Gastroesophageal reflux disease after peroral endoscopic myotomy: Facts and fictions
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Peroral endoscopic myotomy (POEM) has today evolved to be the gold standard for the treatment of achalasia cardia and other spastic esophageal disorders. Its minimal invasive nature, safety and encouraging outcomes have made POEM the most commonly practiced submucosal tunneling procedure. Gastroesophageal reflux disease (GERD) or abnormal esophageal acid exposure time (AET), however, continues to haunt and dampen the encouraging clinical outcome after a POEM procedure. This is mainly because as against a laparoscopic Heller’s myotomy, the procedure of POEM is not combined with an anti-reflux procedure. The incidence of GERD or AET after the POEM procedure has been shown to be, however, dissimilar in various studies. This is probably due to the inconsistency in the definitions of GERD and AET seen on 24-hr-pH studies. It is a known fact that continued abnormal esophageal acid exposure can lead to erosive esophagitis, Barrett’s metaplasia, and esophageal cancer in the long run. Current literature also suggests that almost 50% of patients do develop abnormal acid exposure after a POEM procedure though only around one third develop symptoms or have erosive esophagitis. This concern has led to the development of techniques like POEM with fundoplication wherein an endoscopic fundoplication is performed in the same sitting of the POEM procedure, or even some techniques of endoscopic full-thickness plication/trans-oral incisionless fundoplication which can be performed after the POEM procedure selectively. Given the fact that almost 50% of patients undergoing POEM do develop an abnormal acid exposure, it is imperative that we need to clearly develop a rational strategy to deal with this reality. This review aims to realign the facts and fictions of the menace of post-POEM GERD and suggest a rational algorithmic approach.
Abstract
Peroral endoscopic myotomy (POEM) has today evolved to be the gold standard for the treatment of achalasia cardia and other spastic esophageal disorders. Its minimal invasive nature, safety and encouraging outcomes have made POEM the most commonly practiced submucosal tunneling procedure. Gastroesophageal reflux disease (GERD) or abnormal esophageal acid exposure time (AET), however, continues to haunt and dampen the encouraging clinical outcome after a POEM procedure. This is mainly because as against a laparoscopic Heller’s myotomy, the procedure of POEM is not combined with an anti-reflux procedure. The incidence of GERD or AET after the POEM procedure has been shown to be, however, dissimilar in various studies. This is probably due to the inconsistency in the definitions of GERD and AET seen on 24-hr-pH studies. It is a known fact that continued abnormal esophageal acid exposure can lead to erosive esophagitis, Barrett’s metaplasia, and esophageal cancer in the long run. Current literature also suggests that almost 50% of patients do develop abnormal acid exposure after a POEM procedure though only around one third develop symptoms or have erosive esophagitis. This concern has led to the development of techniques like POEM with fundoplication wherein an endoscopic fundoplication is performed in the same sitting of the POEM procedure, or even some techniques of endoscopic full-thickness plication/trans-oral incisionless fundoplication which can be performed after the POEM procedure selectively. Given the fact that almost 50% of patients undergoing POEM do develop an abnormal acid exposure, it is imperative that we need to clearly develop a rational strategy to deal with this reality. This review aims to realign the facts and fictions of the menace of post-POEM GERD and suggest a rational algorithmic approach.
참고문헌 (30)
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