Introduction

Peroral endoscopic myotomy (POEM) is standard treatment for achalasia. Gastroesophageal reflux disease (GERD) after POEM has been a limiting factor with this procedure. Preservation of the sling fiber during POEM was reported to reduce post-POEM GERD in Japan [1], but there are no reports of this technique in a western population.

Aims & Methods

The aim is to investigate the association of sling-fiber preservation during POEM and post-POEM GERD symptoms at our institution, which is a large therapeutic endoscopy referral center in Canada. This is a retrospective, single-center study of patients who underwent POEM from October 2017 to January 2023 at our center. The initial cohort of patients were treated by conventional POEM until June 2021, after which a second cohort underwent POEM with sling-fiber preservation, as the techniques advanced. The primary outcome was the rate of positive GERD symptoms after POEM. The secondary outcomes were procedure time, gastric myotomy length, clinical success rate (Eckard score ≦3), adverse events rate (Clavien-Dindo classification ≧Grade II) and use of PPI at follow-up.

Results

148 POEM cases (52.5±15.6 y/o, female:61(43%)) were included in this study. There was no significant difference in patient characteristics between the groups. The mean procedure time (108.6±34.5 vs 109.1±45.7 min, P=0.93) and rate of adverse events (21% vs 14%, P=0.36) were similar between the traditional and modified groups. In the sling fiber preservation group, gastric myotomy length was significantly longer (2.2±0.7 vs 1.6±0.8 cm, P<0.05) yet the GERD symptom rate at follow-up was significantly lower (22% vs 41%, P<0.05), although PPI use was similar (57% vs 50%, P=0.47). Finally, the clinical success rate was similar between groups (88% vs 84%, P=0.6).

Conclusion

Sling fiber preservation during POEM is safe and reduces post-POEM GERD symptoms, despite the longer gastric myotomy length. As such, sling fiber preservation may be a useful solution to reduce post-POEM GERD in western populations.

References

1. Shiwaku H, Inoue H, Shiwaku A et al. Safety and effectiveness of sling fiber preservation POEM to reduce severe post-procedural erosive esophagitis. Surg Endosc. 2022 Jun;36(6):4255-4264.

Introduction

Peroral endoscopic myotomy (POEM) is considered a standard method for achalasia treatment with excellent long term treatment success. However, the benefits of POEM are tempered by the risk of post-POEM reflux complications.

Aims & Methods

The aim of this retrospective analysis of prospectively collected data was to assess the long-term post-POEM reflux. Data from all consecutive patients who underwent POEM between December 2012 and April 2023 were analyzed. The patients assessed symptoms at 3 and 12 months after the procedure and every year thereafter. The patients underwent upper GI endoscopy, high-resolution manometry (HRM) and 24-hour pH monitoring 3 months after the procedure; endoscopy was then repeated at 2-3 years and at 6 year follow-up. Reflux esophagitis, reflux parameters measured by 24h pH monitoring (off PPIs), reflux symptoms and the use of proton pump inhibitors (PPIs) were the principal outcomes.

Results

A total of 539 POEM procedures (20x re-POEM) were performed in 519 patients. Three months after the procedure, 390 patients underwent 24h pH monitoring with abnormal acid exposure in 178 of them (45.6% [95% CI: 40.7, 50.6]). Reflux esophagitis was present in 181/463 patients (39.1% [95% CI: 34.7, 43.6]; LA C/D in 20 patients, 4.3%) at 3 months, in 94/263 patients (35.7% [95% CI: 30.2, 41.7]; LA C/D in 5 patients, 1.9%) at 24-36 months and in 18/88 patients (20.5% [95% CI: 13.3, 30]; LA C/D in 0 patients) 6 years after procedure. Follow- up questionnaires were completed in 185, 161 and 106 patients 48, 60, 72 months after the procedure and 34.6%, 35.7% and 34.4% of patients claimed occasional heartburn and 18.1%, 20.4% and 19.6% experienced occasional regurgitation of gastric content. However, only the minority (under 2% of the patients at 48, 60, 72 months) experienced the symptoms on daily basis. PPIs were administered to 53.3%, 48.4% and 54.3% of patients at 48, 60 and 72 months after POEM with majority of them (80%) taking PPIs on daily basis. We also investigated whether there were any differences in patients with and without PPIs. In patients with PPIs, there were less cases of reflux esophagitis 3 months after POEM (32.4% vs. 43.5%). More patients with PPIs experienced post-POEM heartburn (42.3% vs. 25.9%) at 48 months and at 60 months (48.7% vs. 25.4%). There were no significant differences in terms of pathological reflux on 24-hour pH monitoring and in the occurrence of severe esophagitis between patients with vs. without PPIs. Regarding severe reflux complications, there were no new cases of Barrett's esophagus and esophageal adenocarcinoma. One patient developed peptic stricture, which was successfully treated with balloon dilation. The outcomes were not different among patients who underwent anterior (60%) vs. posterior myotomy (40%).

