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

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.

[Alternative Surgical Anti-Reflux Procedures]

Patient satisfaction when treated with acid-suppressing medication for chronic GERD disease is less than 70%. Surgical standardisation, centralisation, improved awareness of patient selection and new surgical methods have stimulated interest in surgical reflux therapy in recent years. Magnetic sphincter augmentation (MSA) seems to be a safe alternative to laparoscopic fundoplication, with reported complication rates of 0.1% and reoperation rates of 3.4% and is also effective (GERD-HRQL improvement from 19.9 to 4.1, p = 0.001 as well PPI cessation and pH normalisation in 79 and 89% of patients, respectively). Electric sphincter augmentation shows promising short-term results in small patient cohorts (92% symptomatic improvement). However, randomised controlled studies comparing these new techniques to the "gold standard" of laparoscopic fundoplication are still missing.

Electrical stimulation therapy of the lower esophageal sphincter in GERD patients—a prospective single-center study

Background

Electrical stimulation therapy (EST) of the lower esophageal sphincter (LES) for gastro esophageal reflux disease (GERD) treatment increases LES pressure through chronic stimulation, with a low risk for gastrointestinal side effects and preservation of hiatal anatomy. The aim of this study was to evaluate the efficacy and safety of this novel technique in a high-output specialized reflux center.

Methods

This is a prospective single-center study including GERD patients indicated for anti-reflux therapy who consented to undergo LES-EST. Patients underwent prospective scheduled follow-up visits including interrogation of the stimulation device, clinical examination, and assessment of health-related quality of life (HRQL).

Results

Within a 4-year period, 37 LES-EST implantations were performed. The majority of patients were male (54.1%), mean BMI was 25.8 (SD 4.4), and mean age was 54.0 (SD 15.8). The median GERD HRQL composite score was 41 (IQR 21–49). Median total % of pH <4 was 10.1 (IQR 4.4–17.3). Six (16.2%) individuals underwent explantation of the entire system (IPG and leads) due to technical defect (n = 4) or failure of therapy (n = 2). HRQL score improved from 41 (IQR 21–49) to 8.50 (IQR 4.25–20.5, p < 0.001) and 9 (23.7%) patients were on at least occasional PPI treatment.

Conclusion

Due to the low rate of GI side effects and its minimal invasive character preserving the hiatal anatomy, this novel technique might find its place in anti-reflux surgery. However, the considerably high rate of device dysfunction needs further investigation.

Endoscopic and Surgical Treatments for Achalasia: Who to Treat and How?

Achalasia is a progressive neurodegenerative disorder characterized by failure of relaxation of the lower esophageal sphincter (LES) and altered motility of the esophagus. The traditional, highly effective, surgical approach to relieve obstruction at the LES includes cardiomyotomy. Fundoplication is added to decrease risk of postoperative reflux. Per oral endoscopic myotomy is a new endoscopic procedure that allows division of the LES via transoral route. It has several advantages including less invasiveness, cosmesis, and tailored approach to the length on the myotomy. However, it is associated with increased rate of post-procedural reflux. Various endoscopic interventions are used to address this problem.

Novel Therapies for Gastroesophageal Reflux Disease: Beyond Proton Pump Inhibitors

PURPOSE OF REVIEW

Despite the many areas of unmet needs in gastroesophageal reflux disease (GERD), proton pump inhibitors (PPIs) remain the cornerstone of medical therapy. However, since their introduction, the therapeutic limitations of PPIs in GERD management have been increasingly recognized.

RECENT FINDINGS

In this review we discuss the new medical, endoscopic, and surgical therapeutic modalities that have been developed over the last decade. They include the potassium-competitive acid blockers (P-CABs) which provide a rapid onset, prolonged, and profound acid suppression, mucosal protectants which promote the physiological protective barrier of the esophageal mucosa, new prokinetics and neuromodulators. There are growing numbers of novel therapeutic endoscopic techniques that are under investigation or were recently introduced into the market, further expanding our therapeutic armamentarium for GERD. The development of diverse therapeutic modalities for GERD, despite the availability of PPIs, suggests that there are many areas of unmet need in GERD that will continue and drive future exploration for novel therapies.