Treatment procedures for intractable gastroesophageal reflux disease after peroral endoscopic myotomy for achalasia: a retrospective study in South Korea

BACKGROUND: No study has compared the safety and efficacy of anti-reflux mucosal ablation (ARMA), anti-reflux mucosectomy (ARMS), and Stretta radiofrequency (SRF) for intractable gastroesophageal reflux disease (GERD) after peroral endoscopic myotomy (POEM). METHODS: Twenty-two patients with post-POEM GERD underwent either ARMA (n=12), ARMS (n=6), or SRF (n=4). GERD questionnaire (GERDQ) score, endoscopic Los Angeles classification, flap valve grade based on Hill's type EndoFLIP distensibility index (DI), and rate of proton pump inhibitor withdrawal were analyzed and compared. The factors associated with the occurrence of post-POEM intractable GERD were also evaluated. RESULTS: The ARMS group demonstrated a significant improvement in GERDQ scores after 6 months of follow-up (p=0.04). No significant differences were observed in the endoscopic Los Angeles grade (p=0.68), flap valve grade (p=0.38), or EndoFLIP DI (p=0.15). Type III achalasia and posterior myotomy orientation during POEM were identified as risk factors for reintervention. Postprocedural adverse events (bleeding and stricture) occurred in the ARMA and ARMS groups. CONCLUSIONS: Among the three procedures, ARMS produced the most notable improvement in symptoms, whereas endoscopic esophagitis and EndoFLIP DI did not show a similar improvement.