POEM (Peroral Endoscopic Myotomy)

Achalasia is a rare esophageal disorder, affecting about 10 in 100,000 adults. The nerves in the esophagus degenerate, so the lower esophageal sphincter (LES) fails to relax and the esophagus loses its ability to squeeze food downward. The result is (Jacobson and Lichtenstein, JAMA, 2019):

• Difficulty swallowing solids and liquids
• Regurgitation and chest pain
• Weight loss and aspiration into the lungs

Three treatments offer lasting relief (Patel et al., Gastroenterology, 2022):

• Pneumatic balloon dilation
• Laparoscopic Heller myotomy (LHM), usually with a partial fundoplication
• POEM (peroral endoscopic myotomy)

POEM was first described in 2010 and is now accepted as a first-line treatment for achalasia (Pandolfino et al., Yamada's Textbook of Gastroenterology, 2022). It achieves the same goal as Heller myotomy, dividing the tight sphincter muscle, but works entirely from inside the esophagus.

The American Gastroenterological Association states that POEM, Heller myotomy, and pneumatic dilation are all effective for type I and II achalasia, chosen through shared decision-making. It names POEM the preferred treatment for type III (spastic) achalasia (Yang et al., AGA Clinical Practice Update, 2024).

POEM also treats diffuse esophageal spasm, jackhammer esophagus, and selected cases of EGJ outflow obstruction. Adaptations of the same technique treat gastroparesis (G-POEM) and Zenker's diverticulum (Z-POEM).

• The problem: in achalasia, the circular muscle of the LES stays contracted, creating a functional blockage where the esophagus meets the stomach.
• The solution: POEM cuts the circular muscle fibers of the LES and lower esophagus. The opening can then relax and stay open, so food and liquid flow into the stomach by gravity.
• The "third space": the surgeon works in the submucosal layer, the space between the lining and the muscle. A tunnel is created there, and the myotomy is performed inside the tunnel. The inner lining stays intact, and the entry point is closed with clips (Savarino et al., Nature Reviews Disease Primers, 2022).
• A tailored length: POEM allows a myotomy of any length:
  • Types I and II achalasia: a short myotomy is usually enough.
  • Type III achalasia: a long myotomy extends up the esophagus to treat the spastic segment. Laparoscopic surgery can't easily reach that far (Savarino et al., Nature Reviews Disease Primers, 2022; Yang et al., AGA Clinical Practice Update, 2024).
• No hiatal dissection: POEM doesn't disturb the natural anti-reflux structures around the hiatus and avoids abdominal adhesions that could complicate future surgery (Kahrilas et al., AGA Clinical Practice Update, 2017).

• Equal to Heller myotomy:
  • In a 221-patient European randomized trial, POEM succeeded in 83.0% vs 81.7% for Heller myotomy at 2 years.
  • Serious adverse events occurred in 2.7% vs 7.3% (Werner et al., New England Journal of Medicine, 2019).
• Superior to balloon dilation. In a randomized JAMA trial, POEM succeeded in 92% vs 54% for pneumatic dilation at 2 years, with no serious adverse events after POEM (Ponds et al., JAMA, 2019).
• The best option for type III achalasia. Success was 93% with POEM vs 71% with Heller myotomy (Vaezi et al., ACG Clinical Guideline, 2020).
• No incisions. No abdominal scars and less pain, and many patients go home the next day.
• Shorter operation and hospital stay. Compared with Heller myotomy in long-term studies, POEM was about 32 minutes shorter, with a hospital stay about 0.8 days shorter (Abosheisha et al., Diseases of the Esophagus, 2025).
• Durable results. In a 610-patient U.S. series, clinical success was 98% at 1 year and 91% at 7 years (Modayil et al., Gastrointestinal Endoscopy, 2021).
• Works after other treatments fail, including balloon dilation, Botox, prior Heller myotomy, or prior POEM (Khashab et al., Gastroenterology, 2018).

