Abstract
Background:
Between 1995 and 2010, the laparoscopic Heller myotomy (LHM) was considered in most centers the treatment of choice for esophageal achalasia. The technique evolved over time, and the initial thoracoscopic approach was abandoned in favor of LHM with the addition of a fundoplication, due to the high incidence of postoperative reflux. Recently, a new endoscopic technique has been adopted in the treatment of achalasia—peroral endoscopic myotomy (POEM), which has slowly become the preferred treatment modality in many centers. While POEM is as effective as LHM in relieving symptoms, it has been associated with a very high rate of pathological reflux, development of strictures, Barrett's esophagus, and adenocarcinoma. In addition, many patients still complain of heartburn and regurgitation even when treated with high doses of proton pump inhibitors.
Methods:
We described 3 cases of achalasia patients with reflux symptoms refractory to medical treatment after POEM who underwent laparoscopic antireflux surgery.
Results:
The operations were completed laparoscopically despite presence of mediastinal adhesions, probably secondary to micro-leaks during POEM. All patients had resolution of their symptoms.
Conclusions:
This is the first report that describes patients who developed severe heartburn and regurgitation refractory to medical treatment following POEM, who eventually underwent a laparoscopic partial fundoplication with resolution of their symptoms. Our experience shows that post-POEM reflux is a serious concern, especially when refractory to medical treatment. We feel that this is a worrisome problem that will require frequent surgical interventions in the future.
Introduction
Between 1995
In the past 10 years a new endoscopic technique for the treatment of achalasia has been developed, becoming today the preferred treatment modality in many centers—peroral endoscopic myotomy (POEM).6–10 Although there is no question that at a short-term follow-up POEM is as effective as LHM in relieving symptoms, it has been associated with a very high rate of pathological reflux, with development of strictures, Barrett's esophagus, and adenocarcinoma.11,12 In addition, many patients still complain of heartburn and regurgitation, even when treated with high doses of proton pump inhibitors (PPIs).
This is the first report that describes patients who developed severe heartburn and regurgitation refractory to medical treatment after POEM, and who underwent a laparoscopic partial fundoplication with resolution of their symptoms.
Patient 1
A 65-year-old man with type-2 esophageal achalasia. He reported dysphagia for 1 year, with frequent regurgitation, chest discomfort, and weight loss. Initially, he underwent endoscopic botulin toxin injection (EBTI) with near resolution of dysphagia. However, the effect of EBTI lasted for only 2 weeks. Subsequently, he underwent POEM. Although he reported relief of dysphagia, he started experiencing heartburn and regurgitation, which did not improve with high doses of PPIs. He eventually underwent a laparoscopic posterior partial fundoplication. It is of note that during the procedure severe adhesions were encountered in the posterior mediastinum, probably secondary to microperforations caused by POEM. The patient recovered from surgery without complications and had complete resolution of the heartburn and regurgitation.
Patient 2
An 80-year-old woman with diffuse esophageal spasm. She reported severe dysphagia, chest pain, and regurgitation leading to four episodes of aspiration pneumonia, with prolonged hospital admissions. EBTI did not bring any significant improvement, and subsequently she underwent POEM. After POEM she had a dramatic relief of dysphagia and was able to tolerate a regular diet. However, she developed heartburn, regurgitation, and a new episode of aspiration pneumonia. She underwent a laparoscopic hiatal hernia repair with Heller myotomy and partial posterior fundoplication. During the procedure severe periesophageal adhesions were found, and the adherent left pleura was entered during the mobilization of the esophagus. She had an uneventful recovery and complete resolution of her symptoms.
Patient 3
A 47-year-old woman with type-3 achalasia and 2-year history of worsening dysphagia. She underwent a long POEM. After treatment she reported partial relief of dysphagia and developed occasional regurgitation and heartburn. The patient was initially treated with PPIs, which she did not tolerate. H2-blocking agents provided only partial relief of her symptoms. She underwent laparoscopic Heller myotomy with extension onto the gastric wall, and a partial posterior fundoplication. She recovered uneventfully, with complete resolution of her symptoms.
