POEM and GERD – dose technique matter? (GIE, Jan-2026)

POEM Techniques and GERD: Does Technique Matter?

POEM is a minimally invasive endoscopic procedure used to treat achalasia, a motility disorder of the esophagus. There are two primary techniques for POEM:

1. Full-Thickness (FT) POEM:

• This technique involves cutting through all layers of the esophageal muscle, including both circular and longitudinal fibers.
• While FT POEM is effective in relieving achalasia symptoms, it has been associated with higher incidences of GERD, as the full-thickness myotomy disrupts the integrity of the lower esophageal sphincter (LES), increasing the likelihood of acid reflux.

2. Modified Myotomy (MM) POEM:

• MM POEM includes techniques such as:
• Selective Circular Myotomy (CM): Only the circular muscle fibers are incised, sparing the longitudinal fibers.
• Oblique Fiber-Sparing Myotomy (OS): A more targeted approach that spares oblique fibers while addressing the circular fibers.
• These techniques aim to preserve some of the LES functionality, potentially reducing the incidence of GERD while still effectively treating achalasia.

GERD Incidences and Technique Differences:

The meta-analysis described in the context highlights the following key findings regarding the impact of POEM techniques on GERD:

• FT POEM:

• Associated with a higher rate of symptomatic GERD (Odds Ratio [OR]: 1.58; 95% CI: 1.12-2.23, P = .009) compared to MM POEM.

• This is likely due to the complete disruption of LES function caused by cutting through all muscle layers.

• MM POEM:

• Specifically, the Oblique Fiber-Sparing (OS) technique was found to have reduced symptomatic reflux compared to FT POEM.

• Selective Circular Myotomy (CM) showed similar rates of symptomatic reflux as FT POEM but had the advantage of shorter procedure duration.

Clinical Implications:

• The choice of POEM technique matters significantly in terms of GERD outcomes. Patients undergoing FT POEM may experience higher rates of post-procedure GERD, necessitating close monitoring and potential use of acid-suppressive therapies (e.g., proton pump inhibitors).
• MM POEM, particularly the OS technique, appears to be a promising alternative for reducing GERD risk while maintaining clinical efficacy in treating achalasia.
• However, the meta-analysis emphasizes the limited number of studies available and the observational nature of most included research, suggesting that further randomized controlled trials are needed to confirm these findings.

Conclusion:

The technique used in POEM does indeed influence GERD outcomes, with MM POEM techniques (especially OS) showing a potential advantage in reducing symptomatic reflux compared to FT POEM. The choice of technique should be tailored to individual patient needs, balancing the risk of GERD with the effectiveness of achalasia symptom relief.