Per-Oral Endoscopic Myotomy (POEM) Treatment Approach for Achalasia and Swallowing Disorders

Treatment Recommendations by Achalasia Subtype

The American Gastroenterological Association recommends POEM as the first-line treatment for type III achalasia and considers it a treatment option comparable to laparoscopic Heller myotomy (LHM) for all achalasia syndromes, with specific treatment selection based on achalasia subtype 1
For type I and type II achalasia, both pneumatic dilation (PD) and LHM are highly efficacious in randomized controlled trials, with PD having less morbidity and cost 2
POEM has shown high efficacy in short-term data compared to PD for type I and type II achalasia 2, 3
POEM is the preferred treatment option for type III achalasia due to its ability to perform longer myotomy 1, 2

Post-POEM patients should be considered high risk for developing reflux esophagitis, and patients should be advised about the potential need for indefinite proton pump inhibitor therapy and/or surveillance endoscopy before undergoing the procedure 1
POEM should be performed by experienced physicians in high-volume centers, with an estimated 20-40 procedures needed to achieve competence 1

Accurate diagnosis is essential as several conditions can mimic achalasia, including eosinophilic esophagitis, cancer, reflux stricture, and post-myotomy stricture 2, 3
Patient selection should consider Chicago Classification subtype, comorbidities, disease stage, and primary or secondary causes 1

Patients must be informed about the high risk of post-POEM reflux and the potential need for long-term PPI therapy 1
POEM requires specialized training and should not be performed by inexperienced endoscopists 1