When antireflux surgery is needed to treat GERD after endoscopy

Researchers report a growing awareness of gastroesophageal reflux problems among patients who undergo endoscopic, nonsurgical treatment for esophageal achalasia, frequently requiring future surgical intervention. Peroral endoscopic myotomy (POEM) has been a treatment of choice for the past decade, but patients may develop severe heartburn and regurgitation that does not respond to medical treatment, as described in an article published in Journal of Laparoendoscopic & Advanced Surgical Techniques (JLAST).

Kamil Nurczyk, MD, Timothy Farrell, MD, and Marco Patti, MD, from University of North Carolina at Chapel Hill and Medical University of Lublin (Poland) coauthored the article entitled "Antireflux Surgery for Gastroesophageal Reflux Refractory to Medical Treatment after Peroral Endoscopic Myotomy." The authors express the concern that with POEM, one disease, achalasia (the backup of food within the esophagus) is being replaced with another, gastroesophageal reflux disease (GERD). They describe patients who experienced post-POEM reflux that was refractory to treatment with high doses of proton pump inhibitors and who required laparoscopic partial fundoplication surgery to eliminate their symptoms.

Editor-in-Chief P. Marco Fisichella, MD, MBA, Northwestern University, Feinberg School of Medicine, states: "This is the first report that confirms that the severity of reflux after POEM should not be underestimated. For years, the standard of care in the treatment of achalasia has been to perform a myotomy to relieve dysphagia coupled with a partial fundoplication to prevent reflux. However, with POEM, the advantages of a fundoplication are lost, thus subjecting the patient to reflux, which in most cases is asymptomatic. This report, however, highlights that reflux is still deleterious and resistant to medical treatment to the point of requiring another operation to correct it. The implications of this study are relevant, as it underscores how some patients who undergo POEM might need a second operation, which could be avoided should POEM be reserved only for those who might benefit the most from this procedure, such as those with type 3 achalasia. As of today, it is difficult to predict who will need a second operation—a fundoplication—after POEM. Yet, research should focus on identifying which patients might still benefit from POEM, while taking into account that the resultant reflux is a non-negligible complication."