Preservation of Oblique Sling Fibers During POEM Does Not Reduce Postprocedure GERD

Peroral endoscopic myotomy (POEM) is a standard treatment option for patients with achalasia but is associated with a high incidence of postprocedure gastroesophageal reflux disease (GERD). Various techniques have been attempted to prevent GERD after POEM, including preserving certain muscle fibers, performing selective circular myotomy, using natural orifice transluminal endoscopic surgery for fundoplication, and restricting the length of gastric myotomy to <4 cm.

In this randomized controlled trial, eligible patients with type I and II achalasia were randomly assigned to one of two groups: conventional myotomy (CM) or oblique fiber-sparing (OFS). Exclusion criteria included type III achalasia, sigmoid esophagus, and a history of Heller’s myotomy. The primary outcome of the study was the incidence of reflux esophagitis (≥ grade B) in both groups. 

The study included 115 patients, with 58 in the CM group and 57 in the OFS group. POEM was technically successful in all patients. Overall, reflux esophagitis was observed in 56 patients, which accounted for 48.7% of all study participants. The incidence of ≥ grade B esophagitis was similar in both groups, with 25.9% in the CM group and 31.6% in the OFS group (P=.541). Other measures, such as the mean number of reflux episodes, increased esophageal acid exposure (>6%), and high DeMeester scores, were also similar between the two groups, with no statistically significant differences (P>.05). There were no notable differences in the rate of symptomatic reflux (GerdQ >7) or the use of proton pump inhibitors at the one-year mark.