GERD after Peroral Endoscopic Myotomy: Assessment of Incidence and Predisposing Factors.
Journal
Journal of the American College of Surgeons
ISSN: 1879-1190
Titre abrégé: J Am Coll Surg
Pays: United States
ID NLM: 9431305
Informations de publication
Date de publication:
01 01 2023
01 01 2023
Historique:
pubmed:
16
12
2022
medline:
20
12
2022
entrez:
15
12
2022
Statut:
ppublish
Résumé
Peroral endoscopic myotomy (POEM) is an effective intervention for achalasia, but GERD is a major postoperative adverse event. This study aimed to characterize post-POEM GERD and identify preoperative or technical factors impacting development or severity of GERD. This is a retrospective review of patients who underwent POEM at our institution. Favorable outcome was defined as postoperative Eckardt score of 3 or less. Subjective GERD was defined as symptoms consistent with reflux. Objective GERD was based on a DeMeester score greater than 14.7 or Los Angeles grade C or D esophagitis. Severe GERD was defined as a DeMeester score greater than 50.0 or Los Angeles grade D esophagitis Preoperative clinical and objective data and technical surgical elements were compared between those with and without GERD. Multivariate logistic analysis was performed to identify factors associated with each GERD definition. A total of 183 patients underwent POEM. At a mean ± SD follow-up of 21.7 ± 20.7 months, 93.4% achieved favorable outcome. Subjective, objective, and severe objective GERD were found in 38.8%, 50.5%, and 19.2% of patients, respectively. Of those with objective GERD, 24.0% had no reflux symptoms. Women were more likely to report GERD symptoms (p = 0.007), but objective GERD rates were similar between sexes (p = 0.606). The independent predictors for objective GERD were normal preoperative diameter of esophagus (odds ratio [OR] 3.4; p = 0.008) and lower esophageal sphincter (LES) pressure less than 45 mmHg (OR 1.86; p = 0.027). The independent predictors for severe objective GERD were LES pressure less than 45 mmHg (OR 6.57; p = 0.007) and obesity (OR 5.03; p = 0.005). The length of esophageal or gastric myotomy or indication of procedure had no impact on the incidence or severity of GERD. The rate of pathologic GERD after POEM is higher than symptomatic GERD. A nonhypertensive preoperative LES is a predictor for post-POEM GERD. No modifiable factors impact GERD after POEM.
Sections du résumé
BACKGROUND
Peroral endoscopic myotomy (POEM) is an effective intervention for achalasia, but GERD is a major postoperative adverse event. This study aimed to characterize post-POEM GERD and identify preoperative or technical factors impacting development or severity of GERD.
STUDY DESIGN
This is a retrospective review of patients who underwent POEM at our institution. Favorable outcome was defined as postoperative Eckardt score of 3 or less. Subjective GERD was defined as symptoms consistent with reflux. Objective GERD was based on a DeMeester score greater than 14.7 or Los Angeles grade C or D esophagitis. Severe GERD was defined as a DeMeester score greater than 50.0 or Los Angeles grade D esophagitis Preoperative clinical and objective data and technical surgical elements were compared between those with and without GERD. Multivariate logistic analysis was performed to identify factors associated with each GERD definition.
RESULTS
A total of 183 patients underwent POEM. At a mean ± SD follow-up of 21.7 ± 20.7 months, 93.4% achieved favorable outcome. Subjective, objective, and severe objective GERD were found in 38.8%, 50.5%, and 19.2% of patients, respectively. Of those with objective GERD, 24.0% had no reflux symptoms. Women were more likely to report GERD symptoms (p = 0.007), but objective GERD rates were similar between sexes (p = 0.606). The independent predictors for objective GERD were normal preoperative diameter of esophagus (odds ratio [OR] 3.4; p = 0.008) and lower esophageal sphincter (LES) pressure less than 45 mmHg (OR 1.86; p = 0.027). The independent predictors for severe objective GERD were LES pressure less than 45 mmHg (OR 6.57; p = 0.007) and obesity (OR 5.03; p = 0.005). The length of esophageal or gastric myotomy or indication of procedure had no impact on the incidence or severity of GERD.
CONCLUSION
The rate of pathologic GERD after POEM is higher than symptomatic GERD. A nonhypertensive preoperative LES is a predictor for post-POEM GERD. No modifiable factors impact GERD after POEM.
Identifiants
pubmed: 36519909
doi: 10.1097/XCS.0000000000000448
pii: 00019464-202301000-00013
pmc: PMC9750114
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
58-70Commentaires et corrections
Type : CommentIn
Informations de copyright
Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Surgeons.
Références
Lois AW, Oelschlager BK, Wright AS, et al. Use and safety of per-oral endoscopic myotomy for achalasia in the US. JAMA Surg. 2022;157:490–497.
Bhayani NH, Kurian AA, Dunst CM, et al. A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia. Ann Surg. 2014;259:1098–1103.
Kumagai K, Tsai JA, Thorell A, et al. Per-oral endoscopic myotomy for achalasia. Are results comparable to laparoscopic Heller myotomy? Scand J Gastroenterol. 2015;50:505–512.
Teh JL, Tham HY, Soh AYS, et al. Gastro-esophageal reflux disease (GERD) after peroral endoscopic myotomy (POEM). Surg Endosc. 2022;36:3308–3316.
Repici A, Fuccio L, Maselli R, et al. GERD after per-oral endoscopic myotomy as compared with Heller’s myotomy with fundoplication: a systematic review with meta-analysis. Gastrointest Endosc. 2018;87:934–943.e18.
Akintoye E, Kumar N, Obaitan I, et al. Peroral endoscopic myotomy: a meta-analysis. Endoscopy. 2016;48:1059–1068.
Velanovich V. The development of the GERD-HRQL symptom severity instrument. Dis Esophagus. 2007;20:130–134.
Slone S, Kumar A, Jacobs J, et al. Accuracy of achalasia quality of life and Eckardt scores for assessment of clinical improvement post treatment for achalasia. Dis Esophagus. 2021;34:doaa080.
Kahrilas PJ, Bredenoord AJ, Fox M, et al. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil. 2015;27:160–174.
Kwiatek M, Pandolfino J. The Bravo™ pH capsule system. Dig Liver Dis. 2008;40:156–160.
Hoppo T, Sanz AF, Nason KS, et al. How much pharyngeal exposure is “normal”? Normative data for laryngopharyngeal reflux events using hypopharyngeal multichannel intraluminal impedance (HMII). J Gastrointest Surg. 2012;16:16–25.
Heller E. Extramukose karkioplastik beim chronisken Kardiospasmus mit dilation des Oesophagus. Mitt Grenzzeb Med Chir. 1914;17:141.
Swanstrom LL, Kurian A, Dunst CM, et al. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg. 2012;256:659–667.
Dor J, Humbert P, Dor V, Figarella J. L´ interet de la technique modifiee la prevention du reflux apres cardiomytomie extra muqueuse de Heller. Mem Acad. 1962.
Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg. 2004;240:405–12; discussion 412.
Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42:265–271.
Stavropoulos SN, Desilets DJ, Fuchs K-H, et al. Per-oral endoscopic myotomy white paper summary. Surg Endosc. 2014;28:2005–2019.
Stavropoulos SN, Modayil RJ, Friedel D, Savides T. The international per oral endoscopic myotomy survey (IPOEMS): a snapshot of the global POEM experience. Surg Endosc. 2013;27:3322–3338.
Inoue H, Sato H, Ikeda H, et al. Per-oral endoscopic myotomy: a series of 500 patients. J Am Coll Surg. 2015;221:256–264.
Karyampudi A, Nabi Z, Ramchandani M, et al. Gastroesophageal reflux after per-oral endoscopic myotomy is frequently asymptomatic, but leads to more severe esophagitis: a case-control study. United European Gastroenterol J. 2021;9:63–71.
Blonski W, Slone S, Richter JE. Update on the diagnosis and treatment of achalasia. Dysphagia. 2022;1:13.
Hirano I. Pathophysiology of achalasia and diffuse esophageal spasm. GI Motility Online. 2006.
