From the Guidelines
Proton pump inhibitors (PPIs) should be strongly considered for all patients after a POEM procedure, given the increased risk of postprocedure reflux and esophagitis, as recommended by the most recent guidelines 1. The use of PPIs after POEM is crucial due to the disruption of the lower esophageal sphincter, which increases the risk of gastroesophageal reflux disease (GERD) and esophagitis, affecting 41%-65% of patients 1. Key points to consider when prescribing PPIs after POEM include:
- Standard regimens such as omeprazole 20-40 mg daily, pantoprazole 40 mg daily, or esomeprazole 40 mg daily, with some patients requiring twice-daily dosing initially
- Medication should be taken 30-60 minutes before meals to ensure adequate absorption and activation
- Review of diet and lifestyle modifications, such as avoiding late meals, elevating the head of the bed, and limiting alcohol and acidic foods, can complement medical therapy
- Patients should undergo monitoring for GERD after POEM, and those with persistent esophagitis and/or reflux-like symptoms despite PPI use should undergo additional testing to evaluate for other etiologies besides pathologic acid exposure and management to optimize and achieve reflux control 1.
From the Research
PPI after POEM Procedure
- The use of proton pump inhibitors (PPIs) after peroral endoscopic myotomy (POEM) is a common practice to manage gastroesophageal reflux disease (GERD) [(2,3,4)].
- Studies have shown that PPIs are effective in reducing symptoms of GERD after POEM, with one study finding that 81.4% of patients with erosive esophagitis responded to PPI therapy 3.
- However, the long-term use of PPIs after POEM is still a topic of debate, with some studies suggesting that patients may need to continue using PPIs for an extended period [(5,6)].
- A study found that 75% of patients who underwent transoral incisionless fundoplication (TIF) after POEM were able to discontinue or significantly reduce their PPI use 2.
- Another study found that the incidence of GERD after POEM is high, but most cases are mild and responsive to PPI therapy 3.
- The efficacy of PPIs in managing post-POEM GERD has been reviewed in the literature, with most studies suggesting that PPIs are an effective management strategy 4.
- A randomized clinical trial found that the anterior and posterior approaches to POEM had similar outcomes in terms of clinical success and GERD symptoms, with no significant difference in PPI use between the two groups 5.
- A nationwide register-based follow-up study found that more than 50% of patients became long-term PPI users 10-15 years after antireflux surgery 6.