Prediction, prevention and management of gastroesophageal reflux after per-oral endoscopic myotomy: An update

Figure 1 Approach to evaluation and management of gastroesophageal reflux after per-oral endoscopic myotomy. POEM: Per-oral endoscopic myotomy; LA: Los Angeles.

Figure 2 Conventional and sling fiber preservation technique of per-oral endoscopic myotomy. A: Endoscopic image revealing second penetrating vessel along gastric side. Note that the sling fibers are located towards the left of penetrating vessel; B: Conventional myotomy performed along left side of the penetrating vessel to include sling fibers; C: Completion of conventional myotomy; D: Myotomy along the right side of the penetrating vessel to preserve sling fibers; E: Completion of myotomy (Note the preservation of sling fibers towards the left of second penetrating vessel).

Figure 3 Natural orifice transluminal endoscopic surgery fundoplication. A: Dissection of sub-serosal fibrofatty tissue to reach the peritoneal membrane; B: Creation of opening in the peritoneal membrane; C: Application of loop and endoclips along the serosal aspect of anterior wall of stomach; D: Application of second series of clips along the distal end of myotomy; E: Tightening of the endoloop; F: Endoscopic confirmation of the fundoplication wrap.

Figure 4 Impact of technique of myotomy on gastroesophageal reflux after per-oral endoscopic myotomy. GERD: Gastroesophageal reflux disease; NOTES: Natural orifice transluminal endoscopic surgery fundoplication.

Figure 5 Summary of the current understanding regarding the prediction, prevention, evaluation, and management of gastroesophageal reflux after per-oral endoscopic myotomy. GERD: Gastroesophageal reflux disease; NOTES: Natural orifice transluminal endoscopic surgery fundoplication; POEM: Per-oral endoscopic myotomy; LES: Lower esophageal sphincter.