Management of reflux after peroral endoscopic myotomy

Peroral endoscopic myotomy (POEM) has emerged as an attractive treatment option for patients suffering from achalasia. The endoscopic nature of the procedure prevents an accompanying fundoplication to decrease post-procedure gastroesophageal reflux (GER). A large amount of literature exists reporting incidence of post-POEM GER but differences in the metric used to report GER, short follow-up and infrequent objective measuring creates wide variation in this data. Moderately sized multi-institutional trials and meta-analysis that use the most sensitive metric of GER suggest the incidence is close to 50%, which is significantly higher than traditional Heller myotomy with fundoplication. Although chronic GER has serious risks and implications in this patient population, many studies report complete subjective and objective resolution with anti-reflux medications. Novel endoscopic fundoplication technologies are emerging but their role in post-POEM GER is yet to be determined.