Reflux symptom burden and objective findings at long-term follow-up after peroral endoscopic myotomy

Abstract

BACKGROUND: Peroral endoscopic myotomy (POEM) effectively treats achalasia but confers a significant risk of postoperative gastroesophageal reflux. Studies demonstrate poor short-term correlation between reflux symptoms and objective findings, but long-term outcomes remain unclear. We evaluated long-term GERD Health-Related Quality of Life (GERD-HRQL) scores, Bravo pH results, and proton pump inhibitor (PPI) use after POEM. METHODS: We conducted a prospective survey study of adults who underwent POEM at our institution from 2011 to 2024 with > 1 year of follow-up. Standardized surveys included the validated GERD-HRQL questionnaire and questions regarding PPI use and post-POEM interventions. Chart review verified medication use, Bravo results, and endoscopic findings. The primary endpoint was reflux symptom control, defined as GERD-HRQL score < 10. Secondary endpoints included chronic PPI use (> 6 months), Bravo results, and the reflux-dysphagia relationship. Multivariable logistic regression identified predictors of reflux symptom control. RESULTS: Seventy-nine patients completed the questionnaire at a median follow-up of 68 months. The median GERD-HRQL score was 10 (IQR 4-17), with 42 patients (53.2%) reporting clinically significant reflux (GERD-HRQL ≥ 10). Most (58; 73.4%) had chronic PPI use, 55.2% of whom reported poor symptom control. Among patients with GERD-HRQL ≥ 10, 52.4% had Eckardt scores > 3, suggesting concurrent dysphagia. Thirty-one patients underwent post-POEM Bravo; results were negative in 13 (41.9%), positive in 13 (41.9%), and inconclusive in 5 (16.1%). Six of 10 Bravos performed for reflux symptoms were negative. Endoscopy (n = 56) demonstrated esophagitis in 16 patients (28.6%). Older age (OR 1.04; 95% CI 1.01-1.08) and preoperative weight loss ≥ 5 kg (OR 6.72; 95% CI 1.57-28.74) predicted reflux control on multivariable analysis. CONCLUSIONS: At long-term follow-up, over half of patients reported clinically significant reflux, and most required chronic PPI therapy. Reflux symptoms correlated inconsistently with objective findings, mirroring short-term data and highlighting the need for ongoing surveillance and targeted reflux mitigation after POEM.