Subjective Gastroesophageal Reflux After Per Oral Esophgeal Myotomy Does Not Correlate With Objective Ph Studies: Should All Patients Be On Proton Pump Inhibitors?

Edward L Jones, MD, Michael P Meara, MD, Jennifer S Schwartz, MD, Jeffrey W Hazey, MD, Kyle A Perry, MD. The Ohio State University

Introduction: Per-oral endoscopic myotomy (POEM) is an emerging treatment for esophageal achalasia. Some surgeons have expressed concern about the potential for post-operative gastroesophageal reflux in the absence of an associated anti-reflux procedure. It is unknown whether subjective reports of reflux symptoms and PPI use correlate with objective reflux measurements. The purpose of this study was to compare the objective measurement and subjective reports of reflux after POEM.

Methods and Procedures: Data on all patients undergoing POEM were collected prospectively between August 2012 and June 2014. Baseline data collected included demographics, objective testing (manometry, endoscopy, barium swallow), Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) and GERD Symptom Scale (GERSS). Outcomes of interest included symptom and disease-specific quality of life scores, antisecretory medication use, and pH studies performed 6 months after POEM. Post procedure pH studies were performed routinely, and proton pump inhibitor (PPI) use was recommended only if patient reported symptoms of reflux. Data are presented as incidence (%), mean ± SD, or median (range) as appropriate, and a p-value of <0.05 was considered statistically significant.

Results: Thirty-six patients underwent POEM during the study period. Mean age was 53.3±18.5 years with a BMI of 29.3 ± 8.7 kg/m2, and 21 (58%) were male. Twenty-eight patients (78%) completed at least 6 months of follow-up and 16 (44%) underwent repeat pH measurement. Twenty-one (58%) were taking PPIs pre-operatively which decreased to 8 (29%) post-operatively. Dysphagia scores improved to 0 (0-3) compared to 4 (1-5) at baseline (p<0.001). GERSS improved from to 34 (1-67) to 5 (0-47) following POEM (p<0.001) and GERD-HRQL scores improved to 5 (0-27) from 20 (3-43) at baseline (p<0.001). Of those undergoing follow-up pH testing, 6 (38%) had normal esophageal acid exposure, and 10 (62%) had elevated DeMeester scores. Median GERSS (12.9 versus 9, p=0.956) and GERD-HRQL (3.5 versus 6.5, p=0.913) scores were not significantly different for those with and without abnormal esophageal acid exposure. Similarly, median GERSS scores were not significantly different for those patients taking a PPI (19.5) versus not (9, p=0.105). In contrast, follow-up GERD-HRQL scores were higher for patients taking a PPI (11.5) than those who were not (3, p=0.018). PPI use did not correlate with abnormal esophageal acid exposure, and 60% of patients not taking a PPI had abnormal DeMeester compared to 67% of those not taking a PPI at 6 month follow-up.

Conclusions: Per-oral endoscopic myotomy provides excellent dysphagia relief for patients with achalasia, but is associated with a significant rate of post-procedure reflux as measured by pH testing. GERD symptoms, however, may not be a reliable indicator of post-procedure reflux in this patient population, as 60% of patients with abnormal esophageal acid exposure in this series were not taking PPIs based on symptoms alone. Due to the long-term risk of complicated GERD in patients with silent reflux, routine PPI use or post-operative pH testing to guide PPI therapy should be utilized for patients undergoing POEM.

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