Efficacy, safety, and outcomes for peroral endoscopic myotomy versus laparoscopic Heller myotomy for achalasia: an updated narrative review

Introduction

Background

Achalasia is a rare esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and esophageal dysmotility, often diagnosed by high-resolution manometry using the Chicago classification. Predominant symptoms include dysphagia, regurgitation, chest pain, heartburn, and weight loss (1). In the United States, the incidence is estimated at approximately 10.5–26.0 per 100,000 person-years, and the prevalence ranges from 18.0 to 162.1 per 100,000 individuals, with a slight female predominance (2). Although the exact etiology remains unclear, autoimmune and viral factors are suspected contributors (3).

Historically, treatment has been focused on symptom relief, with pneumatic dilation (PD) and laparoscopic Heller myotomy (LHM) as the first-line therapies. Since its introduction in 2008 (4), peroral endoscopic myotomy (POEM) has emerged as a minimally invasive alternative, now endorsed in major guidelines (1). POEM and LHM have demonstrated higher efficacy and lower re-intervention rates compared to PD (5,6), leading PD to fall out of favor at many centers.

Rationale and knowledge gap

Over the past two decades, POEM has gained rapid adoption due to its minimally invasive nature and technical flexibility. While initial studies between POEM and LHM showed similar overall efficacy. More recent data offer deeper insights into long-term durability, different outcomes by achalasia subtypes, and procedure-related adverse events such as gastroesophageal reflux disease (GERD). Despite the expanding body of evidence, the literature remains heterogeneous across study design, follow-up, duration, and reported endpoints.

A contemporary synthesis is needed to clarify the relative performance of POEM vs. LHM, defining which patient subgroups derive the greatest benefit, and identifying ongoing concerns such as reflux risk, and long-term symptom control, all of which can influence the treatment selection. As more randomized trials, large cohort studies, and meta-analyses emerge, an updated review is needed to reassess these uncertainties.

Objective

To provide a comprehensive, contemporary synthesis of the evidence from PubMed and Google Scholar on POEM vs. LHM for achalasia, focusing on efficacy, long-term outcomes, subtype specific responses, and adverse events with an emphasis on randomized trials and meta-analyses. We present this article in accordance with the Narrative Review reporting checklist (available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-19/rc).

Methods

A literature review was performed using PubMed and Google Scholar to find relevant articles comparing POEM and LHM for the treatment of achalasia through March 2025. The search terms included peroral endoscopic myotomy, laparoscopic Heller myotomy, achalasia, safety, efficacy, and outcomes. All available manuscripts were reviewed. Data not pertaining to achalasia was excluded. Only studies including adult patients greater than 18 years of age were included. Only articles written in English were included. A strong focus was placed on randomized controlled trials, meta-analyses, and high-quality cohort studies in the query results. Case reports and studies involving pediatric patients were excluded (Table 1, Figure 1).

Figure 1 Flow diagram of study selection.

Results

Overall efficacy

As POEM has gained acceptance as an alternative to LHM over the past two decades, numerous studies have demonstrated comparable efficacy. A multicenter non-inferiority trial in Europe showed no significant difference at 5-year follow-up between POEM and LHM-F in clinical success, reduction in Eckardt scores, improvement in gastroenterology quality of life index (GQLI), or changes in integrated relaxation pressure (IRP) on manometry (7).

Symptom outcomes

Dysphagia

Dysphagia is a prominent and often debilitating symptom of achalasia, making its improvement a key therapeutic goal. In a single-center retrospective study, average dysphagia scores decreased significantly more in the POEM group than in the LHM group (−2.30 vs. −1.12, P=0.003) (8) (Table 2).

Eckardt score

The Eckardt score, ranging from 0 to 12, is a widely used symptom-based tool for assessing achalasia control. Several studies have demonstrated similar improvements in Eckardt scores between POEM and LHM (9-12) (Table 2). However, some meta-analyses have suggested a slight advantage for POEM.

A meta-analysis showed a significantly greater mean reduction in Eckardt scores with POEM as compared to LHM [mean difference: −0.257; 95% confidence interval (CI): −0.512 to −0.002; P=0.048] (14). This meta-analysis used 5 studies that reported post-operative Eckardt scores and only one of these studies revealed a statistically significant greater improvement in Eckardt score in the POEM group versus the LHM group (15). Their study showed a significantly lower post-operative Eckardt score at 1 year in patients with type III achalasia in the POEM group (1.1 vs. 3.1, P<0.05); however, there was no difference when comparing post-operative Eckardt scores between all POEM and LHM patients (0.9±1.6 vs. 1.0±1.3, P>0.05) (15).

