Transoral Incisionless fundoplication for reflux after peroral endoscopic myotomy: a crucial addition to our arsenal

 

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Abstract

Introduction Increased esophageal acid exposure is seen in a large percentage of patients with achalasia who undergo peroral endoscopic myotomy (POEM). Endoscopic transoral fundoplication (TIF) is a novel endoscopic technique for the management of patients with chronic gastroesophageal reflux (GERD). We present the first case series evaluating the role of TIF post-POEM.

Methods Consecutive patients 18 years or older from our academic institution who underwent a POEM procedure and subsequently underwent TIF for symptomatic reflux or regurgitation between December 2014 and June 2017 were included. The primary outcome was discontinuation of proton-pump inhibitor (PPI) use and healing of esophagitis (when initially present) on post-procedure esophagogastroduodenoscopy (EGD). Technical success was defined as successful completion of the endoscopic fundoplication. Adverse events (AEs) were recorded for all patients.

Results Five patients were included (60 % male, average age 55 ± 14 years). Technical success was achieved in 100 % of patients. Discontinuation of PPI use was achieved in 5/5 patients (100 %). Three patients had esophagitis pre-procedure and all were noted to have resolution of inflammation on post-procedure EGD. No adverse events were noted. Mean follow-up time was 27 months (range 5 – 34 months).

Conclusion TIF post-POEM appears feasible, safe, and efficacious in improving symptoms and esophagitis, decreasing long-term risks of acid exposure, and decreasing risks of long-term PPI use in patients post-POEM in this small cohort of patients. Larger studies are needed to confirm these initial findings.

• References

• 1 Nabi Z, Ramchandani M, Chavan R. et al. Per-oral endoscopic myotomy for achalasia cardia: outcomes in over 400 consecutive patients. Endosc Int Open 2017; 5: E331-E339
  Article in Thieme ConnectPubMedGoogle Scholar
• 2 Repici A, Fuccio L, Maselli R. et al. Post-poem reflux a systematic review and meta-analysis. Paper presented at Digestive Disease Week; May 5–9, 2017; Chicago, IL. Presentation number 1221
  PubMedGoogle Scholar
• 3 Wu QN, Zhang X, Li Q. et al. Outcomes of peroral endoscopic myotomy for treatment of esophageal achalasia with a median follow-up of 4 years. Paper presented at Digestive Disease Week; May 5–9, 2017; Chicago, IL. Presentation number 218
  PubMedGoogle Scholar
• 4 Kumbhari V, Familiari P, Bjerregaard NC. et al. Gastroesophageal reflux after peroral endoscopic myotomy: a multicenter case-control study. Endoscopy 2017; 49: 634-642
  Article in Thieme ConnectPubMedGoogle Scholar
• 5 Guo H, Yang H, Zhang X. et al. Long-term outcomes of peroral endoscopic myotomy for patients with achalasia: a retrospective single-center study. Dis Esophagus 2017; 30: 1-6
  CrossrefPubMedGoogle Scholar
• 6 Johansson J, Hakansson HO, Mellblom L. et al. Prevalence of precancerous and other metaplasia in the distal oesophagus and gastro-oesophageal junction. Scand J Gastroenterol 2005; 40: 893-902
  CrossrefPubMedGoogle Scholar
• 7 Hvid-Jensen F, Pedersen L, Drewes AM. et al. Incidence of adenocarcinoma among patients with Barrett’s esophagus. NEJM 2011; 365: 1375-1383
  CrossrefPubMedGoogle Scholar
• 8 Freedberg DE, Kim LS, Yang YX. The risks and benefits of long-term use of proton pump inhibitors: expert review and best practice advice from the American Gastroenterological Association. Gastroenterology 2017; 152: 706-715
  CrossrefPubMedGoogle Scholar
• 9 Cheung KS, Chan EW, Wong AYS. et al. Long-term proton pump inhibitors and risk of gastric cancer development after treatment for Helicobacter pylori: a population-based study. Gut 2018; 67: 28-35
  CrossrefPubMedGoogle Scholar
• 10 Bell RC, Cadiere GB. Transoral rotational esophagogastric fundoplication: technical, anatomical, and safety considerations. Surg Endosc 2011; 25: 2387-2399
  CrossrefPubMedGoogle Scholar
• 11 Kumta NA, Kedia P, Sethi A. et al. Transoral incisionless fundoplication for treatment of refractory GERD after peroral endoscopic myotomy. Gastrointest Endosc 2015; 81: 224-225
  CrossrefPubMedGoogle Scholar
• 12 Trad K, Fox M, Simoni G. et al. Transoral fundoplication offers durable symptom control for chronic GERD: 3-year report from the TEMPO randomized trial with a crossover arm. Surg Endosc 2017; 31: 2498-2508
  CrossrefPubMedGoogle Scholar
• 13 Hunter JG, Kahrilas PJ, Bell RC. et al. Efficacy of transoral fundoplication vs omeprazole for treatment of regurgitation in a randomized controlled trial. Gastroenterology 2015; 148: 324-333
  CrossrefPubMedGoogle Scholar
• 14 Schlottmann F, Luckett DJ, Fine J. et al. Laparoscopic Heller myotomy versus peroral endoscopic myotomy (POEM) for achalasia: A systematic review and meta-analysis. Ann Surg 2018; 267: 451-460
  CrossrefPubMedGoogle Scholar