Rate AJ, Hobson AR, Barlow J, Bancewicz J. Abnormal neurophysiology in patients with oesophageal motility disorders. Br J Surg. 2002;86:1202–1206.
Jung DH, Park H. Is gastroesophageal reflux disease and achalasia coincident or not? J Neurogastroenterol Motil. 2017;23:5–8.
Nguyen P, Scott M, Castell DO. Evidence of gender differences in esophageal pain threshold. Am J Gastroenterol. 1995;90.
Bhat YM, Bielefeldt K. Capsaicin receptor (TRPV1) and non-erosive reflux disease. Eur J Gastroenterol Hepatol. 2006;18:263–270.
Chen C-L. Visceral hypersensitivity in non-erosive reflux disease: neurogenic overwhelming in esophagus? Dig Dis Sci. 2013;58:2131–2132.
Dodds WJ, Dent J, Hogan WJ, et al. Mechanisms of gastroesophageal reflux in patients with reflux esophagitis. N Engl J Med. 1982;307:1547–1552.
Kumbhari V, Familiari P, Bjerregaard NC, et al. Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case-control study. Endoscopy. 2017;49:634–642.
Shiwaku H, Inoue H, Sasaki T, et al. A prospective analysis of GERD after POEM on anterior myotomy. Surg Endosc. 2016;30:2496–2504.
Rice TW, McKelvey AA, Richter JE, et al. A physiologic clinical study of achalasia: should Dor fundoplication be added to Heller myotomy? J Thorac Cardiovasc Surg. 2005;130:1593–1600.
Almogy G, Anthone GJ, Crookes PF. Achalasia in the context of morbid obesity: a rare but important association. Obes Surg. 2003;13:896–900.
Greer KB. Management of GERD in patients with obesity. Foregut. 2021;1:321–327.
Locke IG, Talley NJ, Fett SL, et al. Risk factors associated with symptoms of gastroesophageal reflux. Am J Med. 1999;106:642–649.
Ayazi S, Hagen JA, Chan LS, et al. Obesity and gastroesophageal reflux: quantifying the association between body mass index, esophageal acid exposure, and lower esophageal sphincter status in a large series of patients with reflux symptoms. J Gastrointest Surg. 2009;13:1440–1447.
Wu JCY, Mui LM, Cheung CMY, et al. Obesity is associated with increased transient lower esophageal sphincter relaxation. Gastroenterology. 2007;132:883–889.
Lambert DM, Marceau S, Forse RA. Intra-abdominal pressure in the morbidly obese. Obes Surg. 2005;15:1225–1232.
Grimes KL, Bechara R, Shimamura Y, et al. Gastric myotomy length affects severity but not rate of post-procedure reflux: 3-year follow-up of a prospective randomized controlled trial of double-scope per-oral endoscopic myotomy (POEM) for esophageal achalasia. Surg Endosc. 2020;34:2963–2968.
Onimaru M, Inoue H, Fujiyoshi Y, et al. Long-term clinical results of per-oral endoscopic myotomy (POEM) for achalasia: First report of more than 10-year patient experience as assessed with a questionnaire-based survey. Endosc Int Open. 2021;9:E409–E416.
Ramchandani M, Nabi Z, Reddy DN, et al. Outcomes of anterior myotomy versus posterior myotomy during POEM: a randomized pilot study. Endosc Int Open. 2018;6:E190–E198.
Chiu PWY. Reflux after per-oral endoscopic myotomy: do we have a solution? J Gastroenterol Hepatol. 2019;34:2055–2056.
Khashab MA, Sanaei O, Rivory J, et al. Peroral endoscopic myotomy: anterior versus posterior approach: a randomized single-blinded clinical trial. Gastrointest Endosc. 2020;91:288–297.e7.
Tanaka S, Toyonaga T, Kawara F, et al. Novel per-oral endoscopic myotomy method preserving oblique muscle using two penetrating vessels as anatomic landmarks reduces postoperative gastroesophageal reflux. J Gastroenterol Hepatol. 2019;34:2158–2163.