Another meta-analysis showed significantly lower postoperative scores in the POEM group (mean difference: −0.30; CI: −0.42 to −0.18; P<0.001) (16). These findings were based on two studies that reported post-operative Eckardt scores (16). Of these, one study found lower post-operative Eckardt scores in the POEM group but there was no significant difference in the improvement in scores between POEM and LHM (17). The other study that was cited found significantly better improvements in Eckardt scores in the POEM group versus LHM group (1.8 vs. 0.8, P<0.0001) at one month post procedure; however, the improvement in Eckardt score at 6 months was no longer statistically significant (1.7 vs. 1.2, P=0.1) (12) (Table 2).

GQLI

GQLI is a 36-item questionnaire assessing quality of life in patients with gastrointestinal disorders, incorporating social, psychological, and emotional factors. In a multicenter randomized trial, no significant difference was observed in post-interventional GQLI scores between POEM and LHM-F (mean difference: 0.14 points; CI: −4.01 to 4.28) (13). Similarly, a multicenter randomized non-inferiority trial found no significant difference in GQLI outcomes between POEM and LHM-F at five years (7) (Table 2).

Objective outcomes

Manometry

Esophageal manometry is essential for diagnosing achalasia under the Chicago Classification, identifying elevated LES IRP and absent normal peristalsis (1). Post-interventional manometric changes can offer valuable insights into treatment efficacy. Multiple studies with follow-up ranging from 2 months to 5 years have shown no significant differences between POEM and LHM in post-treatment manometric improvements (7,10,18,19).

However, a single prospective study found significantly higher post-myotomy resting LES pressures in the POEM group compared to LHM (16 vs. 7 mmHg, P=0.006) (12). Despite this, no significant differences were noted in absolute or relative reductions in resting and relaxation pressures at a median 6.8-month follow-up (12). Symptomatically, rates of dysphagia to liquids, heartburn, and reflux were similar, though significantly more patients undergoing LHM reported regular dysphagia to solids (29% vs. 0%, P=0.001) (12).

Timed barium esophagogram (TBE)

TBE is a useful adjunct in diagnosing achalasia, with barium column heights over 5 cm at 1 minute and over 2 cm at 5 minutes suggesting the disease (20). A retrospective review comparing POEM and LHM outcomes at 2 months showed significant improvements in barium column height for both groups, with no significant difference between them (8).

Patient subgroups

Type III achalasia

Type III achalasia, characterized by spastic contractions proximal to the LES, requires a tailored myotomy length per American Gastroenterological Association (AGA) guidelines (21). In a retrospective cohort study, POEM achieved significantly higher success rates at 4 years than LHM for type III achalasia (53.3% vs. 44.4%, P<0.05), based on Eckardt scores, achalasia-related hospitalizations, and need for repeat interventions (22). Additionally, Shally et al. reported that POEM results in a significantly longer median myotomy length compared to LHM (11 vs. 8 cm) (8).

Chagas disease

Chagas disease, a known cause of achalasia, is more prevalent in South America, yet few studies have compared POEM and LHM in this context. In a prospective study across nine Latin American centers, both POEM and LHM significantly reduced post-intervention Eckardt scores (by 5.71 points, P<0.00001, and 1.56 points, P=0.043, respectively) (21). Clinical success (Eckardt score <3) was achieved in 71% of POEM patients versus 22% with LHM. Overall, POEM showed significantly higher clinical success rates than LHM (86% vs. 60%, P=0.0013), a difference that remained significant even among patients with Chagas disease (23).

Older age, higher body mass index (BMI), and prior treatments

Balancing the risks versus benefits in a surgical versus endoscopic approach plays an important role in patient selection. In a retrospective single-center review, POEM and LHM showed no significant differences in post-procedure manometry or TBE at 2-month follow-up, despite the POEM group being older (55.4 vs. 46.5 years, P=0.013) and having a higher BMI (29.1 vs. 26 kg/m², P=0.012) (19).