• Achalasia confirmed by high-resolution manometry:
  • Type I or II: POEM, Heller myotomy, or dilation, based on shared decision-making
  • Type III: POEM preferred (Yang et al., AGA Clinical Practice Update, 2024)
• Spastic esophageal disorders, such as diffuse esophageal spasm and jackhammer esophagus, with chest pain and dysphagia that don't respond to medication (Rengarajan and Aadam, Diseases of the Esophagus, 2024).
• EGJ outflow obstruction (EGJOO), only after a comprehensive workup and only when less invasive options have failed. EGJOO alone shouldn't justify a permanent intervention (Yang et al., AGA Clinical Practice Update, 2024).
• Failed prior treatment, including Heller myotomy, dilation, or Botox (Khashab et al., Gastroenterology, 2018).
• Patients who want to avoid abdominal surgery, or who have adhesions from prior abdominal operations.

POEM may not be the best choice when a patient has:

• A medium or large hiatal hernia. Heller myotomy with partial fundoplication is preferred, because it repairs the hernia at the same time (Patel et al., Gastroenterology, 2022). See Heller Myotomy and Hiatal Hernia Repair.
• Severe pre-existing reflux or erosive esophagitis
• A strong preference for avoiding long-term acid-suppressing medication

POEM is performed under general anesthesia in four steps (Jacobson and Lichtenstein, JAMA, 2019):

1. Mucosal incision. A small opening is made in the esophageal lining several centimeters above the LES.
2. Submucosal tunnel. The endoscope is advanced through a tunnel down the esophageal wall and about 2–3 cm onto the stomach.
3. Myotomy. The circular muscle is divided from inside the tunnel, across the LES and onto the gastric cardia. In type III achalasia, it's extended up the esophagus over the spastic segment.
4. Closure. The entry point is sealed with endoscopic clips or sutures.

Other details:

• Measurement: FLIP (functional lumen imaging probe) may be used to measure how well the junction opens before and after the myotomy (Yang et al., AGA Clinical Practice Update, 2024).
• Gastric myotomy length: it's deliberately limited, because excessive gastric myotomy increases post-POEM reflux (Olson et al., Current Gastroenterology Reports, 2022).
• Operative time: median 54 minutes in a large U.S. series (Modayil et al., Gastrointestinal Endoscopy, 2021).

• Reflux (GERD) is the most important long-term risk:
  • Abnormal acid exposure: 41–56% of patients after POEM
  • Esophagitis: 41–65%
  • Silent reflux: about one-quarter of patients with reflux have no symptoms (Yang et al., AGA Clinical Practice Update, 2024)
  • Severity: most esophagitis is mild and responds to PPIs. Severe (grade C/D) esophagitis was similar to Heller myotomy at 2 years (5% vs 6%) (Werner et al., New England Journal of Medicine, 2019).
• Procedural adverse events are uncommon. In 1,826 patients, they were (Kahrilas et al., AGA Clinical Practice Update, 2017):
  • Mild: 6.4%
  • Moderate: 1.7%
  • Severe: 0.5%
• Specific complications: mucosal injury, bleeding, perforation, pneumothorax, or pneumomediastinum. Most are managed endoscopically without surgery (Pandolfino et al., Yamada's Textbook of Gastroenterology, 2022).
• Experience matters. Adverse events were more likely when the operator had performed fewer than 20 cases or the patient had a sigmoid-shaped esophagus (Khashab et al., ASGE Guideline, 2020).
• Surgical backup. The authors of the landmark randomized trial would not perform POEM without on-site surgical backup (Werner et al., New England Journal of Medicine, 2019).
• Persistent or recurrent symptoms occur in a minority of patients.

• Hospital stay: typically overnight.
• Imaging: a contrast swallow study may be done before eating to confirm the lining is sealed.
• Diet: clear liquids, then full liquids, then soft foods over about 1–2 weeks.
• Pain: minimal compared with laparoscopic surgery, because there are no abdominal incisions.
• Return to work: usually within 1 week.
• PPIs: acid-suppressing medication is strongly recommended right after POEM and continued for at least 3–6 months until reevaluation (Yang et al., AGA Clinical Practice Update, 2024).

• Durable relief for most patients:
  • Meta-analysis of 16 studies: 87.1% long-term success in studies with 5 or more years of follow-up (Chen et al., Surgical Endoscopy, 2026).
  • European randomized trial at 5 years: 75.0% of POEM patients vs 70.8% of Heller patients remained in clinical remission (Semaan et al., Surgical Endoscopy, 2026).
• Early response predicts lasting success. Most failures happen in the first months. Patients in remission at 6 months had a 6-year success rate of 95.5% (Chen et al., Surgical Endoscopy, 2026).
• Prior sphincter treatment lowers the odds. Previous dilation, Botox, or myotomy made long-term failure 3.8 times more likely (Perananthan et al., Internal Medicine Journal, 2026).
• Reflux often improves over time as the sphincter heals and remodels (Yang et al., AGA Clinical Practice Update, 2024).
• Achalasia is a chronic condition. Lifelong surveillance is recommended.

More in Esophageal Motility and Swallowing Procedures

Related procedures: Dor Fundoplication for Reflux and After Heller Myotomy, Esophageal Diverticulum, Esophageal Dilation, Diagnostic Upper Endoscopy, Laparoscopic Heller Myotomy. For an overview of all options, see Foregut Surgery.

Conditions treated: Achalasia, Dysphagia, Esophagogastric Junction Outflow Obstruction, Diffuse Esophageal Spasm, Jackhammer Esophagus, Esophageal Diverticulum.

Health Improvements

• Recovery from malnutrition, with improving protein, vitamin, and mineral levels.
• Lower aspiration risk as food no longer pools in the esophagus, reducing nighttime regurgitation and lung complications (Jacobson and Lichtenstein, JAMA, 2019).
• Better hydration and energy as eating and drinking become comfortable again.

Preventing symptom recurrence and complications after POEM:

• Surveillance endoscopy is strongly encouraged after POEM. It monitors for disease progression and silent reflux damage, sometimes alternating with barium esophagram (Yang et al., AGA Clinical Practice Update, 2024).
• Reflux monitoring for every patient. Esophagitis can develop even when you feel fine. In one trial, 31% of patients with an initially normal exam developed esophagitis later (Kahrilas et al., AGA Clinical Practice Update, 2017).
• Early evaluation if swallowing problems, regurgitation, or chest pain return.

Dr. Nestor de la Cruz-Muñoz, MD, FACS, DABOM is a foregut surgeon who performs every definitive achalasia operation: POEM, Heller Myotomy, Dor Fundoplication, and Toupet Fundoplication. Your treatment is chosen by your anatomy, achalasia subtype, and reflux risk, not by which procedure a single specialist happens to offer.

• Surgeon-performed POEM. The trial that established POEM recommended on-site surgical backup. Here, the endoscopist is the surgeon.
• Reflux expertise built in. Reflux is the main trade-off after POEM. His practice manages the full anti-reflux spectrum: medication, Transoral Incisionless Fundoplication (TIF), Nissen Fundoplication, Toupet Fundoplication, LINX, and Hiatal Hernia Repair.
• The full rescue toolkit. When symptoms return, options include redo POEM, Heller myotomy, or Esophageal Dilation, all within one practice.
• Educator of surgeons. He served for 10 years as a bariatric surgery fellowship program director, training 13–14 fellows in advanced foregut and minimally invasive surgery.
• Complete foregut program, coordinated with gastroenterology, manometry, radiology, and nutrition. See Foregut Surgery.

Choosing between POEM and a surgical myotomy is easier with a surgeon versed in both endoscopic and laparoscopic foregut work. Dr. de la Cruz-Muñoz has performed over 15,000 minimally invasive procedures over more than 25 years, including complex foregut, hernia, gallbladder and abdominal operations as well as bariatric surgery.

