POEM vs Heller Surgery for Achalasia: Complete Guide Updated 2025
Analysis based on the most recent scientific evidence for clinical decision-making
Esophageal achalasia is a primary motor disorder affecting the lower esophageal sphincter, causing dysphagia and other symptoms that significantly impact patients' quality of life. As a specialist in advanced endoscopy, I have observed the constant evolution of surgical and endoscopic techniques for its treatment.
Currently, we have two main therapeutic options: peroral endoscopic myotomy (POEM) and laparoscopic Heller surgery with fundoplication. Both techniques have proven highly effective, but they present distinctive characteristics that may influence the choice of the most appropriate treatment for each patient.
Visual comparison between POEM and Heller surgery techniques
POEM: The Endoscopic Revolution
Peroral endoscopic myotomy (POEM) represents one of the most significant advances in endoscopic treatment of achalasia. This technique, introduced by Inoue in 2010, and which I was trained in with him in 2013 (Northern Yokohama Hospital, Japan) allows for precise myotomy (cutting) of the lower esophageal sphincter through natural endoscopic approach without incisions.
POEM Advantages
- Shorter hospitalization: Usually 24-48 hours
- Less postoperative pain: No abdominal incisions
- Faster recovery: Return to normal activities in 7-10 days
- Superior in type III achalasia: Greater myotomy length
- No external scars: Endoscopic technique
POEM Considerations
- Higher incidence of gastroesophageal reflux
- Need for long-term PPI in some cases
- Requires specific experience in advanced endoscopy
Heller Surgery: The Established Standard
Laparoscopic Heller myotomy with fundoplication has been the reference treatment for achalasia for decades. This technique combines division of the lower esophageal sphincter with an anti-reflux procedure, usually Dor or Toupet fundoplication.
Characteristics of Heller Surgery
- Integrated fundoplication: Lower risk of postoperative reflux
- Established experience: Decades of follow-up and results
- Laparoscopic approach: Minimally invasive technique
- Hospitalization: Usually 2-3 days
Recent Scientific Evidence
Most Recent Research Findings
The most recent evidence indicates that peroral endoscopic myotomy (POEM) and Heller myotomy (LHM) offer equivalent clinical success rates in achalasia treatment, both short and long-term, with relevant differences in adverse effects profile and technical characteristics.
NEJM 2019 Study (Multicenter Randomized Trial):
The most robust multicenter randomized trial demonstrated that POEM is non-inferior to LHM with Dor fundoplication in symptom control at 2 years:
- Clinical success: 83% POEM vs. 81.7% LHM
- Esophageal function: No significant differences
- Gastroesophageal reflux: 44% POEM vs. 29% LHM at 24 months
2025 Meta-analysis:
The most recent systematic review and meta-analysis confirms similar long-term efficacy (OR 1.43; CI 0.96-2.13), but POEM is associated with:
- Shorter operative time
- Shorter hospital stay
- Higher risk of reflux esophagitis (OR 2.57; CI 1.45-4.53)
Direct Comparison: POEM vs Heller
| Aspect | POEM | Heller Surgery |
|---|---|---|
| Clinical efficacy | 83% success at 2 years | 81.7% success at 2 years |
| Hospitalization | 24-48 hours | 2-3 days |
| Postoperative pain | Minimal (no incisions) | Moderate |
| Recovery | 7-10 days | 2-3 weeks |
| Postoperative reflux | 44% at 2 years | 29% at 2 years |
| Type III achalasia | Superior | Standard |
Scientific Society Recommendations
The American Gastroenterological Association and American Society for Gastrointestinal Endoscopy clinical guidelines establish clear recommendations:
Type I and II Achalasia
Both techniques recommended as first-line options with equivalent efficacy.
Type III Achalasia
POEM as preferred due to its greater myotomy length and better symptomatic response.
Clinical Experience and Decision Making
In my experience as a specialist in advanced endoscopy and POEM, I have observed significant advantages of the endoscopic technique, particularly in terms of recovery and patient comfort. Likewise, our experience with a selective approach cutting only circular muscle fibers seems to significantly reduce the rate of gastroesophageal reflux, further improving the results of this technique over classic surgery.
Key Decision Factors
- Patient age: Young patients may benefit more from the less surgical trauma of POEM
- Type of achalasia: POEM is clearly superior in type III achalasia
- Reflux risk: Consider previous history and risk factors
- Patient preferences: Hospitalization, recovery and follow-up
The less postoperative pain and rapid recovery of POEM allow patients to resume normal activities within a week, compared to the typical 2-3 weeks of laparoscopic surgery. This difference is especially valued by professionally active patients.
Conclusions and Recommendations
Both POEM and Heller surgery are highly effective techniques for achalasia treatment, with similar long-term success rates. However, differences in adverse effects profile and technical characteristics can significantly influence the choice of the most appropriate treatment.
POEM's Outstanding Advantages
- Significantly shorter hospitalization (24-48h vs 2-3 days)
- Less postoperative pain due to absence of abdominal incisions
- Faster recovery with early return to activities
- Clear superiority in type III achalasia according to international guidelines
The main consideration of POEM is the higher risk of postoperative gastroesophageal reflux, which must be evaluated individually and can be effectively managed with proton pump inhibitors in most cases.
In summary, POEM and Heller surgery are equally effective for achalasia, but POEM offers significant advantages in terms of recovery and patient comfort, being the preferred technique in type III achalasia and an excellent option for patients who value faster recovery.
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- 1. Werner YB, Hakanson B, Martinek J, et al. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia. N Engl J Med. 2019;381(23):2219-2229.
- 2. de Moura ETH, Jukemura J, Ribeiro IB, et al. Peroral Endoscopic Myotomy vs Laparoscopic Myotomy and Partial Fundoplication for Esophageal Achalasia: A Single-Center Randomized Controlled Trial. World J Gastroenterol. 2022;28(33):4875-4889.
- 3. Schlottmann F, Luckett DJ, Fine J, Shaheen NJ, Patti MG. Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-Analysis. Ann Surg. 2018;267(3):451-460.
- 4. Ma O, Brar K, McCluskey S, et al. Long-Term Outcomes After Per-Oral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy in the Treatment of Achalasia: A Systematic Review and Meta-Analysis. Surg Endosc. 2025.
- 5. Shally L, Saeed K, Berglund D, et al. Clinical and Financial Outcomes of Per-Oral Endoscopic Myotomy Compared to Laparoscopic Heller Myotomy for Treatment of Achalasia. Surg Endosc. 2023;37(7):5526-5537.
- 6. Yang D, Bechara R, Dunst CM, Konda VJA. AGA Clinical Practice Update on Advances in Per-Oral Endoscopic Myotomy (POEM) and Remaining Questions-What We Have Learned in the Past Decade: Expert Review. Gastroenterology. 2024;167(7):1483-1490.
- 7. Khashab MA, Vela MF, Thosani N, et al. ASGE Guideline on the Management of Achalasia. Gastrointest Endosc. 2020;91(2):213-227.e6.