Abstract
BackgroundPeroral endoscopic myotomy (POEM) is an emerging, minimally invasive procedure capable of overcoming limitations of achalasia treatments, but gastroesophageal reflux disease (GERD) after POEM is of concern and its risk factors have not been evaluated. This prospective study examined GERD and the association of POEM with reflux esophagitis.MethodsAchalasia patients were recruited from a single center. The pre- and postoperative assessments included Eckardt scores, manometry, endoscopy, and pH monitoring.ResultsBetween September 2011 and November 2014, 105 patients underwent POEM; 70 patients were followed up 3 months after POEM. Postoperatively, significant reductions were observed in lower esophageal sphincter (LES) pressure [from 40.0 ± 22.8 to 20.7 ± 14.0 mmHg (P < 0.05)], LES residual pressure [from 22.1 ± 13.3 to 11.4 ± 6.6 mmHg (P < 0.05)], and Eckardt scores [from 5.7 ± 2.5 to 0.7 ± 0.8 (P < 0.05)]. Symptomatic GERD and moderate reflux esophagitis developed in 5 and 11 patients (grade B, n = 8; grade C, n = 3), respectively, and were well controlled with proton pump inhibitors. Univariate logistic regression analysis revealed integrated relaxation pressure was a predictor of ≥grade B reflux esophagitis. No POEM factors were found to be associated with reflux esophagitis.ConclusionPOEM is effective and safe in treating achalasia, with no occurrence of clinically significant refractory GERD. Myotomy during POEM, especially of the gastric side, was not associated with ≥grade B (requiring medical intervention) reflux esophagitis. Extended gastric myotomy (2–3 cm) during POEM is recommended to improve outcomes.
Highlights
Background Peroral endoscopic myotomy (POEM) is an emerging, minimally invasive procedure capable of overcoming limitations of achalasia treatments, but gastroesophageal reflux disease (GERD) after POEM is of concern and its risk factors have not been evaluated
The use of the POEM procedure was approved by the Institutional Review Board (IRB) of Fukuoka University Hospital, and written informed consent was obtained from all patients prior to enrollment in the study
A questionnaire assessment, endoscopy of the upper GI tract, and 24-h pH monitoring were done for 70 cases at 3 months or later after the POEM (Table 1)
Summary
The data for our single-center POEM procedures were collected prospectively. The use of the POEM procedure was approved by the Institutional Review Board (IRB) of Fukuoka University Hospital, and written informed consent was obtained from all patients prior to enrollment in the study. Three months after POEM, manometry and endoscopy were performed to evaluate the effectiveness of POEM and determine the presence and extent of postsurgical reflux esophagitis. Patients were hospitalized 1 day before the POEM procedure so that esophagogastroduodenoscopy (EGD) could be performed to ensure all food remnants were removed from the esophagus prior to surgery. A proximal-to-distal circular myotomy was performed with care to preserve the longitudinal muscle layers of the esophagus and stomach. On the first day after surgery, an endoscopy was performed to confirm mucosal integrity, as was barium swallow to confirm the smooth passage of contrast media into the stomach without leakage or stasis. A PPI was prescribed for patients diagnosed with symptomatic GERD or reflux esophagitis ([grade B, LA classification); these patients were re-evaluated another 3 months later by elicitation of symptoms during examination and an upper GI endoscopy. All statistical analyses were performed using the SPSS v 21.0 software program for Windows (SPSS, Chicago, Illinois, USA)
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