Conclusion

The rate of post-POEM reflux esophagitis decreases over time, however approximately 50% of patients require long-term antisecretory treatment. Even if the risk of reflux complications is low, patients after POEM should remain under long-term surveillance.

Introduction

Peroral endoscopic myotomy has become the mainstay of treatment of achalasia. Oral feeding has been initiated if no submucosal leak of the contrast fluid was detected on the X-ray contrast study which was performed the following day after the procedure. However, as major adverse events are rare, and in case of their occurrence, are rarely asymptomatic, it has become unclear whether routine X-ray contrast study is necessary. In our center we have been performing POEM procedures since 2015 and initially routinely performed X-ray contrast study. However,during the course of time it has become unavailable and we were forced to initiate oral feeding diet based on our clinical decision. We adopted a protocol of the initiation of oral liquids on the 2 nd postoperative day (or later in case of suspected complication). We therefore compared these two strategies in terms of periprocedural and postprocedural complications rate and the length of the hospital stay.

Aims & Methods

This is a retrospective analysis of the single high-volume center. We evaluated (1) the rate of peri- and postprocedural complications and (2) length of the hospital stay in patients hospitalized for POEM for esophageal achalasia in 2015-2023. We separately evaluated the “X-ray subgroup” (oral feeding was initiated after X-ray that was performed the day after the procedure) and the “clinical decision subgroup” (oral feeding was initiated on the 2 nd postoperative day).

Results

We analyzed a total number of 274 POEM procedures (129 males, 145 females), mean age was 52,3±16 years. 102 patients (37.2%) received X-ray contrast study after the procedure, in 169 patients (62.8%) the initiation of oral feeding was based on clinical decision. The mean time of the hospital stay was 7.2±2.9 vs. 6.5±1.4 days in the X-ray group and in the clinical decision group, resp. (p<0.004).
In the X-ray group we detected complications in 8 patients (7.7%). 5 were periprocedural (mucosal perforation or aspiration during intubation), were solved during the procedure and did not lead to the extension of the hospital stay. There were postprocedural complications in 3 patients. In one case submucosal leak was detected on X-ray contrast study the following day after the procedure due to loosened clip in the mucosal entry and was solved by placing additional clips. In one case patient presented with bleeding from the mucosal entry after discharge. In one case the patient developed mediastinitis that led to the extension of the hospital stay. In the clinical decision group we detected complications in 10 patients (5.9 %), 9 of them were periprocedural (mucosal perforation or aspiration during intubation), 8 of which were solved during the procedure by endoscopic clipping and did not lead to the extension of the hospital stay, 1 required surgery. In one case of postprocedural complication perforation with pleural effusion was detected on CT scan and required
surgical intervention that led to the extension of the hospital stay.

Conclusion

Our analysis shows that severe complications after POEM are rare. In the X-ray subgroup there was only single postprocedural event in which X-ray was helpful in its early detection (1%). In the clinical decision subgroup there was also only single event that could have been identified on the X-ray (0.6%). The length of the hospital stay in the clinical judgement group was significantly shorter than in the X-ray group. This can be attributed to the improvement of overall experience with the management of the POEM patients as X-ray contrast has become unavailable after performing c.a. 100 POEM procedures.

References

Weusten, Bas L A M et al. “Endoscopic management of gastrointestinal motility disorders - part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.” Endoscopy vol. 52,6 (2020): 498-515. doi:10.1055/a-1160-5549

Introduction

Gastroesophageal reflux disease (GERD) patients with atypical symptoms represents a diagnostic and therapeutic challenge. In particular, the diagnosis of GERD is often suspected by ENT surgeons according to laryngoscopic findings, but their sensitivity and specificity for diagnosis is low. The aim of this study was to assess the prevalence of GERD in patients with atypical symptoms undergoing laryngoscopic examination and pH monitoring.

