From the Guidelines
Peroral endoscopic myotomy (POEM) is the preferred treatment for achalasia, particularly for type III achalasia, and should be considered as primary therapy or as a treatment option comparable to laparoscopic Heller myotomy for any of the achalasia syndromes, as supported by the most recent evidence from 2024 1. The indications for POEM in achalasia include:
- Patients with significant dysphagia, regurgitation, chest pain, or weight loss that impacts quality of life
- Patients with confirmed achalasia diagnosis through manometry, barium esophagram, and endoscopy
- Patients who have failed prior treatments such as Heller myotomy or pneumatic dilation
- Patients with type III achalasia, where POEM has shown particularly strong results due to its ability to perform an extended myotomy along the distal esophagus The procedure involves creating a submucosal tunnel and selectively cutting the circular muscle fibers of the lower esophageal sphincter, preserving the outer longitudinal muscle layer, and has been shown to result in excellent clinical outcomes with success rates of 80-95% and lower risk of complications like perforation compared to surgical approaches, as noted in the 2017 study 1. However, patients should be counseled about the potential for post-procedure gastroesophageal reflux disease, which occurs in approximately 30-50% of cases and may require acid-suppressive medication, as highlighted in the 2024 study 1. It is also important to consider the expertise and experience of the physician performing the procedure, as well as the patient's individual characteristics and preferences, when deciding between treatment modalities, as emphasized in the 2024 study 1.
From the Research
Treatment Options for Achalasia
The treatment options for achalasia include:
- Pneumatic dilation: a procedure where a balloon is used to dilate the lower esophageal sphincter (LES) to improve esophageal emptying 2, 3, 4
- Laparoscopic Heller myotomy: a surgical procedure where the LES is cut to reduce its pressure and improve esophageal emptying 2, 5, 6
- Peroral endoscopic myotomy (POEM): a minimally invasive procedure where the LES is cut using an endoscope 5
- Botulinum toxin injection: a procedure where botulinum toxin is injected into the LES to reduce its pressure and improve esophageal emptying 2, 5, 6
Efficacy of Treatment Options
The efficacy of treatment options for achalasia varies:
- Pneumatic dilation has a success rate of 81-90% 3, 4
- Laparoscopic Heller myotomy has a success rate of 84-94% 2, 5
- POEM has a success rate of up to 90% 5
- Botulinum toxin injection has a success rate of up to 75% but requires periodic reinjection 5, 6
Complications of Treatment Options
The complications of treatment options for achalasia include: