Gastroesophageal reflux following per-oral endoscopic myotomy: Can we improve outcomes?

Abstract

This editorial is an analysis the review article by Nabi et al recently published in this journal. Achalasia Cardia is a disease whose pathophysiology is still unclear. It is known that there is inflammation of unknown aetiology leading to loss of ganglion cells in the muscularis propria. The end result is lower oesophageal sphincter spasm, loss of receptive relaxation, decreased oesophageal peristalsis, all leading on to varying degrees of dysphagia. The treatment of this condition is palliative in nature, performed by myotomy of the lower oesophagus either surgically or endoscopically. Gastroesophageal reflux disease (GERD) has been associated with the myotomy performed, particularly with the Peroral Endoscopic Myotomy (POEM) procedure. Nabi et al have provided an excellent overview of the latest developments in predicting, preventing, evaluating, and managing GERD subsequent to POEM. Based on this theme, this review article explores the concept of using histology of the oesophageal muscle layer, to grade the disease and thereby help tailoring the length/type of myotomy performed during the POEM procedure. In the future, will a histology based algorithm available preoperatively, help modify the POEM procedure, thereby decreasing the incidence of GERD associated with POEM?

Keywords: Achalasia cardia; Histologic grading; Histopathology; Laparoscopic Heller’s myotomy; Peroral endoscopic myotomy.

Figure 1

Mild fibrosis, in a patient with achalasia cardia. A: Mild fibrosis, in a patient with early stage of achalasia cardia (AC); B: Severe fibrosis and muscle atrophy, in a patient with late stage of AC.

Figure 2

Immunohistochemistry. A: Lymphocytes seen by CD3 immunohistochemistry; B: Mast cells seen on immunohistochemistry (CD117).

Figure 3

Degenerated pre and post ganglionic nerve cells on electron microscopy.