Is it necessary to explore modified peroral endoscopic myotomy strategies to prevent the occurrence of gastroesophageal reflux?

We read with interest the study by Nabi et al,1Nabi Z. Chandran V. Basha J. et al.Conventional versus oblique fiber-sparing endoscopic myotomy for achalasia cardia: a randomized controlled trial.Gastrointest Endosc. 2024; 99: 1-9Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar who performed a randomized controlled trial to compare the incidence of gastroesophageal reflux (GER) between conventional peroral endoscopic myotomy (POEM) and oblique fiber-sparing POEM. Finally, they found that modified oblique fiber-sparing POEM did not reduce the occurrence of GER. In this regard, we would like to raise some considerations on the issue of postoperative GER. POEM has been demonstrated to be a safe and effective treatment for achalasia, but the high incidence of postoperative GER has always attracted considerable controversy. Therefore, many researchers have been committed to exploring modified POEM techniques to prevent GER. Previous studies had demonstrated that short esophageal myotomy2Gu L. Ouyang Z. Lv L. et al.Safety and efficacy of peroral endoscopic myotomy with standard myotomy versus short myotomy for treatment-naïve patients with type II achalasia: a prospective randomized trial.Gastrointest Endosc. 2021; 93: 1304-1312Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar and preservation of oblique muscle3Tanaka S. Toyonaga T. Kawara F. et al.Novel per-oral endoscopic myotomy method preserving oblique muscle using two penetrating vessels as anatomic landmarks reduces operative gastroesophageal reflux.J Gastroenterol Hepatol. 2019; 34: 2158-2163Crossref PubMed Scopus (24) Google Scholar might reduce the incidence of GER. However, these conclusions have been contradicted by recently published randomized controlled trials showing no significant difference.1Nabi Z. Chandran V. Basha J. et al.Conventional versus oblique fiber-sparing endoscopic myotomy for achalasia cardia: a randomized controlled trial.Gastrointest Endosc. 2024; 99: 1-9Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,4Familiari P. Borrelli de Andreis F. Landi R. et al.Long versus short peroral endoscopic myotomy for the treatment of achalasia: results of a non-inferiority randomised controlled trial.Gut. 2023; 72: 1442-1450Crossref PubMed Scopus (6) Google Scholar It seems that much time and energy has been invested without finding a shortcut to reduce the occurrence of GER. This could be attributed to POEM's inevitable destruction of the esophageal antireflux structure integrity. However, is it necessary to explore modified POEM to prevent GER? Although the incidence of GER is very high, current studies have confirmed that proton pump inhibitors can control the majority of GER.5Nabi Z. Ramchandani M. Kotla R. et al.Gastroesophageal reflux disease after peroral endoscopic myotomy is unpredictable, but responsive to proton pump inhibitor therapy: a large, single-center study.Endoscopy. 2020; 52: 643-651Crossref PubMed Scopus (28) Google Scholar In addition, 1 reason for concern is that GER may cause esophageal stricture, Barrett's esophagus, and esophageal adenocarcinoma. However, a meta-analysis involving 2342 patients showed that only 2 cases of esophageal stricture and 1 of Barrett's esophagus were observed during long-term follow-up, without any report of esophageal adenocarcinoma.6Vespa E. Pellegatta G. Chandrasekar V.T. et al.Long-term outcomes of peroral endoscopic myotomy for achalasia: a systematic review and meta-analysis.Endoscopy. 2023; 55: 167-175Crossref PubMed Scopus (13) Google Scholar Therefore, we believe that the pathogenesis, risk factors, and treatment strategies of postoperative refractory GER deserve more attention than the prevention of GER. Nevertheless, this is what the current research lacks. All authors disclosed no financial relationships.