Is peroral endoscopic myotomy (POEM) a curative treatment for achalasia or merely a palliative surgical intervention?

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POEM is Palliative, Not Curative for Achalasia

POEM is a palliative intervention for achalasia, not a cure—it provides highly effective symptom relief by mechanically disrupting the lower esophageal sphincter, but does not address the underlying neurodegeneration and requires lifelong management of complications, particularly gastroesophageal reflux disease.

Understanding the Nature of Achalasia Treatment

Achalasia is a progressive neurodegenerative disorder characterized by loss of inhibitory neurons in the myenteric plexus, leading to impaired LES relaxation and absent peristalsis. No current treatment—including POEM, laparoscopic Heller myotomy (LHM), or pneumatic dilation—reverses this underlying pathophysiology. All interventions are palliative, aimed at relieving the mechanical obstruction at the gastroesophageal junction 1.

Why POEM is Palliative

Mechanism of Action

POEM works by performing an endoscopic myotomy of the circular muscle layer of the esophagus and LES, mechanically disrupting the sphincter to allow food passage. This addresses the consequence of the disease (obstruction) but not the cause (neuronal loss) 1.

Evidence of Palliation Rather Than Cure

Symptom recurrence occurs in 10-15% of patients after initial myotomy (POEM or LHM), requiring repeat interventions 2. This demonstrates that the disease process continues despite treatment.

Persistent esophageal dysfunction remains: While POEM significantly improves Eckardt scores (from ~7-8 pre-procedure to 0-1 post-procedure) 3, 4, patients still lack normal esophageal peristalsis. The esophagus relies on gravity and residual pressure for emptying rather than coordinated muscular contractions.

Long-term complications require ongoing management:

  • Gastroesophageal reflux disease develops in 41-65% of patients, with esophagitis in 41-65% 2
  • Abnormal acid exposure occurs in 41-56% of cases 2
  • Critically, 31% of patients with initially normal endoscopy develop esophagitis at subsequent surveillance (mean 29 months), including new Barrett's esophagus in some cases 1
  • Most patients require indefinite proton pump inhibitor therapy 2, 1

Increased cancer risk persists: Patients with achalasia have a 5-fold higher risk of esophageal cancer (hazard ratio 4.6; 95% CI 2.3-9.2) compared to those without achalasia, supporting the need for ongoing endoscopic surveillance even after successful POEM 2.

Clinical Efficacy as Palliation

POEM demonstrates excellent palliative efficacy:

  • Clinical success rates of 83-92% at 2 years 3
  • Significant reduction in LES pressure (from ~25.5 mmHg to 4.5 mmHg in type III achalasia) 5
  • Improved esophageal emptying on timed barium swallow (retention reduced from 63% to 5% at 5 minutes) 4
  • Durable symptom relief maintained at follow-up beyond 12 months 4

However, these outcomes represent symptom control and functional improvement, not disease eradication.

Comparison to Other Palliative Treatments

POEM is noninferior to LHM plus Dor's fundoplication for symptom control at 2 years (83.0% vs 81.7% clinical success) 3. Both procedures are equally palliative. The key differences lie in:

  • POEM has higher rates of reflux esophagitis (44-57% vs 20-29% with LHM) 3
  • POEM offers advantages in type III achalasia due to the ability to perform longer myotomies (averaging 17.2 cm) targeting spastic segments 1
  • POEM may be superior for failed initial myotomy (62% vs 27% success compared to pneumatic dilation) 2

Lifelong Management Requirements

Post-POEM patients require:

  1. Pharmacologic acid suppression should be strongly considered immediately post-POEM given increased reflux risk 2

  2. Objective evaluation for reflux with follow-up endoscopy and/or pH monitoring at 6-12 months, as reflux symptoms may not correlate with pathologic acid exposure 2

  3. Surveillance endoscopy for erosive esophagitis and Barrett's esophagus, given the high rate of asymptomatic esophagitis and persistent cancer risk 2, 1

  4. Potential indefinite PPI therapy for symptomatic reflux or erosive esophagitis 1

Common Pitfalls

  • Assuming symptom relief equals cure: Excellent dysphagia control does not mean the underlying neurodegenerative process has stopped
  • Underestimating reflux burden: Many patients with erosive esophagitis are asymptomatic, requiring objective testing rather than relying on symptoms alone 2, 1
  • Inadequate long-term follow-up: The development of delayed esophagitis and Barrett's esophagus necessitates ongoing surveillance 1

The Bottom Line

POEM should be presented to patients as a highly effective palliative procedure that reliably controls dysphagia and improves quality of life, but requires lifelong management of reflux complications and surveillance for esophageal cancer. It is not a cure, as it does not restore normal esophageal neuronal function or peristalsis, and the underlying disease process continues 2, 1, 3.

References

3
Research

Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia.

The New England journal of medicine, 2019

5
Research

Peroral endoscopic myotomy provides effective palliation in type III achalasia.

The Journal of thoracic and cardiovascular surgery, 2022

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