Long-term outcomes of peroral endoscopic myotomy (POEM): reflux esophagitis and complications including Barrett esophagus and peptic strictures

Summary

Peroral endoscopic myotomy (POEM) is an effective and safe treatment for achalasia, but short-term follow-up studies suggest an increased risk of gastroesophageal reflux after treatment. The aim of this study was to evaluate the risk of reflux esophagitis and the long-term complications in achalasia patients more than 5 years after POEM. This prospective cohort study included achalasia patients who underwent POEM between August 2011 and December 2019 and were scheduled for follow-up upper gastrointestinal endoscopy at least five years after treatment. Multivariate regression was used to assess predictive factors for reflux esophagitis after POEM. In total 161 achalasia patients were included of whom 153 completed questionnaires. Median age at follow-up was 56 years and 49.7% were female. Reflux esophagitis was diagnosed in 67 patients (41.6%, 95%-CI 34.0%–49.2%), with 22 of these cases classified as severe (grade C/D, 32.8%). Prior laparoscopic Heller myotomy (OR 0.44, 95%-CI 0.20–0.98) and retreatment with PD (OR 0.36, 95%-CI 0.17–0.75) were associated with lower observed rates of reflux esophagitis. Factors associated with severe reflux esophagitis (grade C/D) included BMI (OR 1.13, 95%-CI 1.04–1.23) and PD after POEM (OR 0.12, 95%-CI 0.02–0.93). Barrett esophagus was observed in five patients (3.1%). Peptic strictures were seen in three patients (1.9%) necessitating dilation and no cases of esophageal adenocarcinoma were identified. Reflux esophagitis remains a common long-term finding in achalasia patients more than 5 years after POEM and is classified as severe in nearly one-third of these cases.