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LONG TERM SINGLE CENTER COMPREHENSIVE ANALYSIS OF POST-POEM GASTROESOPHAGEAL REFLUX AND ITS SEQUELAE IN MORE THAN 500 PATIENTS

Dagmar Simkova 1, Zuzana Vackova 1, Jan Mareš 1, Kristina Hugova 1, Tomas Hucl 1, Petr Stirand 1, Rastislav Hustak 1, julius spicak 1, Jan Martinek 1

Affiliations

1 Institute for Clinical and Experimental Medicine (IKEM), Prague, Czechia

Summary

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A retrospective analysis of 519 patients who underwent peroral endoscopic myotomy (POEM) for achalasia shows that reflux esophagitis rates decline from 39.1% at 3 months to 20.5% at 6 years, but approximately half of patients require long-term proton pump inhibitor therapy.

Among 390 patients tested at 3 months post-POEM, 45.6% had abnormal acid exposure on 24-hour pH monitoring off proton pump inhibitors.
Reflux esophagitis decreased over time: 39.1% at 3 months, 35.7% at 24-36 months, and 20.5% at 6 years, with severe esophagitis (LA grade C/D) declining from 4.3% at 3 months to 0% at 6 years.
At 48, 60, and 72 months, approximately 53%, 48%, and 54% of patients were taking proton pump inhibitors, with 80% using them daily.
Severe reflux complications were rare: no new cases of Barrett's esophagus or esophageal adenocarcinoma occurred, and one patient developed a peptic stricture that was successfully treated with balloon dilation.
The authors conclude that patients after POEM should remain under long-term surveillance despite the low risk of reflux complications.

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Abstract

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.

Conference

UEG Week Copenhagen 2023

Topics

Oesophagus

Submission format

Abstract

Session

PP 01 Oesophageal, gastric and duodenal disorders (Posters)

Citation

United European Gastroenterology Journal 2023; 11 (Supplement 8)

Published

2023

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Panel discussion: Metabolic and vascular disorders of the liver

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Panel discussion: Metabolic and vascular disorders of the liver

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Abstract

Event

UEG Postgraduate Teaching Programme Berlin 2025

Topics

Hepatobiliary

Session

Metabolic and vascular disorders of the liver

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Autoimmunity in the liver

Bogdan Dumitru Procopet 1

Affiliations

1 University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania

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Abstract

Event

UEG Week Copenhagen 2023

Topics

Hepatobiliary Immunology Pancreas

Session

Autoimmunity in HPB

Published

2023

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Future trends in diagnosis and management of coeliac disease

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Future trends in diagnosis and management of coeliac disease

Fabiana Zingone 1

Affiliations

1 University of Padua, Padua, Italy

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Abstract

Event

UEG Week Berlin 2025

Topics

Immunology Small Intestine & Nutrition

Session

Coeliac or non-coeliac enteropathy?

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Spontaneous bacterial peritonitis (Complete Session)

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Spontaneous bacterial peritonitis (Complete Session)

Angelo Armandi 1, Marina Berenguer 2, Javier Fernandez Gomez 3

Affiliations

1 University of Turin, None, Italy

2 La Fe University Hospital, Valencia, Spain

3 Hospital Clinic - Liver Unit, Hospital Clinic; Barcelona/ES, Barcelona, Spain

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Abstract

Event

UEG Week Copenhagen 2023

Topics

Hepatobiliary Mechanisms & Personalised Medicine

Session

Spontaneous bacterial peritonitis

Published

2023

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EFFICACY OF THE SYMPTOM–REFLUX ASSOCIATION TO DETERMINE SECONDARY TREATMENT FOR PPI-/P-CAB REFRACTORY TRUE GERD PATIENTS

Satsuki Takahashi 1,2, Tomoaki Matsumura 1, Michiko Sonoda 1, Tomomi Ozaki 1, Tatsuya Kaneko 1, Ryosuke Horio 1, Chihiro Goto 1, Akane Kurosugi 1, Tsubasa Ishikawa 1, Yuki Ohta 1, Takashi Taida 1, Atsuko Kikuchi 1, Kenichiro Okimoto 1, Jun Kato 1

Affiliations

1 Chiba University Hospital, Chiba, Japan

2 Queen Mary University of London, London, United Kingdom

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Abstract

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.

Conference

UEG Week Berlin 2025

Topics

Oesophagus

Submission format

Abstract

Session

OESOPHAGEAL, GASTRIC AND DUODENAL (Posters)

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Marte Lie Høivik

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Share via Email Share on Facebook Share on X Share on LinkedIn Share on Bluesky

PROTON PUMP INHIBITORS NEGATIVELY IMPACT THE COURSE OF ULCERATIVE COLITIS – A COHORT STUDY OF OVER 10000 NEWLY DIAGNOSED PATIENTS IN NORWAY

This content is part of Gutflix. Log in with your myUEG account, or create one free, to watch it.

