What is the difference in myotomy technique between Heller's myotomy and Peroral Endoscopic Myotomy (POEM) for a patient with achalasia cardia?

Technical Differences Between Heller Myotomy and POEM

The fundamental difference is that POEM creates a submucosal tunnel to access and divide the muscle layers endoscopically without external incisions, while Heller myotomy requires surgical isolation of the gastroesophageal junction through abdominal incisions with disruption of anti-reflux mechanisms, necessitating fundoplication. 1, 2

Anatomical Approach and Access

Heller Myotomy (LHM)

• Requires complete surgical isolation of the esophagogastric junction through laparoscopic abdominal incisions, which mandates division of the phrenoesophageal ligament and short gastric vessels 1
• This surgical dissection disrupts critical anti-reflux mechanisms that maintain the angle of His, making concomitant fundoplication (Toupet or Dor) necessary to prevent postoperative reflux 3, 1
• The myotomy divides circular and longitudinal muscle layers after complete mobilization to accurately identify the gastroesophageal junction 1
• Typical myotomy length is approximately 8 cm 4

POEM Technique

• Creates a mucosal incision 10-15 cm proximal to the lower esophageal sphincter and develops a submucosal tunnel extending distally 2-4 cm onto the gastric cardia 2
• The circular muscle myotomy begins at least 2-3 cm distal to the mucosotomy and progresses to the distal point of cardia dissection 3, 2
• Avoids gastroesophageal junction dissection entirely, preserving the phrenoesophageal ligament and short gastric vessels 3
• Allows for significantly longer myotomy (average 16 cm) without requiring mediastinal dissection 4
• No fundoplication is performed 3

Technical Advantages of Each Approach

POEM Advantages

• No abdominal incisions with more rapid recovery and option to avoid general anesthesia with airway intubation 3
• Ease of performing longer myotomy when desired, particularly beneficial for Type III achalasia with spastic contractions 3, 4
• Avoidance of vagal nerve injury 3
• No intra-abdominal adhesions that might hinder future surgery 3
• Significantly shorter operative time (102 minutes vs 264 minutes for LHM) despite longer myotomy length 4
• Shorter hospital stay (approximately 0.70 days less than LHM) 5, 6
• Less postoperative pain 5

Heller Myotomy Considerations

• Provides opportunity for concurrent fundoplication to address reflux risk 1
• Established long-term efficacy data 7
• Direct visualization of the gastroesophageal junction 1

Clinical Outcomes and Complications

Efficacy

• POEM demonstrates higher clinical success rates (98% vs 80.8% for LHM in Type III achalasia) 4
• Both procedures show treatment success rates >90% with equivalent long-term efficacy at ≥24 months follow-up 2, 6
• POEM shows significantly lower short-term clinical treatment failure rates compared to LHM 8

Reflux Complications

• POEM carries substantially higher reflux risk despite avoiding EGJ dissection, with endoscopic or pH-metry evidence of GERD in up to 58% of patients 3, 9
• Erosive esophagitis occurs in 23-48% of POEM patients (including 8.3% with Los Angeles grade C or D) compared to 13% after pneumatic dilation 3, 9
• Meta-analysis shows odds ratio of 9.31 for erosive esophagitis with POEM compared to LHM 3
• 31% of POEM patients with initially good outcomes develop esophagitis at mean 29-month follow-up, including new Barrett's esophagus in some cases 3
• Many patients remain asymptomatic despite erosive esophagitis, requiring surveillance endoscopy 3

Other Complications

• POEM: Serious adverse events (perforation, pneumothorax, bleeding) occur in 0.5-3.2% of cases 2
• LHM: Potential for fundoplication-related obstructive dysphagia given the aperistaltic esophagus 3
• Overall complication rates are comparable between procedures 8, 5

Postoperative Management Differences

POEM Protocol

• Overnight observation with clear liquids if no adverse events 2
• Upper gastrointestinal contrast study the day after to ensure no leakage 2
• Full-liquid diet for 5-7 days, then 5-6 small meals of low-fiber, low-fat solids 2
• Mandatory 8 weeks of proton pump inhibitor therapy with consideration for indefinite PPI given high reflux rates 2, 9

Heller Myotomy Protocol

• Similar dietary advancement 1
• 8 weeks of PPI therapy recommended, with consideration for lifelong therapy given reflux rates up to 58% 1, 9
• Aggressive antiemetic therapy critical as vomiting can disrupt myotomy site and displace fundoplication 9

Procedure Selection Algorithm

For Type III achalasia with spastic contractions: POEM is superior due to ability to perform longer myotomy (16 cm vs 8 cm) with better clinical response rates (98% vs 80.8%) 4

For patients prioritizing minimal reflux risk: LHM with fundoplication provides better reflux control, though POEM with aggressive PPI therapy remains effective 3, 6

For patients requiring faster recovery: POEM offers shorter operative time, hospital stay, and less postoperative pain 5, 4, 6

For treatment-naïve achalasia: Both procedures show equivalent long-term efficacy, but POEM requires mandatory surveillance endoscopy for asymptomatic erosive esophagitis 3, 6