Management of Gastric Reflux Following Per-Oral Endoscopic Myotomy

Author
Year of publication
Location
Number of cases reported
Time point after POEM in months
Percentage of patients with symptoms assessed
Percentage of those assessed with GERD symptom
Definition of having GERD symptom
Familiari
2016
Rome, Italy
149
Mean of 7.6 ± 3.6
69%
18.4%
/
Shiwaku
2016
Fukuoka, Japan
100
3
100%
9.0%
FSSG
Chen
2015
Shanghai, China
26
Mean of 24.6
100%
14.8%
/
Inoue
2015
Yokohama, Japan
500
2 (n = 500)
85%
16.8%
/
370
12–24 (n = 370)
78%
19.4%
105
36 (n = 105)
58%
21.3%
Ramchandani
2015
Hyderabad, India
102
12
100%
21.6%
/
Werner
2015
International multicenter
85
3–6
93%
24.1%
Presence of heartburn
12–18
89%
31.6%
>24 (mean 29)
86%
37.0%
Ling
2014
Nanjing, China
87
3
100%
10.3%
/
Stavropoulos
2014
Mineola, New York, US
 
Mean of 13.3
 
32% (daily 3%, few times per week 13%, few times per months 16%)
/
Teitelbaum
2014
Chicago, Illinois, US
41
12
95%
14.6%
GERDQ score > 7
Li
2013
Shanghai, China
234
12
94%
16.7%
GERDQ score > =7
von Renteln
2013
European MCT
70
3
100%
32.8% (daily 1.5%, occasionally 31.3%)
/
61
6
30% (daily 6.6% daily, occasionally 23.4%)
51
12
37.2% (daily 7.8%, occasionally 29.4%)
Chiu
2013
Hong Kong, China
16
3
100%
6.3%
/
Minami
2013
Nagasaki, Japan
28
Median of 16
100%
21.4%
/
Verlaan
2013
Amsterdam, Netherlands
10
3
100%
30.0%
/
Swanstrom
2012
Portland, Oregon, US
18
6
100%
44% (daily 11.1%, occasionally 16.7%, rarely 16.7%)
/
von Renteln
2012
Hamburg, Frankfurt
16
3
100%
0.0%
/

Endoscopic Evidence of Reflux

Esophagitis found upon endoscopy is an objective indication of the likely presence of reflux, but endoscopy is not routinely performed in all centers that have reported their series. Stratification of severity in esophagitis is mostly reported using the Los Angeles classification of esophagitis [12].
Rate of esophagitis seen upon endoscopy had a larger variation compared with rate of symptoms, ranging from 6.3 to 64.7% (Table 13.2). The proportion of studied patients who received an endoscopy also varies quite significantly from 10 to 100%. Series with a lower endoscopy surveillance rate often report a higher incidence of esophagitis, likely due to selection bias. Studies with less than 60% of the studied patients having had endoscopy all reported an incidence of over 50% [4, 8, 13]. The incidence in the remaining reports still varies significantly, but most reports lie within 20–42%.
Table 13.2
Reported incidence of esophagitis
Author
Year of publication
Location
Number of cases reported
Time point after POEM in months
Percentage of studied patients that received endoscopy
Percentage of endoscopy done having esophagitis
LA Grade A
LA Grade B
LA Grade C
LA Grade D
Percentage of patients with esophagitis having symptoms
Familiari
2016
Rome, Italy
149
Mean of 7.6 ± 3.6 months
69%
20.4%
8.7%
5.8%
4.9%
1.0%
42.8%
Chen
2015
Shanghai, China
26
Mean of 24.6
100%
11.5%
0.0%
11.5%
0.0%
66.7%
Inoue
2015
Yokohama, Japan
500
2 (n = 500)
83%
64.7%
33.8%
25.8%
4.8%
0.2%
370
12–24 (n = 370)
52%
59.2%
35.6%
13.1%
7.9%
2.6%
105
36 (n = 105)
15%
56.3%
43.8%
6.3%
6.3%
0.0%
Ramchandani
2015
Hyderabad, India
102
12
82%
16.6%
12.0%
4.8%
0.0%
0.0%
Sharata
2015
Portland, Oregon, US
100
Mean of 21.5
73%
27.4%
20.5%
4.1%
2.7%
0.0%
Shiwaku
2015
Fukuoka, Japan
70
3
100%
64.0%
48.6%
5.7%
10.0%
0.0%
11.1%
Werner
2015
International MCT
85
3–6
80%
36.8%
20.6%
16.2%
0.0%
0.0%
12–18
85%
37.5%
20.8%
12.5%
2.8%
0.0%
Ling
2014
Nanjing, China
87
3
10%
55.6%
33.3%
22.2%
0.0%
0.0%
Only symptomatic patients had endoscopy
Stavropoulos
2014
Mineola, New York, US
 
