Gastroesophageal Reflux after Peroral Endoscopic Myotomy: Myth or Reality?

Peroral Endoscopic Myotomy: Short Versus Long Esophageal Myotomy for Achalasia Cardia: A Randomized Controlled Noninferiority Trial

BACKGROUND AND AIMS

The appropriate length of esophageal myotomy in peroral endoscopic myotomy (POEM) for achalasia cardia remains unclear. This study aimed to compare the outcome of short (≤3 cm) and long (≥6 cm) esophageal myotomy in patients with type I and II achalasia cardia.

METHODS

This single-blinded, randomized controlled noninferiority trial was conducted at a tertiary center between July 2021 and December 2021. Patients with achalasia types I and II were randomized into short (≤3 cm) and long (≥6 cm) esophageal myotomy groups. The primary outcome of the study was clinical success (Eckardt score ≤3) 1 year after the procedure. The secondary outcomes included a comparison of technical success, operating duration, occurrence of intraoperative adverse events, alterations in integrated relaxation pressure (IRP), change in barium column height after 5 minutes (1 mo), and gastroesophageal reflux disease (3 mo) between the groups.

RESULTS

Fifty-four patients were randomized into the short (n=27) or long (n=27) esophageal myotomy groups. Technical success rates were 100% (27/27) and 96.3% (26/27) in short myotomy (SM) and long myotomy (LM) groups, respectively. The clinical success rates were 96.3% (26/27) and 96.2% (25/26) in the SM and LM groups, respectively ( P =0.998). The mean (±SD) length of the esophageal myotomy was 2.75±0.36 cm in the SM and 6.69±1.35 cm in the LM groups ( P <0.001). The mean (±SD) procedure time for the SM and LM groups was 61.22±8.44 and 82.42±14.70 minutes ( P <0.001), respectively. The mean integrated relaxation pressure (IRP), Eckardt score, adverse events, reflux esophagitis, symptomatic gastroesophageal reflux disease, and esophageal acid exposure (>6%) did not differ significantly between the 2 groups following POEM treatment.

CONCLUSIONS

Short myotomy is noninferior to long myotomy in terms of clinical success, gastroesophageal reflux disease, and intraoperative adverse events at the short-term follow-up ( P >0.05). Short myotomy resulted in a reduced operative time ( P <0.05).

Gastroesophageal reflux after per oral endoscopic myotomy for achalasia: Results of a monocentric cohort

BACKGROUND AND STUDY AIMS

Peroral endoscopic myotomy (POEM) has become the first line treatment for achalasia, but controversies remain about the prevalence of gastro-esophageal reflux disease (GERD) after the procedure. The aim of this study was to evaluate post-POEM GERD by a retrospective analysis of a single center cohort.

PATIENTS AND METHODS

Achalasia patients aged 18 or above, who underwent POEM between 2012 and 2021, were included, provided they had an endoscopic control of reflux at least one year after POEM. GERD symptoms based on GerdQ questionnaire, and proton pomp inhibitors (PPI) consumption were also evaluated.

RESULTS

Among a consecutive cohort of 422 patients treated by POEM, 254 patients were included. Endoscopic results were available after a mean follow-up of 1.9 ± 1.5 years. 71/254 patients (28 %) had erosive esophagitis (86 % Los Angeles Grade A or B). At the last follow-up (mean 4.5 ± 2.2 years), clinical success of POEM (Eckardt score ≤ 3) was achieved in 79.5 % of patients. 44.5 % of patients were on PPI. Mean GerdQ score was 2.2 ± 2.7, with only 13 patients (6.5 %) with a score ≥ 8.

CONCLUSION

In this cohort of achalasia patients with an endoscopic follow-up at least 1 year after POEM, GERD did not appear a major threat concern: clinical symptoms were mild in most cases, as was the degree of erosive esophagitis. Furthermore, at the time of last follow up, less than half of patients required treatment with PPI.

Prevention, detection and management of adverse events of third-space endoscopy

Third space endoscopy (TSE) or sub-mucosal endoscopy using a mucosal flap valve (SEMF) enables the endoscopist to operate in the deeper layers of the gastrointestinal tract or gain access to the mediastinal/peritoneal cavity for natural orifice transoral endoscopic surgery (NOTES). TSE procedures are essentially endoscopic surgical procedures with a variable learning curve. Adverse events (AEs) during TSE are specific and follow a certain pattern across the spectrum of TSE procedures. These can be broadly categorized according to either type of AE, time of presentation relative to the procedure or according to degree of severity. Three major categories of AEs encountered during TSE include insufflation related AEs, mucosal injuries (MIs) and bleeding. Other relevant AEs include infectious complications, aspiration pneumonia, post-procedural chest/abdominal pain, atelectasis, cardiac arrhythmias, pleural effusion and pulmonary embolism. Reported incidence of AEs during TSE procedures varies according to the type and complexity of procedure. Acquaintance regarding potential risk factors, technical tips and precautions, alarm signs for early recognition, assessment of degree of severity, morphological characterization of AEs and finally, expeditious selection of appropriate management strategy are crucial and imperative for successful clinical outcomes. The current review discusses the current evidence and practical guidelines for prevention, early detection and management of TSE-related AEs.