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PROTON PUMP INHIBITORS NEGATIVELY IMPACT THE COURSE OF ULCERATIVE COLITIS – A COHORT STUDY OF OVER 10000 NEWLY DIAGNOSED PATIENTS IN NORWAY

Reidar Fossmark 1, Sandre Svatun Lirhus 2, Marte Lie Høivik 3

Affiliations

1 Norwegian University of Science and Technology, Trondheim, Norway

2 University of Oslo, Oslo, Norway

3 Oslo University Hospital, Oslo, Norway

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Abstract

Introduction

Ulcerative colitis (UC) occurs in genetically predisposed individuals. The influence of environmental factors and the gastrointestinal microbiome is thought to be of particular importance in this disorder. Proton pump inhibitors (PPIs) affect the microbiome along the entire GI tract and PPI use is the single factor that influences fecal microbial composition to the largest extent at a population level. Only few studies have previously investigated the association between PPI use and UC, but these suggest that PPIs may increase the risk of UC and possibly also affect the disease course. The objective of the study was to examine how PPI exposure is associated with disease course in a large national cohort of newly diagnosed UC patients.

Aims & Methods

Nationwide data from the Norwegian Patient Registry (NPR) and the Norwegian Prescription Database (NorPD) were linked and a study cohort including all newly diagnosed UC patients in Norway between 2010 and 2020 was drawn based on predefined case definitions. PPI exposure was included as a time dependent variable and defined as PPI dispensal of at least 0.5 defined daily doses for 28 days. A 30 day time lag from dispensal was added and the exposure period extended 60 days after the duration of the prescription. Outcomes were classed by use of advanced therapies (adalimumab, infliximab, golimumab, vedolizumab, ustekinumab and tofacitinib), systemic glucocorticoids, and starting any additional systemic anti-inflammatory medication and colectomy during follow-up. Time-dependent Cox regressions included the variables PPI use (time-dependent), first systemic glucocorticoid prescription (time-dependent), first UC hospitalization (time-dependent), age-groups 0-19, 20-39, 40-59, 60+ years and sex. In the multivariate analyses using systemic glucocorticoids and colectomy as outcomes, advanced therapies was also included as a variable. Patients were followed from time of diagnosis until the outcome of interest, death or December 2020, whichever came first.

Results

There were 10149 patients in the study cohort. The median age was 40 years (IQR 27-56) and 56% were males. PPI use independently increased the risk of starting glucocorticoids (HR 1.20, 95% CI 1.07-1.34), advanced therapies (HR 1.54, 95% CI 1.36-1.73), any additional anti-inflammatory treatment (HR 1.18, 95%CI 1.05-1.32) and undergoing colon surgery (HR 1.52, 95%CI 1.17-1.98). The strongest risk factor for starting glucocorticoids were hospitalization (HR 4.35 95%CI 3.96-4.77), while young age also was a significant risk factor. Use of glucocorticoids was the strongest risk factor for starting treatment advanced therapies (HR 13.19, 95%CI 11.12-15.63) and younger age was also a significant risk factor in this analysis. In the sensitivity analysis using outcomes occurring without time lag and with 60 days lag, the HR of PPI use were similar. In analyses where patients exposed to NSAID were excluded, PPI use remained a significant risk factor for starting advanced therapies HR 1.66 (1.47-1.88) and undergoing colectomy HR 1.64 (1.25-2.15), but PPI use was no longer a risk factor for starting glucocorticoids or starting any anti-inflammatory treatment.

Conclusion

In this national cohort of newly diagnosed patients with UC, PPI use was a risk factor for unfavorable outcomes including advanced therapy initiation, additional anti-inflammatory medications and undergoing colectomy. Although further studies are needed, the evidence suggests that PPIs could affect the course of UC and should be used cautiously in UC patients.

Disclosure

The project was funded by Takeda. The author SSL reports research funding from Takeda during the conduct of the study. RF has received lecture fee from Takeda. MLH reports investigator research grants from Takeda, Pfizer, Tillotts and Ferring, and speaker fees from Tillotts, Ferring, Galapagos, BMS, MSD and AbbVie as well as Advisory board honoraria from Takeda and AbbVie.

Event

UEG Week Copenhagen 2023

Topics

IBD Paediatrics

Submission format

Abstract

Session

IBD aetiology

Citation

United European Gastroenterology Journal 2023; 11 (Supplement 8)

Published

2023

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