Early observations and pilot data that first suggested a new direction
Laparoscopic Heller myotomy with fundoplication became the surgical standard for achalasia in the 1990s, offering a definitive disruption of the lower esophageal sphincter. The European Achalasia Trial (2011) randomized 201 patients with newly diagnosed achalasia to pneumatic dilation or laparoscopic Heller myotomy with Dor fundoplication. At 2 years, success rates were comparable (90% LHM vs 86% pneumatic dilation), establishing both as effective first-line treatments.
Landmark RCTs and pivotal trials that established the evidence base
Inoue and colleagues introduced peroral endoscopic myotomy (POEM) in 2010, performing the procedure in 17 consecutive achalasia patients. POEM achieved an endoscopic myotomy through a submucosal tunnel without external incisions. Short-term outcomes were comparable to Heller myotomy with the advantage of being a natural orifice procedure. Long-term European Achalasia Trial data (10-year follow-up) showed equivalent outcomes between pneumatic dilation and LHM (74% vs 74% success), confirming both approaches as durable treatments.
Follow-up studies, subgroup analyses, and real-world validation
A landmark 2019 RCT compared POEM to LHM with Dor fundoplication in 221 patients with newly diagnosed achalasia. At 2 years, treatment success was equivalent (POEM 83.0% vs LHM 81.7%), establishing POEM as a noninferiority alternative to surgical myotomy. However, gastroesophageal reflux was more prevalent after POEM (44% vs 29%), reflecting the absence of an anti-reflux procedure. This tradeoff — equivalent efficacy but higher reflux risk — became the central clinical consideration in treatment selection.
Integration into clinical practice guidelines and recommendations
Current guidelines recognize all three approaches — pneumatic dilation, LHM, and POEM — as effective treatments for achalasia. The choice depends on patient factors, manometric subtype, local expertise, and reflux risk tolerance.
ACG
Graded pneumatic dilation, LHM, or POEM all recommended for treatment-naive achalasia patients
UEG/ESNM
LHM and POEM both recommended; patient counseling regarding higher GERD risk with POEM essential
Now
Current standard of care and ongoing research directions
Achalasia treatment has evolved from a two-option landscape (pneumatic dilation vs LHM) to three established modalities with the addition of POEM. The key unresolved question is the long-term consequence of POEM-associated reflux, including Barrett's esophagus risk. Active research areas include manometric subtype-guided treatment selection, long-term POEM outcomes beyond 5 years, and the role of POEM for other esophageal motility disorders (spastic esophageal disorders, Zenker's diverticulum).
What is the most effective treatment for achalasia?+
All three established treatments — pneumatic dilation, laparoscopic Heller myotomy, and POEM — achieve comparable 2-year success rates of 81-90%. The European Achalasia Trial showed 74% success at 10 years for both PD and LHM. A 2019 RCT showed POEM (83%) and LHM (82%) are equivalent. The main distinguishing factor is GERD: POEM has higher reflux rates (44% vs 29%) due to the absence of a fundoplication.
What is POEM and how does it differ from Heller myotomy?+
POEM (Peroral Endoscopic Myotomy), developed by Inoue in 2010, performs a myotomy through a submucosal tunnel using a per-oral endoscopic approach with no external incisions. Unlike laparoscopic Heller myotomy, POEM does not include a fundoplication, which explains its higher post-procedure GERD rates (44% vs 29% in the 2019 RCT). POEM is a natural orifice procedure with potential advantages in recovery time and cosmesis.
