How often should upper endoscopy be performed in a patient with a history of achalasia and previous Peroral Endoscopic Myotomy (POEM) surgery?

Post-POEM Endoscopic Surveillance Frequency

All patients with achalasia who have undergone POEM require lifelong endoscopic surveillance performed at regular intervals, alternating between upper endoscopy and esophagram to monitor for GERD complications, disease progression, and esophageal cancer risk. 1

Surveillance Framework

Mandatory Long-Term Monitoring

• Upper endoscopy must be performed at regular intervals to evaluate for erosive esophagitis, Barrett's esophagus, strictures, and structural abnormalities in all post-POEM patients 2, 1
• Surveillance should alternate between esophagram and endoscopy to comprehensively monitor structural changes, esophageal clearance, and mucosal abnormalities 1
• This surveillance is mandatory regardless of symptom status, as achalasia is a chronic progressive condition requiring lifelong monitoring 1

Critical Rationale for Ongoing Surveillance

High GERD Burden:

• 41-65% of post-POEM patients develop esophagitis, with objective evidence of gastroesophageal reflux documented in 46% of patients at 6 months 1, 3
• Critically, 25% of patients with erosive esophagitis remain completely asymptomatic, making symptom-based monitoring dangerously inadequate 1
• At 5-year follow-up, 13% of patients had erosive esophagitis on endoscopy, with one patient developing new non-dysplastic Barrett's esophagus 4

Elevated Cancer Risk:

• Patients with achalasia have a 5-fold increased risk of esophageal cancer (HR 4.6,95% CI 2.3-9.2) compared to the general population 1
• This elevated risk persists after treatment and mandates ongoing endoscopic surveillance 1

Progressive Disease Nature:

• Up to 31% of patients with initially normal endoscopy develop esophagitis at subsequent surveillance, including Barrett's esophagus in some cases 5
• 10-15% of patients experience persistent or recurrent symptoms after POEM, requiring comprehensive re-evaluation 1, 5

Comprehensive Surveillance Protocol

Endoscopic Evaluation Components

• Upper endoscopy to assess mucosal integrity, identify erosive esophagitis, Barrett's esophagus, strictures, and malignancy 1, 5
• Functional luminal impedance planimetry (FLIP) can be incorporated during endoscopy to assess esophagogastric junction opening 1
• Timed barium esophagram to monitor esophageal emptying and structural changes 1, 6

Objective Reflux Assessment

• 24-hour pH monitoring is essential even in asymptomatic patients to objectively document pathologic acid exposure, as symptoms alone are insufficient to detect reflux disease 1, 5
• 38% of patients showed abnormal distal esophageal acid exposure on 24-hour pH monitoring at 6-month follow-up despite symptom improvement 4

Functional Assessment

• High-resolution manometry to assess lower esophageal sphincter function and treatment efficacy 1, 5
• Timed barium swallow provides objective variables valuable in treatment response evaluation 6

Management Based on Surveillance Findings

If Erosive Esophagitis Detected:

• Optimize PPI therapy immediately 1, 5
• Consider lifelong acid suppression given the high rate of abnormal acid exposure post-POEM (41-56% on pH monitoring) 1
• All cases of esophagitis in one series resolved with acid suppression therapy 7

If Barrett's Esophagus Develops:

• Follow established Barrett's surveillance protocols given the already elevated baseline cancer risk 1

If Treatment Failure Confirmed:

• Comprehensive re-evaluation with repeat esophagogastroduodenoscopy, high-resolution manometry, and timed barium esophagram 1, 5
• Consider repeat POEM, which may be superior to pneumatic dilation for failed initial myotomy (62% vs 27% success rate) 1, 5

Critical Pitfalls to Avoid

Never rely on symptoms alone - One-quarter of patients with esophagitis are completely asymptomatic, making objective testing with endoscopy and pH monitoring absolutely essential 1, 5

Never discontinue surveillance prematurely - Achalasia is a chronic progressive condition requiring lifelong monitoring, with complications developing years after the initial procedure 1

Never assume PPI therapy alone is sufficient - Objective documentation of reflux control with pH monitoring is necessary even in patients on PPI therapy, as 25% of patients with esophagitis have no reflux symptoms 1

Long-Term Outcome Data

At 5-year follow-up, while 83% of achalasia patients maintained symptomatic success (Eckardt score ≤3), there was a small but significant worsening of symptoms between 2 and 5 years, emphasizing the importance of continued surveillance 4. At mean 11.4-month follow-up, dysphagia relief persisted for all patients, but objective evidence of gastroesophageal reflux was seen in 46% 3.