Peroral endoscopic myotomy (POEM) is the treatment of choice for achalasia; however, the development of gastroesophageal reflux disease (GERD) after the procedure is considered a limitation. In that regard, the aims of this study were:

a) To assess the proportion of patients treated with POEM who require long-term proton pump inhibitor (PPI) therapy (>12 months).

b) To evaluate the rate of GERD during post-POEM follow-up.

We conducted a retrospective study of patients who underwent POEM between June 2018 and June 2024 in our center (terciary referral hospital for achalasia). We only included patiens with a minimum follow-up of 12 months. GERD was defined as the presence of: a) typical symptoms, b) erosive esophagitis on endoscopy (Los Angeles Classification grade ≥ B), and/or c) abnormal pH monitoring (acid exposure time ≥ 6% combined with manual interpretation consistent with acidic reflux).

A total of 85 patients were included (57% male; mean age 54 ± 15 years). The baseline Eckardt score was 7 ± 2, decreasing to 1 ± 2 post-POEM (median follow-up 20 months, interquartile range (IQR) 13–37). Mean esophageal myotomy length was 6 ± 2 cm and gastric myotomy 2 ± 1 cm. Long-term, 37% of patients did not require PPIs, 34% were on standard-dose PPIs, and 29% on double-dose PPIs (mean follow-up 26 ± 16 months). Indications for maintaining PPI therapy were: abnormal pH monitoring and/or esophagitis without GERD symptoms (49%), abnormal pH monitoring and/or esophagitis with GERD symptoms (40%), and symptoms alone without esophagitis or abnormal pH monitoring (11%).A pathological pH monitoring result was documented in 48% of patients during follow-up. At 3 months post-POEM, the esophagitis rate was 31% (20% grade B, 10% grade C, 1% grade D), but it decreased to 13% long-term (11% grade B, 2% grade C; mean follow-up 22 ± 14 months).

More than one-third of patients do not require long-term PPI therapy after POEM. Post-POEM GERD is generally mild, minimally symptomatic, and tends to decrease over time.