Do long-term reflux symptoms after an achalasia procedure reliably match objective reflux tests?

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Peroral endoscopic myotomy (POEM) effectively treats achalasia but carries a significant risk of postoperative gastroesophageal reflux. Previous studies show poor short-term agreement between reflux symptoms and objective findings, while long-term outcomes remain unclear. This study evaluated long-term GERD Health-Related Quality of Life (GERD-HRQL) scores, Bravo pH test results, and proton pump inhibitor (PPI) use after POEM.

Researchers conducted a prospective survey study of adults who underwent POEM at their institution from 2011 to 2024 and had more than 1 year of follow-up. Standardized surveys included the validated GERD-HRQL questionnaire and questions about PPI use and interventions after POEM. Chart review verified medication use, Bravo results, and endoscopic findings. The primary endpoint was reflux symptom control, defined as a GERD-HRQL score < 10. Secondary endpoints were chronic PPI use (> 6 months), Bravo results, and the relationship between reflux and dysphagia. Multivariable logistic regression was used to identify predictors of reflux symptom control.

Seventy-nine patients completed the questionnaire at a median follow-up of 68 months. The median GERD-HRQL score was 10 (interquartile range 4–17), and 42 patients (53.2%) reported clinically significant reflux, defined as GERD-HRQL ≥ 10. Chronic PPI use was reported in 58 patients (73.4%); among those users, 55.2% reported poor symptom control. Among patients with GERD-HRQL ≥ 10, 52.4% had Eckardt scores > 3, suggesting concurrent dysphagia.

Thirty-one patients underwent Bravo pH testing after POEM: results were negative in 13 (41.9%), positive in 13 (41.9%), and inconclusive in 5 (16.1%). Of 10 Bravo tests performed for reflux symptoms, 6 were negative. Endoscopy in 56 patients showed esophagitis in 16 (28.6%).

In the multivariable analysis, older age (odds ratio [OR] 1.04; 95% confidence interval [CI] 1.01–1.08) and preoperative weight loss ≥ 5 kg (OR 6.72; 95% CI 1.57–28.74) were associated with reflux symptom control.

The researchers concluded that, at long-term follow-up, over half of patients reported clinically significant reflux and most required chronic PPI therapy. Reflux symptoms correlated inconsistently with objective findings, mirroring short-term data and highlighting the need for ongoing surveillance and targeted reflux mitigation after POEM.