Discussion
In 2010, Dr. Inoue from Japan published the first study describing POEM in achalasia patients. 6 His initial report was followed by many other retrospective studies that showed that, at short-term follow-up, POEM was at least as effective as an LHM in relieving symptoms.7–10 However, a common trend soon emerged: although most patients had no reflux symptoms, and few had esophagitis, >50% experienced pathological reflux when it was measured objectively by ambulatory pH monitoring.9,13–15 This was indeed a very worrisome finding—most patients were asymptomatic but had pathological reflux that had been detected just because of the pH testing. In a way this finding was not surprising, as it repeated the experience of the thoracoscopic myotomy without a fundoplication. The initial studies reported in fact excellent control of symptoms in asymptomatic patients, but a 60% rate of pathological reflux when this was measured by pH monitoring. 2 At that time the medical and surgical community realized the need for a change, and this was accomplished with the switch from the thoracoscopic to the laparoscopic approach with the addition of a fundoplication.3,5 Reflux can be very dangerous in achalasia patients because of the pathophysiology of the disease. In achalasia there is no peristalsis, and gastric reflux tends to occur after treatment through the incompetent lower esophageal sphincter. Clearance, however, is very slow with prolonged contact time with the esophageal mucosa. Consequently, cases of peptic strictures, Barrett's esophagus and even adenocarcinoma have been documented after POEM.11,12
A meta-analysis by Schlottmann et al. summarized very well the issues described earlier. 14 They analyzed 53 studies with data on LHM and 21 with data on POEM. Predicted probabilities for improvement in dysphagia were 90% for LHM and 93% for POEM. Gastroesophageal reflux disease (GERD) symptoms were present in 17% of patients after LHM and 19% after POEM; esophagitis was present in 12% of patients after LHM and in 22% after POEM. However, when reflux was measured by pH monitoring, it was present in 11% of patients after LHM but in 48% of patients after POEM. The findings of these retrospective studies14,16 have been recently confirmed by the first prospective and randomized trial comparing LHM with fundoplication to POEM. 17 In this multicenter study, Werner et al. documented clinical success in 81% of patients after LHM and 83% after POEM. However, esophagitis was present in 20% of patients after LHM and in 57% after POEM.
As stressed by Dr. Richter, reflux after POEM is “the real elephant in the room.” 18 Many patients will require lifelong treatment with PPI, medications that are clearly associated with severe side effects. Some, as one of our patients, do not tolerate these medications. In addition, it is particularly concerning that POEM has been used more and more frequently in adolescents, with the risk of a lifelong exposure to reflux. A recent study of 44 children with achalasia, who underwent POEM, showed that at 4-year follow-up 55% had erosive esophagitis and 54% pathological reflux by pH monitoring. 19
Although in the beginning the issue of the post-POEM reflux was disregarded by many, now there is more awareness and concern. Recently Dr. Inohue, who had initially failed to acknowledge the potential problems linked to post-POEM reflux, has proposed to perform an endoscopic fundoplication at the same time of POEM. 20 Unfortunately, we are afraid that this strategy is doomed to failure. In 2015, Hunter et al. in a randomized controlled trial compared the efficacy of an endoscopic fundoplication versus omeprazole in patients with GERD and regurgitation. 21 The results showed that the endoscopic fundoplication was not superior to a combination of a sham esophagogastroduodenoscopy plus PPI, and it did not correct pathological reflux. It is important to note that only patients with normal motility were included in this study (dysmotility was considered one the exclusion criteria), whereas achalasia patients have no peristalsis.
Conclusions
Today POEM has become the preferred treatment for achalasia in many centers throughout the world. Although it is accepted that this technique offers advantages for type-3 achalasia or for recurrent symptoms after LHM,22,23 it is not clear if it should be considered the primary treatment modality in any patient. Patients should be informed of the risk of complications or need for further intervention secondary to reflux, and careful follow-up with objective testing should take place even in asymptomatic patients.
Our concern is that by embracing POEM we are exchanging one disease process—achalasia—with another—GERD. And although we have long-term data for LHM with excellent results, 24 it is unacceptable to have data in only 61 of 500 patients (12%) at 3-year follow-up. 25 What happened to the other 439 patients who had POEM?
Our experience shows that post-POEM reflux is a serious concern, and that it can be refractory to medical treatment. We feel that this is a worrisome problem that will require frequently surgical intervention in the future.
Footnotes
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.