Endoscopic techniques to minimize gastroesophageal reflux during peroral endoscopic myotomy

Peroral endoscopic myotomy (POEM) is an established treatment for achalasia. Sacrificing the lower esophageal sphincter (LES) improves dysphagia but compromises the gastroesophageal junction (GEJ) barrier predisposing patients to acid reflux.

Indeed, 40-60% of patients experience abnormal esophageal acid exposure post-POEM, while clinically significant reflux esophagitis (Los Angeles grade ≥B) is observed in 20-35%. Symptom-reflux discordance is common, necessitating objective assessment with upper endoscopy and/or ambulatory reflux testing using Lyon Consensus 2.0 criteria. Critically, anatomical evaluation must exclude alternative causes of perceived gastroesophageal reflux disease (GERD), including candida esophagitis, failed myotomy or recurrent achalasia, peptic stricture, and blown-out myotomy. Proactive intra-procedural strategies during POEM to minimize reflux have included limiting myotomy length, selective circular-layer myotomy, sling fiber preservation, anterior versus posterior approach selection, and endolumenal functional lumen imaging probe (EndoFLIP)-guided refinement of myotomy, though none has demonstrated consistent reflux reduction in randomized trials. Hybrid procedures combining POEM with endoscopic fundoplication (POEM+F/POEM-F) offer same session approaches that can significantly lower objective reflux up to 3 years.

For proven post-POEM GERD, staged endoscopic options, transoral incisionless fundoplication, endoscopic full-thickness plication, and antireflux mucosectomy, offer symptom improvement and proton pump inhibitor (PPI) reduction in selected patients. A structured clinical pathway integrating proactive surveillance, objective confirmation, and individualized endoscopic intervention is proposed.