Risk factors and long-term course of gastroesophageal reflux disease after peroral endoscopic myotomy: A large-scale multicenter cohort study in Japan

Hironari Shiwaku; Hiroki Sato; Yuto Shimamura; Hirofumi Abe; Junya Shiota; Chiaki Sato; Masaki Ominami; Hiroyuki Sakae; Yoshitaka Hata; Hisashi Fukuda; Ryo Ogawa; Jun Nakamura; Tetsuya Tatsuta; Yuichiro Ikebuchi; Hiroshi Yokomichi; Suguru Hasegawa; Haruhiro Inoue

doi:10.1055/a-1753-9801

Endoscopy, Table of Contents

Endoscopy 2022; 54(09): 839-847
DOI: 10.1055/a-1753-9801

Original article

Risk factors and long-term course of gastroesophageal reflux disease after peroral endoscopic myotomy: A large-scale multicenter cohort study in Japan

Authors

Hironari Shiwaku

¹Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
Hiroki Sato

²Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan

³Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
Yuto Shimamura

⁴Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
Hirofumi Abe

⁵Department of Gastroenterology, Kobe University Hospital, Hyogo, Japan
Junya Shiota

⁶Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
Chiaki Sato

⁷Division of Advanced Surgical Science and Technology, Tohoku University School of Medicine, Miyagi, Japan
Masaki Ominami

⁸Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
Hiroyuki Sakae

⁹Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
Yoshitaka Hata

¹⁰Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
Hisashi Fukuda

¹¹Division of Gastroenterology, Department of Medicine, Jichi Medical University, Tochigi, Japan
Ryo Ogawa

¹²Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan
Jun Nakamura

¹³Department of Endoscopy, Fukushima Medical University Hospital, Fukushima, Japan
Tetsuya Tatsuta

¹⁴Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Aomori, Japan
Yuichiro Ikebuchi

¹⁵Division of Gastroenterology and Nephrology, Department of Multidisciplinary Internal Medicine Tottori University Faculty of Medicine, Tottori, Japan
Hiroshi Yokomichi

¹⁶Department of Health Sciences, University of Yamanashi, Yamanashi, Japan
Suguru Hasegawa

¹Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
Haruhiro Inoue

⁴Digestive Diseases Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan

Abstract

Background Gastroesophageal reflux disease (GERD) and reflux esophagitis remain problems after peroral endoscopic myotomy (POEM). This study aimed to elucidate the risk factors and long-term course of reflux esophagitis and symptomatic GERD after POEM.

Methods This multicenter cohort study involved 14 high volume centers. Overall, 2905 patients with achalasia-related esophageal motility disorders treated with POEM were analyzed for reflux esophagitis, severe reflux esophagitis (Los Angeles classification C or D), and symptomatic GERD.

Results Reflux esophagitis was diagnosed in 1886 patients (64.9 %). Age ≥ 65 years (risk ratio [RR] 0.85), male sex (RR 1.11), posterior myotomy (RR 1.12), esophageal myotomy > 10 cm (RR 1.12), and gastric myotomy > 2 cm (RR 1.17) were independently associated with reflux esophagitis. Severe reflux esophagitis was diagnosed in 219 patients (7.5 %). Age ≥ 65 years (RR 1.72), previous treatments (RR 2.21), Eckardt score ≥ 7 (RR 0.68), sigmoid-type achalasia (RR 1.40), and esophageal myotomy > 10 cm (RR 1.59) were factors associated with severe reflux esophagitis. Proton pump inhibitors (PPIs) were more effective for reflux esophagitis at 5-year follow-up (P = 0.03) than after 1 year (P = 0.08). Symptomatic GERD was present in 458 patients (15.9 %). Symptom duration ≥ 10 years (RR 1.28), achalasia diagnosis (RR 0.68), integrated relaxation pressure ≥ 26 (RR 0.60), and posterior myotomy (RR 0.80) were associated with symptomatic GERD. The incidence of symptomatic GERD was lower at 5-year follow-up compared with that after 1 year (P = 0.04), particularly in PPI users (P < 0.001).

Conclusions The incidence of severe reflux esophagitis was low after POEM, but excessive myotomy for older patients with previous treatments should be avoided. Early phase symptomatic GERD is non-acid reflux dependent and the natural course is favorable, basically supporting conservative treatment.

Full Text

References

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