Aims & Methods

We retrospectively evaluated patients with atypical symptoms with or without typical symptoms associated referred to Gastroenterology Units of six tertiary Italian centres between January and December 2020. Of 477 patients, we enrolled 277 patients who underwent both 24 hours pH-impedance monitoring off-therapy and laryngoscopy. Diagnosis of GERD was made according to Lyon Consensus, and we considered the novel impedance metrics (baseline impedance and post reflux swallow-induced peristaltic wave index) when pH-impedance monitoring was inconclusive in order to add confidence to diagnosis of GERD. Three patients with hypersensitive esophagus were excluded.

Results

The most common atypical symptom was cough (90/274). Laryngoscopic examination showed pathological findings in 195 patients (71.2%), and the most frequent feature detected was posterior laryngitis (77.4%). GERD was diagnosed in 80/274 patients (29.2%) on pH impedance monitoring. Upper endoscopy was made in 269 patients and 5 of them had B grade esophagitis. The prevalence of GERD diagnosis in patients with or without positive laryngoscopy examination was not statistically significant (p=0.075). No difference in the number of proximal refluxes was observed in patients with positive or negative laryngoscopy (65/195, 33.3% vs 19/79, 24.1%; p= 0.133). Sensitivity and specificity of laryngoscopy in diagnosing GERD is 78.8% and 32.0% respectively (PPV= 32.3%; NVP= 28.4%).

Conclusion

Laryngoscopic examination has a poor specificity in diagnosing GERD in patients with atypical symptoms. This study may underline that pathological laryngoscopy findings could only pose a suspect of an underlying GERD, but its diagnosis would still need to be confirmed by impedance-pH monitoring, even in patients with atypical symptoms.

Introduction

The primary treatment goals of gastroesophageal reflux disease (GERD) include resolving symptoms, preventing complications and symptom relapses, and healing erosive oesophagitis.^{1, 2} Heartburn and regurgitation are frequent and typical symptoms of GERD. Vonoprazan, a potassium-competitive acid blocker, is approved in China for the treatment of reflux oesophagitis.^{3, 4} However, there is a paucity of real-world data assessing the relief of typical daily symptoms achieved with vonoprazan in adult Chinese patients.

Aims & Methods

VIEW (NCT04501627) was a multicentre, single-arm, prospective, observational, real-world study conducted in China. Patients received 20 mg vonoprazan, orally, once daily for 4 weeks (8 weeks for insufficient healing). This post hoc subgroup analysis conducted in enrolled patients with GERD assessed changes in symptom scores for all-day or night-time heartburn and/or regurgitation during the first 14 days of treatment. A mixed-effects model for repeated measures assessed statistical differences in symptom scores from baseline for each day; least-squares mean (LSM) and its 95% confidence interval are reported (negative values indicate improvement).

Results

Among the 2214 patients included in the effectiveness analysis population of the GERD group, 86.7% were aged <65 years[A.G.1] and 60.8% were male. The LSM change in symptom scores from baseline demonstrated a significant improvement from day 1 of treatment in all-day heartburn and/or regurgitation, daytime heartburn or regurgitation, and night‑time heartburn or regurgitation (Table). Significant improvement continued to be observed on day 14 and throughout all previous days of treatment.

Conclusion

Vonoprazan provided rapid (from day 1), significant and durable symptom relief in patients with GERD.

Table: Improvement in symptom scores^a from baseline to day 14 of vonoprazan treatment (effectiveness analysis population; MMRM analysis)

References

1. Antunes C, Aleem A and Curtis SA. StatPearls. Treasure Island (FL), 2023.
2. Heidelbaugh JJ, Nostrant TT, Kim C, et al. Am Fam Physician 2003; 68: 1311-1318.
3. Xiao Y, Lu Y, Yang H, et al. Am J Gastroenterol 2023; 118: S345-S345.
4. Oshima T and Miwa H. J Neurogastroenterol Motil 2018; 24: 334-344.

