Peroral Endoscopic Myotomy: Long-term Outcomes and Gastroesophageal Reflux

Background: Peroral endoscopic myotomy has become the first-line therapy for achalasia in many centers worldwide. Post-operative GERD remains controversial. In our initial POEM series published in 2017, we reported controlled myotomy length on the gastric side with comparable GERD rates to Laparoscopic Heller Myotomy. Since then, several groups have published tips to minimize GERD. Here, we report our long-term follow-up series of POEM with consistent outcomes. Methods: Between November 2011 and October 2022, 245 consecutive patients with achalasia underwent elective POEM at our institution. Data were analyzed from a prospectively collected single-cohort database. All procedures followed a standardized POEM technique. GERD was measured using the GERD-HRQL score and endoscopic follow-up. Results: Mean follow-up was 42 ± 12.6 months. POEM was successfully completed in 243/245 (99.1%) patients. The mean Eckardt Score was 9.56 ± 2.34 before POEM and 0.9, 1.5, 1.9, and 2.1 after 6, 12, 24, and 36 months post-POEM, respectively. GERD-HRQL > 12 was present in 49 patients (20%). Endoscopic follow-up was conducted in 204 (83%) patients, with Grade A erosive esophagitis observed in 19 patients (9.3%), Grade B in 12 (5.8%), and Grade C in 2 patients (1%). Most patients with GERD were effectively managed with proton pump inhibitors; 2 patients (0.8%) required fundoplication. There were 5 (2%) major adverse events, including leaks and capnothorax. Conclusions: Long-term follow-up of POEM demonstrated a low rate of severe (Grade C) esophagitis (1%), effectively controlled with PPIs, supporting the safety of POEM regarding reflux-related outcomes.