Achalasia is an uncommon but debilitating disorder, with an estimated incidence of 1.63–4.0 per 100,000 people. Diagnosis relies on high-resolution manometry (HREM), often supplemented by endoscopy and barium swallow studies. The primary goal of treatment is symptomatic relief, particularly of dysphagia, which is commonly assessed using the Eckardt score. While pharmacologic agents and pneumatic dilation offer temporary relief, LHM and POEM represent the most definitive interventions. This review synthesizes current evidence to aid clinicians in selecting the most appropriate myotomy technique based on patient characteristics and clinical context.
Patient Selection: POEM vs. LHM
The decision between POEM and LHM should be tailored to individual patient factors (see Fig. 3 in original manuscript). POEM is particularly advantageous in patients with:
Prior abdominal surgery, as it avoids adhesions and uses native tissue planes.
Type III (spastic) achalasia, due to the ability to perform a longer, tailored myotomy.
Failed LHM, where POEM serves as an effective rescue therapy.
Frailty or intolerance to pneumoperitoneum, as POEM does not require abdominal insufflation.
LHM is preferred in:
PPI-averse patients, given its lower incidence of postoperative reflux.
Concomitant hiatal hernia, which can be repaired during the same procedure.
Pediatric populations, where long-term reflux risks with POEM are a concern.
Prior failed POEM, though data are still evolving.
Outcomes Comparison
Dysphagia Relief
Both procedures offer excellent and comparable dysphagia relief. In a randomized controlled trial by Werner et al. (2019), clinical success rates at two years were 83% for POEM and 81.7% for LHM. Systematic reviews support these findings, with recurrent dysphagia rates of 12.2% for POEM and 14.5% for LHM.
Post-Procedural Reflux
POEM is associated with higher rates of objective reflux. In the same RCT, reflux esophagitis was observed in 44% of POEM patients versus 29% of LHM patients at two years. Symptomatic reflux was reported in 22% of POEM patients in a large meta-analysis. LHM, typically performed with a partial fundoplication (Dor or Toupet), offers better anti-reflux protection. PPI use is often anticipated post-POEM and should be part of the treatment plan.
Complications and Reintervention
Serious adverse events are rare with both procedures. POEM may have a marginally lower risk of perforation or leak. Reintervention rates are slightly higher after LHM (9–15%) than after POEM (1–7%), though long-term data for POEM remain limited.
Technical Considerations
EndoFLIP: This tool measures esophagogastric junction distensibility intraoperatively, allowing surgeons to tailor myotomy length and reduce the risk of incomplete myotomy or reflux.
Learning Curves: Proficiency in POEM is typically achieved after about 25 cases, while LHM requires 16–20 procedures.
Robotic Heller Myotomy (RHM): Robotic assistance may reduce perforation rates and improve visualization, though it comes with higher costs.
Fundoplication Type: Partial fundoplication (Dor or Toupet) is standard with LHM. The choice between anterior (Dor) and posterior (Toupet) approaches depends on surgeon preference and the presence of a hiatal hernia.
Future Directions
Several areas warrant further investigation:
Long-term outcomes of POEM, especially in pediatric patients.
Direct comparisons between robotic Heller myotomy and POEM.
Development of endoscopic fundoplication techniques to reduce post-POEM reflux.
Cost-effectiveness analyses to guide resource allocation in diverse healthcare settings.
Conclusions
POEM and LHM are both safe and effective treatments for achalasia. While they offer equivalent dysphagia relief, they differ in reflux risk, invasiveness, and suitability for specific patient subgroups. POEM excels in complex cases such as type III achalasia and redo procedures, while LHM remains the preferred option for patients with hiatal hernias or concerns about long-term PPI use. The integration of advanced technologies like EndoFLIP and robotic platforms continues to refine surgical precision. Ultimately, treatment should be personalized and delivered at high-volume centers to ensure optimal outcomes.
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The study was recently published in the Journal of Translational Gastroenterology .
Journal of Translational Gastroenterology (JTG) dedicates to improving clinical diagnosis and treatment, advancing understanding of the molecular mechanisms, and promoting translation from bench to bedside of gastrointestinal, hepatobiliary, and pancreatic diseases. The aim of JTG is to provide a forum for the exchange of ideas and concepts on basic, translational, and clinical aspects of gastroenterology, and promote cross-disciplinary research and collaboration.
