S882 Esophageal Peroral Endoscopic Myotomy or Laparoscopic Heller Myotomy Plus Dor Fundoplication for Achalasia? Real-World Evidence on GERD and Reflux Complications

Introduction: Esophageal peroral endoscopic myotomy (E-POEM) is a minimally invasive treatment for achalasia, offering an effective alternative to laparoscopic Heller myotomy (LHM). However, its lack of anti-reflux mechanisms like fundoplication raises concerns about reflux control. This study compares the need for repeat fundoplication, incidence of gastroesophageal reflux disease (GERD), esophagitis, and reflux-related complications in achalasia patients undergoing E-POEM versus LHM plus Dor fundoplication (LHM + DF). Methods: We conducted a retrospective cohort study using the U.S. multi-institutional TriNetX database to identify achalasia patients who underwent E-POEM or LHM + DF between January 2015 and January 2025. Ten-year outcomes included rates of anti-reflux surgery and incidence of GERD, esophagitis, Barrett’s esophagus, esophageal cancer, and strictures. Propensity score matching was applied to balance baseline characteristics between groups. Results: During the study period, 4,660 underwent E-POEM and 4,321 underwent LHM-DF. The average follow-up duration was 849.43 ± 858.71 days for the E-POEM group and 1129.68 ± 999.69 days for the LHM + DF group. In the E-POEM group, 102 patients (2.18%) subsequently underwent surgical or transoral fundoplication within 10 years post-procedure, compared to 133 patients (3.07%) in the LHM + DF group who required redo fundoplication. After propensity score matching, the risk of reintervention was significantly lower in the E-POEM group (2.3% vs 3.13, P = 0.02). The incidence of post-procedure esophagitis was significantly higher in the E-POEM group compared to the LHM + DF group (9.97% vs 7.1%, P < 0.01). Additionally, there was a trend toward a higher incidence of Barrett’s esophagus and esophageal stricture in the LHM + DF group; however, these differences did not reach statistical significance. The rate of esophageal cancer was comparable between the 2 groups (0.42% vs 0.44%, P = 0.86). The incidence of post-procedure GERD was significantly higher in the E-POEM group (37.4%), as opposed to the LHM-DF group (26.11%, P < 0.01). Conclusion: In this large real-world cohort, E-POEM was associated with a significantly lower need for fundoplication compared to LHM + DF. Although rates of post-procedure GERD and esophagitis were modestly higher with E-PEOM, the incidence of reflux-related complications including Barrett’s esophagus, esophageal cancer, and esophageal strictures was comparable between the 2 groups.