Assessment and Management of Reflux-Related Esophageal Stricture After Peroral Endoscopic Myotomy in Achalasia

Patients with reflux-related esophageal stricture after POEM were clinically similar to patients with recurrent achalasia, such as dysphagia and regurgitation. This study aimed to compare the clinical differences between reflux-related stricture and recurrent achalasia, as well as to evaluate the efficacy and safety of endoscopic treatment for reflux-related stricture.

From June 2015 to January 2023, we reviewed 1946 patients with achalasia who underwent POEM. Among these, data from 42 patients with reflux-related strictures and 151 patients with recurrence after POEM were collected. After propensity score matching (PSM), baseline characteristics and procedure-related parameters were retrospectively evaluated.

With similar baseline characteristics between the two groups after PSM, the reflux-related stricture group showed higher rates of regurgitation, heartburn, mucosal edema, mucosal ulcer, and grade C/D esophagitis compared with the recurrence group. The mean LES resting pressure on high-resolution manometry (HRM) was lower in the reflux-related stricture than in the recurrence group (2.8 ± 5.3 vs. 21.1 ± 16.7 mmHg, p = 0.014). Nine endoscopic radial incisions (ERI), eight endoscopic balloon dilations (EBD), and 25 proton pump inhibitors were administered in patients with reflux-related esophageal stricture after POEM. At follow-up of 24 months, the rate of re-stricture was similar between the ERI and EBD groups (33.3% vs. 50.0%, p = 0.637). Multivariate analysis revealed submucosal fibrosis was associated with reflux-related stricture after POEM (OR 2.367, 95% CI 1.274-5.618, p = 0.041).

Despite symptomatic similarities, reflux-related stricture and recurrent achalasia after POEM could be distinguished by symptoms, HRM, and endoscopic presentations. Furthermore, ERI and EBD are safe and effective treatments for reflux-related esophageal stricture after POEM.