Peroral endoscopic myotomy (POEM) is now an established method for the treatment of achalasia cardia with superior outcomes compared to pneumatic balloon dilation and equivalent outcomes compared to laparoscopic Heller’s myotomy.^1,2 Post-procedure gastro-oesophageal reflux disease (GERD) is one of the main short comings of the procedure. Various retrospective studies have shown its incidence between 16% to 50%.³ However, in view of paucity of prospective real world studies, we did a prospective study to know the prevalence of GERD in patients undergoing POEM procedure.  

We conduced a prospective open label study between November 2022 to June 2024 after obtaining an ethical approval. The baseline characteristics, procedure details, and post-procedure follow-up were recorded prospectively. At 12 months post-procedure, patients underwent detailed evaluation to know the prevalence of GERD in this group of patients. GERD was defined as per Lyon 2.0 criteria.⁴ Esophagitis was classified as per Los Angeles criteria. Patients requiring >3 PPI (proton pump inhibitor) intake per week were defined as PPI dependency. Patients reflux symptoms score was defined as per GERD-Q questionnaire. Pearson’s correlation was performed between reflux symptoms score, PPI dependency, esophagitis grade and diagnosis of GERD. Multi-variate analysis was performed to identify risk factors for GERD. 

Total of 75 patients included in the study. Mean age of the included patients was 40.75±16.7 years with 61.3% patients were male. Majority of patients had type I achalasia (64%) and 28% of patients had prior endoscopic treatment in form of either pneumatic ballon dilation (20%) or laproscopic Helle’s myotomy (6.7%). Majority of patients underwent posterior POEM (90.7%) with mean oesophageal myotomy length of 10.49±4.42 cm and gastric myotomy length of 2.75±0.62 cm. 96% patients achieved clinical success. 28.8%, 32.8% and 34.2% patients had GERD-Q score >8 at 3, 6 and 12 months follow-up respectively. At 12 months, 34.2% patients had PPI dependency, 11.8% of patients had significant esophagitis (Grade C/D) and 31.7% of patients had AET>6%. 32.6% of patients were diagnosed as GERD as per Lyon 2.0 criteria. Presence of GERD-Q questionnaire >8 (p=0.002),  having PPI dependency (p=0.003) was correlated with diagnosis of GERD. However, on logistic regression, we could not find any baseline or intra-procedural risk factors for development of GERD.

Around one third of patients develop GERD post-POEM at 12 months of follow-up. Reflux symptoms score and PPI usage are correlated with GERD diagnosis and which should be used to select the patients for further invasive investigations including endoscopy and pH-metry.