POEM (Peroral Endoscopic Myotomy) for Achalasia

POEM (Peroral Endoscopic Myotomy) treats achalasia by cutting the tight, poorly relaxing muscle at the lower end of the esophagus — the underlying cause of achalasia — entirely through an endoscope passed through the mouth. It achieves the same fundamental result as the traditional surgical treatment (Heller myotomy) but without any external incisions.

Yes to both, and the evidence here is unusually strong and consistent. Roughly 9 out of 10 patients get lasting relief from their swallowing difficulty, and that success rate holds up remarkably well over time — still above 9 in 10 at five years and beyond in the largest long-term studies available. Across a combined 373 patients in one major review, there were zero procedure-related deaths. The one honest trade-off: because the procedure works by cutting some of the same muscle that normally helps prevent reflux, somewhere between 1 in 10 and 1 in 5 patients develop new or worse heartburn afterward. This is generally well managed with standard reflux medication and doesn't take away from how effective POEM is at solving the swallowing problem itself. The section further down this page, ‘The evidence in more detail,’ has the specific studies behind these numbers.

POEM belongs to a category of techniques sometimes called 'third space' endoscopy — working within the wall of the esophagus itself, not just its inner lining (see the Advanced Endoscopy Clinic page for more on this concept). The endoscopist creates a small opening in the esophageal lining, then tunnels within the wall of the esophagus to reach the tight muscle layer. That muscle is then carefully cut (myotomy) along a controlled length, relieving the obstruction that prevents food and liquid from passing into the stomach. The entry point in the lining is then closed with endoscopic clips, leaving no external scar.

As covered on the Achalasia page, the Chicago Classification subtype (Type I, II, or III) influences how well different treatments work. POEM is particularly effective for Type II achalasia, and its ability to extend the myotomy to a longer, more customized length has made it an increasingly preferred option for Type III (spastic) achalasia specifically, where traditional surgery is technically more difficult. POEM has also shown strong effectiveness in other esophageal motility disorders beyond classic achalasia, including diffuse esophageal spasm.

• Before: esophageal manometry to confirm the diagnosis and subtype, barium swallow, and upper GI endoscopy
• During: performed under general anesthesia; the procedure typically takes under an hour
• After: a short hospital stay is typical; a gradual diet progression follows, along with monitoring for reflux symptoms
• Follow-up: symptom review and, given the reflux trade-off, proactive discussion of acid-suppressing medication even without symptoms in some cases, plus follow-up endoscopy

This section is for anyone who wants the specific research behind the summary above — it's not necessary reading to understand whether POEM is right for you, but it's here for transparency.

A systematic review pooling 373 patients found a 92.9% overall clinical success rate at a mean follow-up of 30 months, with zero procedure-related deaths. The largest published long-term single-center series, following patients for up to 10 years, reported clinical success of 98% at 1 year, 96% at 2–3 years, 94% at 4 years, 92% at 5 years, and 91% at 6–7 years — durability that has led much of the medical literature to describe POEM as matching or exceeding traditional surgical Heller myotomy. On the reflux trade-off specifically: published rates for new-onset heartburn range from roughly 10% to 19% depending on the study. Technique refinements — such as selectively sparing certain muscle fibers, or combining POEM with a small endoscopic fundoplication (POEM-F) in select cases — are actively reducing this risk further. In related esophageal motility disorders beyond classic achalasia, pooled success rates run from about 87% to 98% depending on the specific condition.

POEM is performed through a submucosal tunnel — the same access principle used in STER for subepithelial tumours, which is why both are done by the same operators here. Our gastroenterologists select POEM on the manometric subtype and on what treatment has already been tried, and follow patients afterwards for reflux, which is the main trade-off of the procedure. To discuss POEM for achalasia, book a consultation.