POEM Versus Surgery for Achalasia Treatment: Which One To Select?

POEM Versus Surgery for Achalasia Treatment: Which One To Select?

Prateek Sharma, MD, FASGE reviewing Werner YB, et al. N Engl J Med 2019 Dec 5.

Both peroral endoscopic myotomy (POEM) and surgical laparoscopic Heller’s myotomy (LHM) are viable treatment options for patients with documented achalasia. This randomized, noninferiority trial compared the efficacy and safety of POEM with LHM plus Dor’s fundoplication in patients with idiopathic achalasia.

In this prospective, multicenter, open-label trial conducted in 8 European centers, achalasia patients were randomly assigned in a 1:1 ratio to undergo either POEM or LHM plus Dor’s fundoplication. The primary end point (clinical success) was defined as an Eckardt symptom score of <3 at the 2-year follow-up. The Eckardt symptom score consists of 4 components: dysphagia, regurgitation, chest pain, and weight loss, with each component graded from 0 to 3 points. 

At the 2-year follow-up, 93 of 112 patients (83.0%) in the POEM group and 89 of 109 patients (81.7%) in the LHM group had clinical success. On high-resolution manometry, improvement in the integrated relaxation pressure of the lower esophageal sphincter did not differ significantly between the treatment groups (difference, −0.75 mm Hg; 95% confidence interval [CI], −2.26-0.76). Similarly, improvement in Gastrointestinal Quality of Life Index scores between baseline and 24 months did not differ significantly between the groups (difference, 0.14 points; 95% CI, −4.01-4.28). Serious adverse events occurred in 2.7% and 7.3% of the patients treated with POEM versus LHM (P=NS), respectively, whereas the incidence of reflux esophagitis was significantly higher in the POEM versus the LHM group at 24 months (44% vs 29%, respectively; odds ratio, 2.00; 95% CI, 1.03-3.85).


The results of this highly awaited randomized controlled trial show that both POEM and surgical myotomy have similar outcomes in improving the Eckardt scores in patients with achalasia at the end of 2 years of follow-up, with similar rates of adverse events. However, posttreatment GERD appears to be significantly higher in the POEM group. Both patient preference and availability of local treatment expertise should drive the management option in this patient population.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Prateek Sharma, MD, FASGE


Werner YB, Hakanson B, Martinek J, et al. Endoscopic or surgical myotomy in patients with idiopathic achalasia. N Engl J Med 2019;381:2219 – 2229. (https://www.nejm.org/doi/full/10.1056/NEJMoa1905380)

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