Comparison of surgical and endoscopic approaches in the treatment of esophageal achalasia: Laparoscopic myotomy versus peroral endoscopic myotomy (POEM)

Current treatment options for achalasia aim to reduce the lower oesophageal sphincter (LES) pressure, as no curative therapy exists. Surgical myotomy remains the mainstay of long-term management. Laparoscopic Heller-myotomy, combined with an antireflux Dor fundoplication (LHD), provides excellent long-term results, with symptom relief in 85-95% of patients, and durable control beyond 20 years in referral centres. Peroral Endoscopic Myotomy (POEM), developed in 2008, represents a minimally invasive endoscopic alternative with comparable efficacy, particularly in type III achalasia, for which longer myotomy can be performed. However, POEM carries a higher risk of postoperative gastroesophageal reflux, often requiring long-term proton pump inhibitor (PPI) therapy. In end-stage achalasia, POEM may have limited efficacy and increased procedural risk, whereas LHD combined with the oesophageal pull-down technique offers superior outcomes, enabling organ-sparing management. The choice between POEM and LHD should be based on achalasia subtype, disease stage, patient profile, and centre expertise.