POEM patients were more likely to have undergone prior treatments with Botox, PD, LHM, and endoscopy compared to those undergoing LHM (72% for POEM vs. 68% for PD vs. 44% for LHM, P=0.003), with comparable efficacies as determined by post interventional manometry and TBE follow up (19).

Post-operative GERD following POEM and LHM

Symptoms and questionnaire-based outcomes

Symptom-based assessments of postoperative reflux show mixed results between LHM and POEM. A retrospective review reported lower GERD health-related quality of life (HRQL) scores in the LHM cohort compared with POEM (11.1 vs. 14.1, P=0.38), along with lower proton pump inhibitor (PPI) use (37.5% vs. 53%, P=0.46) (10). Another retrospective analysis summarized prior literature demonstrating comparable rates of GERD symptoms for POEM and LHM; however, it identified a higher incidence of esophagitis and abnormal esophageal acid exposure in POEM patients (11). In that review, 19% of POEM patients reported GERD symptoms, whereas 59% of POEM patients were found to have endoscopic evidence of esophagitis (11). A meta-analysis similarly found no significant difference between LHM and POEM in postoperative GERD outcomes when evaluating GERD scores, presence of symptoms, pH testing, and PPI use (14) (Table 3).

DeMeester score and pH testing

Objective pH-monitoring outcomes vary across studies. One retrospective analysis found that the POEM cohort had a higher percentage of patients with a normal DeMeester score (47.4% vs. 30.8%, P=0.35), a lower mean DeMeester score (20 vs. 29.4, P=0.26), and a lower percentage of time spent in reflux (5.8% vs. 12.2%, P=0.16) compared with the LHM cohort (10). Alternatively, another retrospective study reported lower median DeMeester scores (2 vs. 4, P=0.2) and fewer median reflux episodes (4 vs. 12, P=0.4) in the LHM group, yet a slightly lower percentage of patients with a DeMeester score >14.7 in the POEM cohort (9% vs. 10%, P=0.4) (12).

Esophagitis

Assessments of postoperative esophagitis generally show a trend favoring LHM. A retrospective review reported lower rates of esophagitis after LHM compared with POEM (31.8% vs. 44.4%, P=0.48) (10).

LHM-F vs. POEM

In contrast, LHM-F appears to show more favorable postoperative reflux outcomes than POEM. A systematic review demonstrated a significant advantage of LHM-F with respect to postoperative PPI use [27% vs. 52.8%; risk ratio (RR) 1.95, 95% CI: 1.35–2.8] (6). The same review observed nonsignificant trends favoring LHM-F in rates of esophagitis (13% vs. 23%; RR 1.79, 95% CI: 0.9–3.59) and patient-reported reflux (2% vs. 6.5%; RR 3.34, 95% CI: 0.71–15.69) (6). Furthermore, a randomized trial demonstrated statistically significant benefits of LHM-F over POEM based on GERD-Q scores (11.1% vs. 64.6%, P<0.02) and endoscopic evidence of esophagitis at 1 month (0% vs. 29.4%, P=0.014), 6 months (5.6% vs. 62.5%, P<0.001), and 12 months (11.1% vs. 37.1%, P=0.002) (18) (Table 3).

Safety and adverse events

A single-center retrospective study found no significant difference in perioperative adverse event rates between POEM (13.3%, 2/15) and LHM-F (26.6%, 4/15; P=0.65) (24). POEM complications included pneumomediastinum and aspiration pneumonia with lung abscess requiring thoracotomy, while LHM-F complications involved urinary retention, nausea, diarrhea, and aspiration pneumonia. Similarly, a multicenter Latin American review reported rare and comparable adverse events in POEM (17%) and LHM (14%), including pneumothorax, bleeding needing transfusion, and mediastinitis (12) (Table 3).

However, a cross-sectional National Inpatient Sample analysis showed a higher overall risk of adverse events with POEM versus LHM (24.8% vs. 13.3%, P<0.001), including increased infectious complications (8.2% vs. 3.5%, P<0.001), gastrointestinal bleeding (5.8% vs. 3.4%, P<0.001), and thoracic events (9% vs. 4.5%, P<0.01) (25) (Table 3).

Perforation and leaks are serious complications associated with both POEM and LHM. In a randomized controlled trial, no perforations and one closure leak occurred among 112 POEM patients, while three perforations and no leaks were reported in 109 LHM patients (18). A systematic review similarly found a higher perforation rate in the LHM group (7.1% vs. 0.56%), whereas leak rates were slightly higher in the POEM group (0.89% vs. 0.41%) (26) (Table 3).

