934-943
• 3 Kumbhari V, Familiari P, Bjerregaard NC. et al. Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case-control study. Endoscopy 2017; 49: 634-642
• 4 Rosch T, Repici A, Boeckxstaens G. Will reflux kill POEM?. Endoscopy 2017; 49: 625-628
• 5 Inoue H, Ueno A, Shimamura Y. et al. Peroral endoscopic myotomy and fundoplication: a novel NOTES procedure. Endoscopy 2019; 51: 161-164
• 6 Csendes A, Braghetto I, Burdiles P. et al. Very late results of esophagomyotomy for patients with achalasia: clinical, endoscopic, histologic, manometric, and acid reflux studies in 67 patients for a mean follow-up of 190 months. Ann Surg 2006; 243: 196-203
• 7 Tyberg A, Choi A, Gaidhane M. et al. Transoral incisional fundoplication for reflux after peroral endoscopic myotomy: a crucial addition to our arsenal. Endosc Int Open 2018; 6: E549-E552