Megan Sippey, MD, Mark Anderson, MD, Jeffrey Marks, MD, FACSFASGE. Case Western Reserve University
Objective: Achalasia is a lifestyle-crippling disease characterized by failure of lower esophageal relaxation leading to progressive dysphagia and recurrent aspiration. Since 2008, Per Oral Esophageal Myotomy (POEM) has become an increasingly-accepted alternative to laparoscopic Heller myotomy as the procedure of choice for achalasia. This minimally-invasive option has been demonstrated to cause less pain and eliminates the risks of abdominal entry such as pneumoperitoneum, incisional infection, and hernia. However, Heller myotomy is a safe, effective, and less technically-challenging procedure that allows for the added benefit of concurrent partial fundoplication to prevent reflux. Obesity (BMI>30) is a well-documented risk factor for reflux, however it is unclear if obese patients are at higher risk of developing iatrogenic reflux. This study aims to analyze the relationship between BMI and post-POEM reflux and offer insight into whether this patient population may benefit from heightened clinical scrutiny prior to offering POEM over laparoscopic myotomy with fundoplication.
Methods: A retrospective review of a prospectively-maintained database was performed on all patients undergoing POEM for achalasia from January 2011 to July 2017 at a single institution. Patients who completed post-operative BRAVO pH study were included in the study as symptoms can be an unreliable measurement of acid exposure in this population. Proton Pump Inhibitor (PPI) use was used as a surrogate for pre-operative reflux.
Results: 36 patients met inclusion criteria. Fifteen were male (42%). BMI ranged from 18 to 42 with fourteen (39%) obese patients. Pre-operative PPIs were used by 64% of non-obese patients and 85.7% of obese patients. Post-operatively, 41% of non-obese patients and 43% of obese patients had reflux using a BRAVO pH cutoff of 4. The average post-operative Demeester score of non-obese patients was 27.1, whereas the average score of obese patients was 34.8. Of note, all six of the obese patients with post-POEM reflux were already taking a pre-operative PPI. Only two (9%) of the non-obese patients with post-POEM reflux had not been taking a PPI pre-operatively.
Conclusions: Achalasia and obesity are not mutually exclusive diseases. While obesity is a risk factor for reflux in the general population, this does necessarily confer a higher superimposed risk of reflux following POEM. Obese patients may similarly benefit from POEM over Laparoscopic Heller myotomy for achalasia without increased risk of iatrogenic reflux. Further study with greater power is needed to confirm this early descriptive finding.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94813
Program Number: S084
Presentation Session: Foregut III
Presentation Type: Podium