Disclosure

This study was funded by Takeda (China) International Trading Co. Ltd. Yinglian Xiao, Dekui Zhang and Jianyong Chen have no conflicts of interest. Kailun Liang and Li Xie are Takeda employees and hold Takeda stock options. Minhu Chen received speaker honoraria from Takeda China, AstraZeneca China, Xian Janssen and Eisai China.

Introduction

Gastroesophageal reflux disease (GERD) is common after per-oral endoscopic myotomy (POEM). Selective sparing of oblique fibers (OFS) during POEM may reduce the incidence of reflux esophagitis after POEM.

Aims & Methods

Aim: In this study, we aim to compare the incidence of GERD between conventional (CM) versus oblique fiber sparing (OFS) techniques of endoscopic myotomy in cases with idiopathic achalasia.
Methods: Eligible patients with type I and II achalasia who underwent POEM from Jan 2020 to October 2020 were randomized into two groups (CM and OFS). Exclusion criteria were: type III achalasia, sigmoid esophagus and history of Heller’s myotomy with fundoplication. The primary outcome of the study was comparison of reflux esophagitis in the two groups. The secondary aims included reflux symptoms, esophageal acid exposure, and clinical success.

Results

115 patients were randomized in CM (58) and OFS (57) groups. Both the groups were similar with regards to the symptom scores, sub-types of achalasia and history of previous treatment. The mean operation time was similar in both the groups (CM 43.7±23.8 mins versus OFS 46.4±24.7 mins). Mean length of total myotomies were comparable in the two groups (9.9±3.0cm vs 9.5 ±3.1cm). Clinical success (Eckardt≤3) was recorded in all the patients. Overall, reflux esophagitis was found in 56 (48.7%) patients. Grade B or higher esophagitis was similar in the two groups (25.9% vs 31.6%, p=0.541). The mean number of reflux episodes (48.2±36.6 vs 48.9±40.3, p=0.933), proportion of patients with increased esophageal acid exposure >6% (45.5% vs 31.7%, p=0.266) and high DeMeester scores (>14.7) (38.6% vs 41.5%, p=0.827) were similar in both the groups. Symptomatic GERD (GERDQ>7) and use of PPIs at 1-year was similar in the two groups (GERDQ>7: 29.8% vs 26.5%, 0.822)(PPIs: 34% vs 28.6%, p=0.661).

Conclusion

Sparing of sling fibers has no significant impact on the incidence of GERD after POEM. Novel strategies need to be explored to prevent GERD after POEM. (NCT04229342)

Disclosure

No disclosure

Introduction

The number of gastroesophageal reflux disease (GERD) patients that do not improve sufficiently by standard treatment is relatively high. Multichannel intraluminal impedance and pH monitoring (MII-pH) is the gold standard for diagnosing GERD, and it can be useful for selecting secondary treatment. However, in some cases, secondary treatments are not remarkably effective even when selected based on the diagnosis. On the other hand, the clinical value of the symptom–reflux association (SRA) obtained using MII-pH remains unknown.

Aims & Methods

The current study aimed to investigate the effect of SRA on the efficacy of secondary treatment in refractory true GERD.
This study included patients who underwent MII-pH monitoring for evaluating proton pump inhibitor (PPI)- or potassium-competitive acid blocker (P-CAB)-refractory GERD symptoms and who were diagnosed with abnormal acid reflux (acid exposure time > 6%). Patients with a positive symptom index (SI) and symptom association probability (SAP) on the MII-pH monitoring were included in the SRA-positive group and the remaining ones in the SRA-negative group. The differences in the subsequent treatment efficacy between the two groups were retrospectively analyzed. Treatment efficacy was evaluated using the Frequency Scale for the Symptoms of GERD (FSSG) questionnaire.

Results

Of the 192 patients with PPI-/PCAB-refractory GERD, 41 (21.4%) were diagnosed with abnormal acid reflux. Among them, 30 (7 in the SRA-positive group and 23 in the SRA-negative group) underwent symptom assessments before and after treatment. The SRA-positive group had a significantly greater symptom improvement after treatment compared with the SRA-negative group (FSSG score changes: −13.0 ± 6.5 vs −5.4 ± 8.2, p = 0.016).

Conclusion

SRA evaluation is effective in predicting secondary treatment outcomes in patients with abnormal acid reflux.