Expert panel perspectives on management of GERD post esophageal POEM: a national survey study

Gastroesophageal reflux disease (GERD) remains a major issue in the management of patients with achalasia after esophageal peroral endoscopic myotomy (E-POEM). This study investigated practice patterns surrounding empiric acid suppression, medication de-escalation, pH testing, and follow-up endoscopy of expert gastroenterologists managing these patients. An online 17-item survey study was conducted in November 2024 with a response rate of 30/60. Expertise was determined by prior E-POEM publications and participation in the Delphi consensus on this topic and was validated by reported years of E-POEM experience and average number of E-POEMs performed annually. 90% of responders performed E-POEM and 10% solely managed patients afterwards. 72% practiced in an academic institution and 45% performed more than 50 E-POEMs annually. There was no consensus on dose of acid suppression, but the most common regimen was a 40 mg omeprazole equivalent daily until follow-up. Responders had varied approaches to de-escalation, with 44% consistently performing pH testing. 48% performed endoscopic screening for Barrett’s esophagus/cancer, and 83% of these continued at a regular interval indefinitely. 65% of responders reported taking procedural steps to minimize GERD after E-POEM, most often short myotomy (76%), and 24% a “tailored” approach using EndoFLIP. The majority of experts reported taking measures during E-POEM to limit the risk of GERD. Despite GERD being an important consideration, experts remained almost evenly divided on the role of reflux testing in medication de-escalation and on the practice of endoscopic screening. Prospective studies informed by these expert insights would be especially valuable in determining whether pH testing and endoscopic screening for GERD complications improve patient outcomes.