Gabriel Arevalo, MD, Megan Sippey, MD, Jack He, MD, Ahmed Ali, MD, Luis Martin Del Campo, MD, Jeffrey Marks, MD, FACS, FASGE. Case Western Reserve University
Introduction: Per Oral Endoscopic Myotomy (POEM) is a less invasive alternative to laparoscopic Heller myotomy for patients with achalasia. While a partial fundoplication is often performed concurrently with a laparoscopic myotomy, an endoscopic approach does not offer this and therefore leaves patients prone to post-operative reflux. The objectives of this study were to 1) identify patients with post-POEM reflux using BRAVO pH and endoscopic evaluations, and 2) investigate risk factors associated with post-POEM reflux and esophagitis to optimize patient selection for POEM and identify those who will benefit from a proactive approach to post-operative reflux management.
Methods: A retrospective review of a prospectively collected database of patients who underwent POEM between January 2011 and July 2017 at a single institution was performed. Demographics along with pre-POEM and post-POEM variables were obtained. Pre-POEM variables included Eckardt score, achalasia type, esophagitis, esophageal shape, prior treatments and PPI use. Post-POEM variables included Eckardt score, BRAVO pH evaluation, hiatal hernia, esophagitis, and time interval between evaluations. Univariate and multivariate analyses were performed, using p-values ≤ 0.05 for statistical significance.
Results: 46 patients were included in the study, with a mean follow up of 358 days. Mean age was 58 ± 19.2; 61% were female. Thirty-six patients underwent 48-hour BRAVO pH testing after POEM, which revealed abnormal esophageal acid exposure in fifteen patients (41.7 %). There was a correlation between positive BRAVO results and the presence of pre-operative esophagitis (p = 0.02). Only 13% of patients had symptom-related reflux episodes based on the Symptom Associated Probability of the BRAVO study. Patients with positive BRAVO results had a decrease interval time in days between surgery and BRAVO study compared to patients with negative BRAVO study (258 days ± 115 versus 390 ± 253 p=0.05). No significant associations were found between positive BRAVO results and sex, age, esophageal shape, Eckardt scores, pre-operative treatments for achalasia, and achalasia type. Postoperative endoscopy revealed 6 patients with esophagitis, compared to 4 patients who had esophagitis on pre-operative endoscopy. Only higher pre-operative Eckardt score was significantly associated with endoscopic evidence of esophagitis post-POEM.
Conclusions: Reflux is common after POEM. A majority of patients with a positive BRAVO study are asymptomatic, which is concerning. Objective follow-up is of paramount importance with upper endoscopy and ambulatory pH monitoring being the gold standard. Furthermore, elevated pre-operative Eckardt score and esophagitis are associated with post-POEM reflux. This population warrants close follow-up.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93708
Program Number: S093
Presentation Session: Flexible Endoscopy I
Presentation Type: Podium