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Review
. 2024 Mar 7;30(9):1096-1107.
doi: 10.3748/wjg.v30.i9.1096.

Prediction, prevention and management of gastroesophageal reflux after per-oral endoscopic myotomy: An update

Zaheer Nabi  1 , Pradev Inavolu  2 , Nageshwar Reddy Duvvuru  3
Affiliations
Review

Prediction, prevention and management of gastroesophageal reflux after per-oral endoscopic myotomy: An update

Zaheer Nabi et al. World J Gastroenterol. .

Abstract

Achalasia cardia, the most prevalent primary esophageal motility disorder, is predominantly characterized by symptoms of dysphagia and regurgitation. The principal therapeutic approaches for achalasia encompass pneumatic dilatation (PD), Heller's myotomy, and the more recent per-oral endoscopic myotomy (POEM). POEM has been substantiated as a safe and efficacious modality for the management of achalasia. Although POEM demonstrates superior efficacy compared to PD and an efficacy parallel to Heller's myotomy, the incidence of gastroesophageal reflux disease (GERD) following POEM is notably higher than with the aforementioned techniques. While symptomatic reflux post-POEM is relatively infrequent, the significant occurrence of erosive esophagitis and heightened esophageal acid exposure necessitates vigilant monitoring to preclude long-term GERD-related complications. Contemporary advancements in the field have enhanced our comprehension of the risk factors, diagnostic methodologies, preventative strategies, and therapeutic management of GERD subsequent to POEM. This review focuses on the limitations inherent in the 24-h pH study for evaluating post-POEM reflux, potential modifications in the POEM technique to mitigate GERD risk, and the strategies for managing reflux following POEM.

Keywords: Achalasia cardia; Esophagitis; Gastroesophageal reflux; Gastroesophageal reflux disease; Per-oral endoscopic myotomy.

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Conflict of interest statement

Conflict-of-interest statement: Authors declare no conflict of interests for this article.

Figures

Figure 1
Figure 1
Approach to evaluation and management of gastroesophageal reflux after per-oral endoscopic myotomy. POEM: Per-oral endoscopic myotomy; LA: Los Angeles.
Figure 2
Figure 2
Conventional and sling fiber preservation technique of per-oral endoscopic myotomy. A: Endoscopic image revealing second penetrating vessel along gastric side. Note that the sling fibers are located towards the left of penetrating vessel; B: Conventional myotomy performed along left side of the penetrating vessel to include sling fibers; C: Completion of conventional myotomy; D: Myotomy along the right side of the penetrating vessel to preserve sling fibers; E: Completion of myotomy (Note the preservation of sling fibers towards the left of second penetrating vessel).
Figure 3
Figure 3
Natural orifice transluminal endoscopic surgery fundoplication. A: Dissection of sub-serosal fibrofatty tissue to reach the peritoneal membrane; B: Creation of opening in the peritoneal membrane; C: Application of loop and endoclips along the serosal aspect of anterior wall of stomach; D: Application of second series of clips along the distal end of myotomy; E: Tightening of the endoloop; F: Endoscopic confirmation of the fundoplication wrap.
Figure 4
Figure 4
Impact of technique of myotomy on gastroesophageal reflux after per-oral endoscopic myotomy. GERD: Gastroesophageal reflux disease; NOTES: Natural orifice transluminal endoscopic surgery fundoplication.
Figure 5
Figure 5
Summary of the current understanding regarding the prediction, prevention, evaluation, and management of gastroesophageal reflux after per-oral endoscopic myotomy. GERD: Gastroesophageal reflux disease; NOTES: Natural orifice transluminal endoscopic surgery fundoplication; POEM: Per-oral endoscopic myotomy; LES: Lower esophageal sphincter.
See this image and copyright information in PMC

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