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Updated: Aug 17, 2025
Use of the Scissor-Type Knife During the Peroral Endoscopy Myotomy Procedure for the Treatment of Achalasia
Published on: March 3, 2023
GERD after Peroral Endoscopic Myotomy: Assessment of Incidence and Predisposing Factors
Mohamad Rassoul Abu-Nuwar1, Sven E Eriksson1, Inanc S Sarici1
1From the Esophageal Institute, Department of Surgery, Allegheny Health Network, Pittsburgh, PA (Rassoul Abu-Nuwar, Eriksson, Sarici, Zheng, Hoppo, Jobe, Ayazi).
Insights
Peroral endoscopic myotomy (POEM) effectively treats achalasia, but gastroesophageal reflux disease (GERD) is a common issue. Lower preoperative lower esophageal sphincter pressure and normal esophageal diameter predict GERD after POEM.
Area of Science:
- Gastroenterology
- Surgical Innovation
- Esophageal Motility Disorders
Background:
- Peroral endoscopic myotomy (POEM) is a primary treatment for achalasia.
- Gastroesophageal reflux disease (GERD) is a significant postoperative complication following POEM.
- Characterizing post-POEM GERD and identifying predictive factors is crucial for patient management.
Purpose of the Study:
- To characterize the incidence and severity of GERD after POEM.
- To identify preoperative and technical factors associated with the development or severity of GERD post-POEM.
- To differentiate between symptomatic and objective GERD in the post-POEM setting.
Main Methods:
- Retrospective review of 183 patients who underwent POEM.
- Defined favorable outcome, subjective GERD, objective GERD, and severe objective GERD.
- Analyzed preoperative clinical and objective data, and technical surgical elements.
- Utilized multivariate logistic analysis to identify predictors of GERD.
Main Results:
- 93.4% of patients achieved a favorable outcome post-POEM.
- Objective GERD occurred in 50.5% of patients, with 24.0% being asymptomatic.
- Independent predictors for objective GERD included normal preoperative esophageal diameter and lower esophageal sphincter (LES) pressure < 45 mmHg.
- Severe objective GERD was predicted by LES pressure < 45 mmHg and obesity.
Conclusions:
- The rate of objective GERD after POEM is higher than symptomatic GERD.
- A nonhypertensive preoperative LES pressure is a significant predictor for post-POEM GERD.
- No modifiable factors were identified as impacting GERD development or severity after POEM.
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.
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