POEM for achalasia: how the procedure works and who it may suit

Peroral endoscopic myotomy, known as POEM, is a treatment for achalasia, a rare condition that makes swallowing food and drink increasingly difficult. During POEM, a specialist uses an endoscope passed through the mouth to cut the muscle that is not relaxing properly, without any cuts to the skin. This guide explains what achalasia is, how POEM works, how it compares with other treatments and what to expect around the time of the procedure.

What is achalasia?

The oesophagus, or food pipe, carries food and drink from the mouth to the stomach. At its lower end is a ring of muscle called the lower oesophageal sphincter. Normally this sphincter relaxes when you swallow, letting food pass into the stomach, and the muscles along the oesophagus contract in waves to push food downwards.

In achalasia, the sphincter does not relax properly and the wave-like contractions are lost. These changes are linked to damage to the nerves in the oesophagus. As a result, food and liquid can collect in the oesophagus instead of passing easily into the stomach.

Common symptoms

• difficulty swallowing both solids and liquids, often worsening gradually;
• bringing back undigested food (regurgitation);
• chest pain, which may be worse after eating;
• heartburn, coughing or choking;
• repeated chest infections;
• losing weight without trying.

Some people have few symptoms, and achalasia is occasionally found on tests done for another reason. Other conditions can cause similar symptoms, which is why a full assessment is important.

How achalasia is diagnosed

A gastroenterologist will usually arrange several tests:

• Oesophageal manometry measures the pressure and movement of the muscles in the oesophagus using a thin tube passed through the nose or mouth.
• Barium swallow uses X-rays to show how a drink passes through the oesophagus and into the stomach.
• Upper endoscopy (gastroscopy) lets the doctor look at the lining of the oesophagus, the muscle ring and the stomach, and rule out other causes.

Some centres also use a test called a functional luminal imaging probe (FLIP), which builds a three-dimensional picture of the oesophagus. Together, these results show which type of achalasia is present, which helps decide on treatment and, for POEM, how much muscle needs to be cut.

Treatment options for achalasia

There is no cure for achalasia, but several treatments aim to reduce pressure at the sphincter so that food and liquid can pass more easily.

Treatment	How it works	Points to consider
Medicines	Relax the muscles of the oesophagus	Effect is short-lived; often used while waiting for longer-term treatment
Injection (botulinum toxin)	Relaxes the muscle ring, given during endoscopy	Effect wears off, so it needs repeating
Balloon dilation	Stretches the muscle ring during endoscopy	Helps many people but may need repeating; small risk of a tear
Heller myotomy	Cuts the muscle ring, usually by keyhole surgery	An anti-reflux procedure is often done at the same time
POEM	Cuts the muscle from inside the oesophagus through an endoscope	No skin wounds; done under general anaesthetic

Surgical and non-surgical treatments can give similar results, and some people need more than one treatment over time. The right choice depends on your type of achalasia, your symptoms, your general health and any treatment you have already had.

How POEM works

POEM is performed under a general anaesthetic, so you are asleep. The specialist passes a gastroscope, a thin flexible tube with a camera, through your mouth into the oesophagus. A small opening is made in the inner lining of the oesophagus wall using an electrosurgical knife. The specialist then creates a tunnel underneath the lining and, working inside this tunnel, cuts the muscle lengthways down to the sphincter and a little way beyond it into the stomach. At the end, the opening in the lining is sealed with temporary clips so that the lining is left intact.

Because the whole procedure is done through the endoscope, there are no skin wounds or stitches. As well as easing swallowing, cutting the muscle can also help symptoms such as chest pain. The procedure commonly takes around an hour or longer, particularly if the muscle is thick.

Who may be suited to POEM

POEM is used for people with a confirmed diagnosis of achalasia. It works better for some types of achalasia and some symptoms than for others, and the likely benefit also depends on what treatment you have had before. Having had balloon stretching or keyhole surgery in the past does not necessarily rule POEM out. Your specialist will meet you beforehand to explain what they plan to do and how likely POEM is to help in your particular situation.

Preparing for POEM

You will normally have a pre-assessment with a nurse, who will explain exactly how to prepare. Typical steps include:

• following a liquid-only diet for a few days beforehand, so that the oesophagus and stomach are empty and clear to see;
• having nothing to drink for a set number of hours before the procedure;
• telling the team about blood-thinning medicines, diabetes medicines and any other treatments, as some may need to be paused;
• letting the anaesthetist know about loose teeth, crowns or bridgework;
• arranging for someone to collect you and stay with you, and staying within easy reach of the hospital afterwards.

After POEM: recovery and eating

You will usually spend the day in the endoscopy unit, and some people stay overnight for observation. Most people do not eat at all for the first day, so that the opening in the lining can heal; fluids, pain relief and medicine to reduce stomach acid are given through a drip.

Eating is then reintroduced in stages. A typical plan moves from thin liquids in the first week, to pureed food in the second week, and then towards a normal diet. Many people find it takes longer to get used to eating again, sometimes a couple of months, so take things slowly and follow your team's guidance.

A sore throat, mild chest discomfort and a crackling feeling under the skin are common for a few days. Your team will also talk to you about reflux, as acid can flow back into the oesophagus after treatments that open the sphincter, and about any follow-up tests.

Risks and when to seek help

Serious complications are uncommon, but possible risks include bleeding during the procedure, a perforation (hole) in the oesophagus wall, infection, inhaling stomach contents (aspiration), damage to teeth or dental work, and reactions to the anaesthetic. Occasionally the procedure cannot be completed.

Seek urgent medical care or contact emergency services if you develop severe or continuous pain in your neck, chest or abdomen, a swollen abdomen, fever or chills, persistent vomiting, worsening difficulty swallowing or black, tarry stools. If swallowing problems or weight loss continue in the longer term after treatment, see your doctor for review.

Questions to ask before choosing a treatment

Achalasia treatment is a shared decision, and it is worth taking time to understand the options. You may find it helpful to bring these questions to your appointment:

• Which type of achalasia do my test results show, and how does that affect the choice between POEM, balloon dilation and keyhole surgery?
• How might my previous treatments influence what you recommend now?
• What benefits can I realistically expect for swallowing, regurgitation and chest pain?
• How will reflux be checked and managed afterwards?
• How long should I plan to stay near the hospital, and when can I travel home?
• What follow-up appointments or tests will I need, and who should I contact if symptoms return?

Writing down your symptoms, how long they have been present, any weight change and the treatments you have already tried can make these conversations more productive. If you have copies of earlier manometry, barium swallow or endoscopy reports, bring them with you, as they help the team plan without repeating tests unnecessarily.

Next steps

If you have increasing difficulty swallowing, regurgitation or unexplained weight loss, or you have already been diagnosed with achalasia and want to explore your treatment options, a gastroenterologist can review your tests and talk you through them. Read more about our gastroenterology care, or use Find my physician to be matched with a suitable specialist.