POEM (Peroral Endoscopic Myotomy) for Achalasia

Peroral endoscopic myotomy (POEM) is a third-space endoscopic procedure for esophageal achalasia and other spastic motility disorders. After mucosotomy in the mid-esophagus, a submucosal tunnel is created down to the gastric cardia, the inner circular muscle is divided over a length determined by the achalasia subtype, and the mucosotomy is closed with clips, achieving Heller-equivalent myotomy without abdominal incisions.

Indications include all Chicago Classification achalasia subtypes (I, II, III), with strongest benefit in type III (spastic) achalasia where a long myotomy can be tailored. Other indications include diffuse esophageal spasm, jackhammer esophagus, post-fundoplication dysphagia in selected cases, and recurrent symptoms after Heller myotomy. Contraindications are severe coagulopathy, prior radiation, and unstable cardiopulmonary status.

Outcomes show clinical success in 85 to 95 percent of patients at 2 years with Eckardt score below 3. The main downside is post-POEM gastroesophageal reflux in up to 30 to 50 percent, often asymptomatic but requiring proton-pump inhibitor therapy and pH monitoring. Adverse events include capnoperitoneum, mucosal perforation, bleeding, and rarely esophageal stricture; experienced centers report serious complications under 5 percent.