Expert Panel Survey on GERD Management After Esophageal POEM

Overview

A national survey of expert endoscopists and esophagologists revealed diverse practices and beliefs regarding GERD management following esophageal per-oral endoscopic myotomy (E-POEM). Despite consensus on some aspects of post-POEM care, significant variability remains in acid suppression duration, use of pH testing, and surveillance strategies for esophageal cancer.

Background

Achalasia is a rare esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and esophageal contraction, leading to symptoms such as dysphagia and regurgitation. Treatment options include pneumatic dilation, laparoscopic Heller myotomy (LHM) with fundoplication, and E-POEM, with E-POEM showing comparable efficacy to LHM in randomized trials. Gastroesophageal reflux disease (GERD) is the most common complication after E-POEM, affecting approximately 38% of patients, but symptom correlation with esophagitis is poor, complicating diagnosis and management. Current guidelines and consensus statements highlight the need for acid suppression and monitoring but lack specific recommendations on testing and surveillance.

Data Highlights

Survey response rate was 50% (30/60 experts), with 90% performing E-POEM. The survey included 17 items covering practice characteristics and management decisions. Key findings showed no consensus on acid suppression duration, pH testing indications, or endoscopic surveillance. Statistical analysis found no significant association between practice type or case volume and decisions on pH testing or surveillance.

Key Findings

• Half of surveyed experts responded, representing experienced E-POEM practitioners and esophagologists.
• Consensus exists on same-day discharge and routine clinic follow-up post-POEM.
• Significant variability in acid suppression therapy duration and de-escalation strategies.
• Disagreement on the role and timing of pH testing to evaluate post-POEM GERD.
• No consensus on the need or interval for endoscopic surveillance for esophageal cancer post-POEM.
• Current guidelines recommend acid suppression and monitoring but lack detailed protocols, reflecting survey findings.

Clinical Implications

Clinicians should strongly consider initiating acid suppression therapy after E-POEM and ensure routine clinical follow-up to monitor for GERD symptoms. Given the poor symptom correlation and lack of consensus on pH testing, individualized assessment is warranted. Long-term surveillance strategies for esophageal cancer remain undefined, emphasizing the need for clinician judgment and patient-specific risk evaluation.

Conclusion

This expert panel survey highlights ongoing controversies and practice variability in managing GERD after E-POEM, underscoring the need for further research to establish evidence-based guidelines. Until then, clinicians must balance current recommendations with individualized patient care.

References

1. Expert Panel/2024 -- Insights from an Expert Panel on the Management of GERD Following Esophageal POEM: Findings from a National Survey