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Gastric myotomy length affects severity but not rate of post-procedure reflux: 3-year follow-up of a prospective randomized controlled trial of double-scope per-oral endoscopic myotomy (POEM) for esophageal achalasia

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Abstract

Background

Since Inoue performed the first POEM in 2008, safety and efficacy have been well-established. Early studies focused on refining the technique and avoiding incomplete myotomy. Following the discovery that many patients with abnormal acid exposure are asymptomatic, the focus shifted to post-POEM reflux, but no studies have identified any associated procedural factors. In this study, we examined the intermediate-term results of our previous randomized controlled trial, with particular attention to post-POEM reflux.

Methods

Previously, 100 consecutive patients were randomized to either double- or single-scope POEM. Endoscopy was conducted 2 months post-POEM and annually thereafter. Patients were included in the present study if they completed endoscopy ≥ 6 months post-POEM, and the clinical results of both groups were analyzed with particular attention to clinical efficacy and post-POEM reflux.

Results

Median follow-up was 3 years, and most myotomies were performed in the posterior location. The final gastric myotomy length was longer in the double-scope group (3.3 vs. 2.6 cm). Clinical efficacy (≥ 80%) and rates of post-POEM reflux (~ 60%) were similar; however, there was a higher incidence of moderate esophagitis (Los Angeles Grade B) in the double-scope group (25% vs. 4%). There were no cases of severe esophagitis (Los Angeles Grade C/D). Among patients with normal endoscopy at 2 months, > 40% developed erosive esophagitis on intermediate-term follow-up.

Conclusions

This is the first study to demonstrate a procedural factor that increases post-POEM esophagitis. Gastric myotomy > 2.5 cm results in increased rates of moderate esophagitis without improving clinical efficacy. Some patients developed esophagitis in a delayed fashion, emphasizing the importance of ongoing surveillance. We also believe that preserving the gastric sling fibers may help to reduce reflux rates. The double-scope method may help to control myotomy length (2.0–2.5 cm) and direction (lesser curve to avoid the gastric sling) to help maximize clinical efficacy while minimizing post-POEM reflux.

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Authors and Affiliations

  1. Department of Surgery, University of Cincinnati College of Medicine, 231 Albert B. Sabin Way, PO Box 670558, Cincinnati, OH, 45267-0558, USA

    Kevin L. Grimes

  2. Division of Gastroenterology, Queen’s University, Kingston, ON, Canada

    Robert Bechara

  3. Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan

    Yuto Shimamura, Haruo Ikeda & Haruhiro Inoue

Authors
  1. Kevin L. Grimes
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  2. Robert Bechara
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  3. Yuto Shimamura
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  4. Haruo Ikeda
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  5. Haruhiro Inoue
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Corresponding author

Correspondence to Kevin L. Grimes.

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Disclosures

Dr. Inoue is a member of the advisory board for Olympus, and has received educational grants from Boston Scientific and Takeda Pharmaceuticals. Drs. Grimes, Bechara, Shimamura, and Ikeda have no conflicts of interest or financial ties to disclose.

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Grimes, K.L., Bechara, R., Shimamura, Y. et al. Gastric myotomy length affects severity but not rate of post-procedure reflux: 3-year follow-up of a prospective randomized controlled trial of double-scope per-oral endoscopic myotomy (POEM) for esophageal achalasia. Surg Endosc 34, 2963–2968 (2020). https://doi.org/10.1007/s00464-019-07079-0

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