Procedure time and hospital stay

Multiple studies consistently report significantly shorter procedural times for POEM compared to LHM (8,12,17,25). Similarly, hospital stays are generally shorter with POEM, with reported durations such as 1.7 vs. 2.6 days (P=0.021) (20), 1.1 vs. 1.6 days (P<0.00001) (23), 1.1 vs. 2.2 days (P<0.0001) (12), and 0.76 vs. 1.2 days (P<0.001) (16). However, a cross-sectional analysis of the National Inpatient Sample found higher adverse event rates with POEM, which correlated with a significantly longer hospital stay compared to LHM (16.6% vs. 9.3%, P<0.001) (25) (Table 3).

Cost comparison between POEM and LHM

A retrospective cohort study at a tertiary center found total admission costs were $1,827 higher for LHM than POEM (P<0.01), though one-year pre- and post-intervention healthcare costs did not differ significantly (22). Another retrospective study reported lower hospital charges for POEM compared to LHM ($30.7±10.3 vs. $35.5±12.8 k, P=0.06) (27). Conversely, a National Inpatient Sample analysis showed similar hospital charges between POEM and LHM ($15,146±1,308 vs. $15,471±406; P=0.82) (23). Another study found higher but non-significant charges for POEM compared to LHM ($14,201 vs. $13,328; P=0.45) (11).

Overall, cost differences between POEM and LHM vary by study and setting, with no consistent significant difference (Table 3).

Discussion

Since its introduction in 2008, POEM has become a widely accepted alternative to LHM for achalasia, with numerous studies demonstrating comparable efficacy between the two approaches. As POEM’s role has expanded, more studies have explored differences in outcomes and patient selection. Overall, efficacy remains similar between POEM and LHM (7). Patients who are older and have a higher BMI achieved comparable outcomes between POEM and LHM-F (19). Selection of therapeutic approach should be individualized, and POEM may be particularly appropriate for patients who are suboptimal candidates for surgery. This strategy increases access to effective treatment without compromising clinical outcomes. The minimally invasive nature of POEM provides an important procedural advantage in appropriately selected patients.

When used as a secondary treatment after Botox injection, PD, LHM, and endoscopic dilation, both POEM and LHM had comparable postoperative outcomes when evaluated by manometry and TBE (13). Both POEM and LHM remain a viable and efficacious modality for patients who have failed prior treatments.

POEM continues to demonstrate comparable efficacy to LHM for the management of achalasia when evaluated by postoperative Eckardt scores. Most studies did not find a significant difference in Eckardt score outcomes between the two procedures (9-12). However, two meta-analyses reported an advantage for POEM (14,16). One meta-analysis identified a significantly greater mean reduction in postoperative Eckardt scores among patients undergoing POEM (14); this finding was largely driven by a study demonstrating lower postoperative Eckardt scores in patients with type III achalasia treated with POEM compared with LHM (15). When considering all achalasia subtypes, that study found no significant difference in postoperative Eckardt scores between POEM and LHM (15). While overall symptomatic efficacy remains comparable, POEM confers a specific advantage in type III achalasia.

In the second meta-analysis, two studies were used to show better outcomes with POEM as compared to LHM (16). In one of these studies, although the POEM cohort demonstrated a lower absolute postoperative Eckardt score, the degree of improvement in Eckardt score did not differ significantly between POEM and LHM (17). In the other study, POEM was associated with a significantly greater improvement in Eckardt score at one month, however this difference was no longer significant at six months (12).

POEM and LHM offer similar efficacy in improving postoperative Eckardt scores, with POEM demonstrating a unique advantage in type III achalasia reaffirming earlier literature (8,15,22). This advantage reflects the ability of POEM to deliver a tailored, extended myotomy that more effectively treats the unique pathophysiology of type III achalasia.

Additionally, POEM demonstrated better clinical success in patients with achalasia secondary to Chagas disease (23), supporting its role over LHM in these subgroups.

