Achalasia treatment: POEM, Heller myotomy or dilation?
Achalasia treatment helps food pass through the lower end of the esophagus. The choice between POEM, Heller myotomy and balloon dilation depends on the swallowing-test findings, previous treatment, fitness for a procedure and reflux considerations.
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Confirm the cause of swallowing difficulty
Achalasia affects relaxation at the junction between the esophagus and stomach and the movement of food through the esophagus. Difficulty swallowing liquids as well as solids, regurgitation and weight loss can occur. Treatment planning begins by confirming the diagnosis and excluding an obstruction that could resemble it.
Upper endoscopy, a barium swallowing study and high-resolution manometry answer different questions. Manometry also helps identify the achalasia subtype. Bring the actual reports, especially the pressure-test findings, rather than only a diagnosis written in a clinic letter.
Sources and references: [1]
The treatment goal is easier passage of food
Procedures reduce resistance at the lower esophageal sphincter. They can improve swallowing, but the follow-up still needs to account for the underlying motility problem and for reflux after treatment.
Describe what a typical meal is like: which textures are difficult, whether you regurgitate at night and whether weight has changed. These details help define what improvement would mean for you. Ask how swallowing, nutrition and symptoms will be reassessed after the procedure, rather than judging success only by the first few days.
How POEM is performed
Peroral endoscopic myotomy, or POEM, uses an endoscope passed through the mouth. The operator creates a tunnel within the esophageal wall and cuts selected muscle to relieve the tightness. It is performed under general anesthesia and requires specialist endoscopic expertise.
POEM can be particularly useful when a longer muscle division is needed for spastic, type III achalasia. The team should explain why the planned length fits your manometry result. Previous procedures and other medical conditions also enter the assessment, including whether anesthesia is suitable.
How Heller myotomy differs
Laparoscopic Heller myotomy reaches the muscle through small abdominal incisions. It is commonly combined with a partial fundoplication, in which part of the stomach is wrapped around the lower esophagus to reduce reflux.
Ask whether an antireflux procedure is included and how it changes the recovery plan. For many patients with type I or II achalasia, several established procedures are reasonable. The comparison should reflect local expertise and your findings, rather than treating the newest technique as the automatic choice.
Sources and references: [1]
Where dilation and botulinum toxin fit
Pneumatic dilation stretches the lower esophageal sphincter using a balloon. Some patients need a series of treatments or later repeat dilation. Perforation is an important risk to discuss, along with the center's plan for managing it.
Botulinum toxin injection may be considered when someone is not fit for a more durable procedure. Its benefit is often less lasting. Ask whether the aim is short-term symptom relief or a longer-term strategy, and how another treatment would be considered if swallowing worsens again.
Sources and references: [1]
Compare reflux and procedural risks
POEM carries a greater risk of gastroesophageal reflux than Heller myotomy with fundoplication or pneumatic dilation. Reflux may require medication and follow-up. Ask how the team will assess it, including when symptoms are mild.
Other procedural risks include bleeding, infection and injury to the esophagus; gas-related complications can occur with POEM. The consultation should address risks in your own case and the hospital's response if a complication occurs. For overseas care, identify the contact and local service to use once you have returned home.
Make a plan for eating and reassessment
Preparation may include a liquid diet and fasting instructions tailored by the treating team. After the procedure, the team determines when and how to advance your diet. Request the instructions in writing, including which medicines to take and whom to call if drinking becomes difficult.
Persistent or recurrent swallowing difficulty deserves reassessment rather than simply repeating the previous treatment. A timed barium study can help evaluate emptying after treatment. Keep the procedure report and follow-up results together so a future clinician knows what was treated and how the esophagus responded.
Preparing a Shanghai gastroenterology enquiry
Renji Hospital has a gastroenterology specialty and is a relevant Shanghai resource for a digestive-disease consultation. An achalasia enquiry should establish which team provides motility assessment and the proposed procedure before a visit is arranged.
EastMedGo can organize the manometry report, endoscopy findings, barium images and details of any previous dilation or myotomy. We can help ask for a comparison focused on your subtype, swallowing problems and reflux risk. Clarifying the assessment and follow-up route first makes it easier to plan the visit around clinical needs.
Sources and references: [3]
Common questions
Is POEM always preferable to Heller myotomy?
No. Achalasia subtype, previous treatment, reflux considerations and procedural expertise affect the choice. POEM can be particularly useful for spastic disease, while Heller myotomy can include an antireflux procedure.
Sources and references: [1]
Can swallowing problems return after treatment?
Yes. Persistent or recurrent symptoms may need further investigation, including assessment of esophageal emptying. The cause should be clarified before choosing another procedure.
Sources and references: [1]
Sources and references
- American College of Gastroenterology: Clinical guideline on diagnosis and management of achalasia
- Johns Hopkins Medicine: Peroral endoscopic myotomy
- Renji Hospital
Prepared with AI assistance by EastMedGo for patients comparing treatment and care options.