Risk of Reflux After Achalasia Treatment: POEM vs. Heller Myotomy

A comparison of esophageal pH findings

Around 3,000 new adults in the United States suffer from achalasia each year, an esophageal dysfunction that causes difficulty swallowing. The condition occurs when the esophagus is unable to carry food through to the stomach.

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For many years, the standard treatment for achalasia was an invasive operation known as laparoscopic Heller myotomy with fundoplication (LHM).

In recent years, however, an alternative novel approach called peroral endoscopic myotomy (POEM) has become increasingly popular.

POEM is much less invasive than LHM because it is performed endoscopically. It is less painful for patients, and the average recovery times are much shorter (less than a week as opposed to two to four weeks!). Many POEM patients go home the next day and need minimal or no pain meds. Patients can swallow much better after POEM, and it equals LHM in terms of efficacy.

Madhu Sanaka, MD, FACG, FASGE, a gastroenterologist and the Medical Director of Center for Advanced Endoscopy at the Cleveland Clinic, learned the POEM technique in 2013 from its inventor, Haru Inoue, MD, of Japan. Dr. Sanaka performed his first POEM in April 2014 and since then, has performed about 90 more in collaboration with thoracic surgery.

While its benefits are many, POEM is not perfect.

“A common side-effect with any achalasia treatment is gastroesophageal reflux disease (GERD),” explains Dr. Sanaka. “POEM leaves patients more susceptible to reflux simply because it doesn’t include the anti-reflux operation (fundoplication) that is a part of the LHM surgery. In POEM, we leave the lower sphincter open.”

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Doctors and patients alike have wondered whether there was an increased rate of reflux in patients who had the POEM procedure, versus patients who had LHM.

“There hasn’t been a well-designed study comparing PH testing after POEM vs. LHM until now,” says Dr. Sanaka, who presented his research on the topic at the American College of Gastroenterology Annual Scientific Meeting 2016. His findings are illuminating.

The study

Dr. Sanaka and his team studied 31 POEM patients and 88 LHM patients, testing their levels of PH two months post-treatment.

While POEM patients showed no statistically significant increase in reflux symptoms, they did have higher abnormal PH study findings. 48% of POEM patients had abnormal levels of esophageal acid exposure, compared to 14% of LHM patients.

Most POEM patients are managed with an anti-reflux medication. This is often unnecessary for LHM patients, because LHM includes a fundoplication — a surgery to tuck the lower sphincter and prevent reflux.

The next stage of this research, explains Dr. Sanaka, is to determine the factors that predict increased acid exposure. “I want to know what subset of patients are at the most risk, and what characteristics predispose them to this,” he says.

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The bottom line

“It’s important to know that POEM patients have higher levels of acid exposure and may thus have more reflux,” says Dr. Sanaka. “This study can help patients make more informed decisions about which course of treatment is right for them.”

For example, a younger patient may elect for the more invasive LHM, because their youth and vitality will help them recover well. Plus, they may not want to be on an anti-reflux medication for the rest of their lives.

An older achalasia patient is more likely to already be on an anti-reflux pill (or another daily pill) and are thus accustomed to the regimen.

“With most older patients, it doesn’t make much of a difference to them,” says Dr. Sanaka. “And most of the patients who have POEM are very satisfied.”