Studies utilizing esophageal manometry and TBE demonstrated comparable post-procedure improvements for POEM and LHM (7,10,18-20). Interestingly, one prospective study reported higher resting LES pressures following POEM; however, absolute and relative improvements were similar between the procedures, and the clinical significance remains unclear (12). Notably, a greater proportion of patients in the LHM group experienced persistent solid-food dysphagia, despite comparable outcomes for liquid dysphagia, heartburn, and reflux. Further investigation is needed to determine whether this finding is reproducible and clinically meaningful. Given the consistent improvements observed in esophageal manometry and TBE, there may be a role for routine postoperative surveillance to objectively assess treatment success.

Postoperative GERD outcomes appear to be variable across studies. A retrospective analysis showed a trend toward higher GERD-related HRQL scores, increased PPI use, and a greater incidence of esophagitis in patients undergoing POEM compared with LHM (10). On the other hand, POEM patients in one study exhibited a higher proportion of normal DeMeester scores, lower mean DeMeester scores, and reduced percentage of time spent in reflux (10), whereas another study reported a lower percentage of patients with a DeMeester score >14.7 in the POEM group but lower median DeMeester scores and fewer median reflux episodes in the LHM group (12). Although these differences did not reach statistical significance, the overall trends suggest that POEM patients may more frequently demonstrate objective evidence of GERD, particularly esophagitis on endoscopy. Findings from pH monitoring were inconsistent and objective measures of acid exposure did not favor either procedure. Overall, neither POEM nor LHM showed a clear advantage in postoperative GERD outcomes, highlighting the need to develop new techniques to improve acid barrier protection.

LHM-F, on the other hand, demonstrated a clear advantage over POEM in post-operative GERD outcomes. A systematic review reported a significant reduction in postoperative PPI use with LHM-F and lower esophagitis and patient-reported reflux symptoms (6). Additionally, a randomized controlled trial demonstrated a statistically significant benefit of LHM-F over POEM in GERD-Q scores and endoscopic esophagitis at 1, 6, and 12 months postoperatively (18). The addition of fundoplication clearly enhances GERD outcomes and represents a major advantage of LHM-F over POEM. Patients with pre-existing GERD or esophagitis are more likely to benefit from LHM-F, and future technical advances in POEM are needed to achieve comparable postoperative acid control.

Adverse events, including perforation, leak, pneumothorax, pneumomediastinum, bleeding, urinary retention, nausea, diarrhea, and aspiration pneumonia, are rare and not significantly different between POEM and LHM in most studies (23,24). However, a national database study reported higher rates of infections, bleeding, and thoracic complications with POEM (25). Perforation appears more frequent with LHM, while leaks are slightly more common after POEM, though both remain uncommon and generally manageable (13,24). Overall, adverse events are infrequent with either approach.

Procedure time and hospital stay are typically shorter for POEM (8,12,18,27), though this finding was not consistent in all studies. Data on accrued hospital charges is mixed, with some studies showing lower charges for POEM (24,27), others finding comparable costs (23), and some reporting higher, though non-significant, accrued charges for POEM (11).

In summary, POEM offers comparable overall efficacy to LHM, with potential advantages in specific subgroups like type III achalasia and Chagas disease, while carrying higher rates of reflux-related complications. POEM has shown comparable efficacy to LHM in short and mid-term outcomes; however, more studies are still required to fully establish the long-term durability of POEM versus LHM.

Strengths and limitations

This review emphasizes recent high-quality evidence comparing POEM and LHM, including randomized controlled trials and meta-analyses. However, as a narrative review, it is limited by subjective study selection and the absence of predefined inclusion criteria, which may introduce potential bias. Another limitation of this study is the exclusion of databases such as EMBASE, the Web of Science, and the Cochrane Library, which may have resulted in the omission of relevant studies.

Conclusions

POEM has emerged as a highly effective, minimally invasive alternative to LHM for achalasia, offering comparable efficacy and the advantage of tailored myotomy for type III disease. However, a higher incidence of post-procedure GERD remains a concern, particularly in the absence of fundoplication. POEM and LHM should be viewed as complementary approaches rather than alternatives, each with distinct advantages and disadvantages in treating specific esophageal conditions and needs such as recovery time and anti-reflux requirements. Future research should focus on optimizing patient selection, refining techniques to mitigate reflux, and further evaluating long-term outcomes and cost-effectiveness.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-19/rc

Peer Review File: Available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-19/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-19/coif). I.B. serves as an unpaid editorial board member of Annals of Esophagus from April 2025 to March 2027. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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