Mean of 13.3
53%
32.1%
Teitelbaum
2014
Chicago, Illinois, US
41
12
54%
59.0%
50.0%
0.0%
0.0%
9.0%
30.8%
Li
2013
Shanghai, China
234
12
100%
8.5%
90.0%
Minami
2013
Nagasaki, Japan
28
Median of 16
100%
39.3%
25.0%
3.6%
3.6%
0.0%
Verlaan
2013
Amsterdam, Netherlands
10
3
100%
60.0%
30.0%
30.0%
0.0%
0.0%
50.0%
von Renteln
2013
European MCT
70
3
42.0%
29.2%
12.3%
0.0%
0.0%
von Renteln
2012
Hamburg, Frankfurt
16
3
100%
6.3%
6.3%
0.0%
0.0%
0.0%
As in primary GERD, discordance between the rates of reflux symptoms and endoscopic evidence of reflux disease exists. Presence of symptoms has low sensitivity in predicting the presence of mucosal damage. As many as 88.9% of patients with esophagitis of Los Angeles Classification grade A or above can be asymptomatic, as reported by Shiwaku et al. [14] Some groups also reported a rate of 10% to almost 70% of asymptomatic patients having esophagitis (Table 13.2). Since long-standing esophagitis left untreated may lead to severe consequences, many authors advocate regular endoscopic surveillance to facilitate timely intervention.

Objective Studies on Reflux

Gastroesophageal reflux disease can also be objectively diagnosed using pH studies. Overall, the rate of an abnormal pH study generally ranges from 20.2% [15] to 57.7% [16], excluding one series in which pH testing was only provided for a single patient who had reflux symptoms registering 13.4% total time with esophageal acid exposure [17]. Assessing reflux with pH testing provides reliable objective data; however, diagnosing GERD with such a singular test may also lack standardization with the presence of different measurement methods and parameters.
In the literature, both 24-h probe-based monitoring and more prolonged monitoring using wireless capsules are used in different centers, some even within the same center (Table 13.3). Prolonged pH studies with wireless capsules are shown to be more sensitive in detecting pathological esophageal acid exposure and positive symptom association [18, 19]. Different normative values of percentage of total time of abnormal esophageal acid exposure for the wireless capsule system, ranging from 4.4 to 5.3%, have been reported [19, 20], which are slightly higher than the most referenced 4.2% for probe-based monitoring [21].
Table 13.3
Reported incidence of esophageal pH studies
Author
Year of publication
Location
Number of cases reported
Time point after POEM in months
Percentage of patients with pH study done
Percentage of pH studies done with positive result
pH monitoring method
Definition of positive pH study
Familiari
2016
Rome, Italy
149
6–12
69%
50.5%
24 h pH probe at 5 cm from OGJ
>5% of total time with pH < 4
Jones
2015
Columbus, Ohio, USA
42
6
62%
57.7%
48 h Bravo capsule
DeMeester score > 14.72
Sharata
2015
Portland, Oregon, US
100
6
68%
38.2%
24 h pH probe
DeMeester score > 14.7
Stavropoulos
2014
Mineola, New York, US
100
52%
32.7%
48 h Bravo capsule
Teitelbaum
2014
Chicago, Illinois, US
41
12

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Sep 30, 2017 | Posted by in GASTROENTEROLOGY | Comments Off on Management of Gastric Reflux Following Per-Oral Endoscopic Myotomy

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