Introduction
Approximately 1/3 patients submitted to Per Oral Esophageal Myotomy (POEM) will develop Gastro-esophageal Reflux (GERD) Symptoms. Several technical characteristics of the procedure and recently Endoluminal functional luminal imaging probe (EndoFLIP) data have been correlated to it.
Aims & Methods
We aimed to evaluate the rate of short-term GERD development among patients submitted to EndoFLIP tailored or not POEM. We included consecutive patients submitted to POEM from 11/2015 to 2/2023. GERD development was assessed by the GERD health-related quality of life (GERD-HRQL) questionnaire and considered positive if ≥13. Patients were evaluated at 3-months post-POEM.
Results
We included 96 patients (M/F: 57/39 mean age: 48 min: 17 - max: 78). Achalasia type distribution was 1/2/3/unclassified: 24/68/1/3. Treatment naïve/experienced were 55/41 .In tailored procedure were submitted 38 while in non-tailored 58 patients. Mean pre-procedural Eckardt score was 7±2 while mean pre-procedural distensibility index (DI) was 2.2±1.6. Anterior approach was selected in 77 while posterior in 19 patients and did not differ between tailored (33/38, 86.8%) vs non-tailored POEM (44/58, 75.9%, p=0.295) while the mean length of myotomy was 10.6±3.4 cm but differed (9.3±2.9 11.4±3.4, p=0.02). GERD was diagnosed in 18/96 (18.7%) and did not differ when comparing tailored vs non-tailored procedure (8/38, 21.1% vs 10/58, 17.2%, p=0.790). The rate of GERD was numerically increased in previously treated vs naïve patients (11/41, 26.8% vs 7/55, 12.7%, p=0.113). When isolating patients with non-tailored POEM, GERD rates did not differ among treated vs untreated (5/31, 16.1% in naïve vs 5/27, 18.5%, p=1.000). While in patients with tailored procedure the rate was significantly increased among previously treated vs naïve patients (6/14, 42.9% vs 2/24 8.3 %, p=0.034). Tailored procedure vs non-tailored procedure led to decreased numerically rates of GERD development in naïve patients (8.3% vs 16.1%, p=0.443) and increased numerically rates among previously treated (non-tailored 18.5% vs tailored 42.9%, p=0.140). In the total cohort GERD development was not correlated to the approach (anterior: 14/77, 18.2% vs posterior: 4/19, 21.1%, p=0.750) or the length of myotomy (10.4 ±3.7 vs 10.7 ± 3.4 cm, p=0.768). In patients with tailored procedure only Baseline DI was correlated to GERD development post POEM even if numerical differences were noted as far as post procedural DI and ΔDI were considered (Table 1). ) In the multivariate analysis only previous treatment was correlated to short term GERD development (p=0.004, OR: 7.412 95% CI: 1.890-29.064).
Table 1
| | GERD development by GERD-HRQL at 3 months | GERD absence by GERD-HRQL at 3 months | p |
| IRP baseline (mmHg) | 25.4±15.8 | 23.3±8.3 | 0.509 |
| DI pre-procedural | 2.9±1.7 | 2.0±1.5 | 0.038 |
| Eckardt baseline | 6±2 | 7±2 | 0.245 |
| Length of myotomy (cm) | 8.3±2.2 | 9.5±3.1 | 0.133 |
| DI post-procedural | 5.3±2.7 | 4.5±2.0 | 0.241 |
| ΔDI | 2.8±1.8 | 2.4±1.4 | 0.390 |
All values expressed as mean ± SD.
Conclusion
Short term GERD symptom development after POEM by selective circular myotomy occurs in 1 out of 5 patients. These rates did not differ among tailored vs non tailored procedure though they were significantly reduced among treatment naïve patients who underwent tailored POEM. Even if DI especially in the pre-procedural setting may predict short term post POEM GERD development in patients submitted to tailored POEM, only experience to previous treatments was independently correlated to development of GERD at 3 months post-POEM as diagnosed by the use of GERD-HRQL.