• Why reflux happens: POEM opens the sphincter but, unlike Heller myotomy, doesn't add a fundoplication, the surgical anti-reflux valve (Patel et al., Gastroenterology, 2022).
• The randomized data:
  • Reflux esophagitis at 2 years: 44% after POEM vs 29% after Heller with Dor fundoplication (Werner et al., New England Journal of Medicine, 2019).
  • Long-term studies: reflux symptoms and esophagitis were similar between the two operations, but POEM patients more often stayed on PPIs (Abosheisha et al., Diseases of the Esophagus, 2025).
• A stepwise approach to post-POEM reflux (Yang et al., AGA Clinical Practice Update, 2024):
  • Optimized PPI therapy
  • Alginates and lifestyle changes
  • Potassium-competitive acid blockers for difficult cases
• Anti-reflux procedures are rarely needed after POEM (about 0.1%) (Olson et al., Current Gastroenterology Reports, 2022). When they are, options include endoscopic or surgical fundoplication. See Transoral Incisionless Fundoplication (TIF), Toupet Fundoplication, and GERD / Acid Reflux.
• Barrett's esophagus has been reported after POEM, which is why surveillance matters (Kahrilas et al., AGA Clinical Practice Update, 2017). See Barrett's Esophagus.

• Redo POEM. It can be performed in a fresh tunnel on the opposite side of the esophagus.
• Laparoscopic or robotic Heller myotomy after a failed POEM.
• POEM after failed Heller myotomy. This is technically successful and effective, and it may be a preferred application of POEM (Khashab et al., Gastroenterology, 2018).
• Pneumatic dilation for selected recurrences. See Esophageal Dilation.
• Treatment of reflux-related problems, such as peptic stricture or refractory esophagitis. See Esophageal Stricture and Erosive (Reflux) Esophagitis.

• POEM is a recognized, medically necessary treatment for achalasia. It is covered by most commercial plans and Medicare.
• Documentation typically includes:
  • High-resolution manometry, with the achalasia subtype
  • Barium esophagram
  • Upper endoscopy
  • Symptom scores (Eckardt score)
  • Prior treatments
• Coverage for non-achalasia indications varies. These include spasm, EGJOO, G-POEM, and Z-POEM. Our team verifies benefits before scheduling.

• High-resolution manometry to confirm the diagnosis and subtype. FLIP is used when manometry isn't conclusive (Yang et al., AGA Clinical Practice Update, 2024).
• Barium esophagram to assess esophageal emptying and shape (sigmoid vs non-sigmoid).
• Upper endoscopy to rule out pseudoachalasia, which is cancer mimicking achalasia, and to assess for hiatal hernia and esophagitis.
• Liquid diet for 1–3 days before the procedure, because food retained in the esophagus increases aspiration risk.
• GLP-1 medications are managed as directed by the anesthesia team.
• Blood thinners are adjusted with your prescribing physician.

• Day of the procedure: nothing by mouth.
• Days 1–3: clear liquids.
• Days 3–7: full liquids and protein shakes.
• Weeks 2–3: soft, moist foods.
• After week 3: a regular diet.

Throughout recovery:

• Eat upright and chew thoroughly.
• Don't lie down for 2–3 hours after eating to reduce reflux.
• Take PPIs as prescribed.

Weight restoration after POEM:

• Achalasia often causes unintended weight loss, because swallowing is difficult.
• Most patients regain weight once they can eat normally again.
• Dietitian guidance supports healthy, protein-forward weight restoration.

Rebuilding Muscle

• Long-standing achalasia often depletes muscle as well as fat.
• InBody or DEXA tracking confirms that regained weight is rebuilding lean mass.
• Protein-forward nutrition once the diet is advanced.
• Resistance training after the initial recovery period.

• Walk the day after the procedure.
• Week 1: light activity only. Avoid heavy straining.
• After 1–2 weeks: a gradual return to normal exercise.
• No abdominal incisions means no lifting restrictions tied to wound healing. Follow your surgeon's specific instructions.

POEM patients traveling from abroad should plan on about a week in Miami. That allows for the procedure, a short hospital stay, a contrast study before eating, and a check before the flight home. Please send your manometry tracings and endoscopy reports ahead of time so the plan can be confirmed before you book travel. Later follow-up, including reflux monitoring, can be arranged virtually with your local gastroenterologist.