Endoscopic Management of Post-POEM Gastroesophageal Reflux Disease in Achalasia: Current Evidence, Techniques, and Clinical Decision Pathways

Abstract

Peroral endoscopic myotomy (POEM) has become a standard therapy for achalasia owing to its high efficacy, minimal invasiveness, and technical flexibility. However, elimination of the lower esophageal sphincter (LES) barrier creates a substantial risk of post-procedural gastroesophageal reflux disease (GERD), with reported rates ranging from 30–60% depending on objective testing. While proton pump inhibitors (PPIs) remain first-line therapy, a considerable subset of patients continue to experience persistent or progressive reflux symptoms, esophagitis, or pathological acid exposure. This has led to rapid development of minimally invasive endoscopic anti-reflux techniques tailored to the unique post-POEM anatomy.

This review summarizes the incidence, mechanisms, and diagnostic evaluation of GERD following POEM, followed by a detailed overview of emerging endoscopic management strategies including transoral incisionless fundoplication (TIF), anti-reflux mucosectomy (ARMS), anti-reflux mucosal ablation (ARMA), Stretta radiofrequency therapy, and endoscopic suturing-based fundoplication. The review highlights the strengths and limitations of each modality, comparative effectiveness, and patient selection criteria. A stepwise management algorithm is proposed integrating symptom assessment, endoscopic findings, pH-impedance metrics, and anatomical considerations.

Endoscopic therapies now bridge the gap between medical and surgical approaches, offering durable reflux control with significantly lower morbidity. As POEM becomes increasingly widespread, structured evaluation and individualized management of post-POEM GERD are essential. Future directions include hybrid POEM-fundoplication (POEM-F), artificial valve restoration devices, and AI-driven prediction models for GERD risk stratification.