Management of GERD After Myotomy for Achalasia

Abstract

Acid reflux is a well-known outcome after surgical or endoscopic myotomy, resulting from disruption of the natural anti-reflux barrier. The incidence of post-myotomy GERD remains difficult to estimate as studies cite variable definitions including endoscopic evidence of reflux, abnormal pH testing, and GERD symptoms. Future studies should focus on “clinically significant reflux” defined as abnormal pH testing associated with either GERD symptoms or endoscopic evidence of reflux esophagitis. Large meta-analyses have demonstrated significantly higher rates of abnormal acid exposure after peroral endoscopic myotomy (POEM) compared to laparoscopic heller myotomy (LHM). Focusing on POEM, studies show that while nearly half of patients will have esophagitis on follow-up endoscopy, the majority of these cases are mild or moderate and do not lead to significant clinical sequelae. While PPI therapy can be used effectively as treatment, new anti-reflux procedures are being developed, including transoral incisional fundoplication (TIF) and POEM + fundoplication (POEM + F) that may help to manage postmyotomy reflux in the same way the Dor fundoplication is performed with Heller myotomy. Currently, there is no reliable method for determining which patients are at risk for post-myotomy GERD. New methods are being developed to help risk- stratify these patients such as the use of EndoFLIP (endoscopic intraluminal functional imaging probe) to tailor the degree of myotomy. In addition, variable techniques of POEM are being studied to understand if the procedure can be performed in such a way as to minimize or even prevent post-myotomy GERD from occurring.