Advances in peroral endoscopic myotomy for achalasia

Achalasia prevents the lower oesophageal sphincter from relaxing normally, causing dysphagia, regurgitation and weight loss. Peroral endoscopic myotomy (POEM) has become a central treatment because it divides obstructing muscle through the mouth, without an abdominal incision. At the 17th World Congress for Esophageal Diseases, held virtually from 27–30 September 2021, discussion moved beyond establishing whether the treatment works to refining selection, technique and follow-up.

For Australian clinicians and patients, the congress offered updates on a changing field. Medicare generally subsidises specialist consultations and public hospital treatment, whereas private treatment can leave out-of-pocket expenses. Scientific sessions, workshops and CME information therefore mattered for local practice, even though the meeting took place remotely.

Changing the treatment pathway

POEM creates a submucosal tunnel and divides the lower oesophageal sphincter, extending into the oesophageal body when required. It offers an alternative to surgical myotomy for achalasia, with often rapid recovery. The approach also allows the length and direction of the muscle division to be adapted to individual anatomy.

Compared with Heller myotomy and a partial fundoplication, POEM avoids abdominal surgery but shifts attention towards reflux after treatment. Decisions should combine patient preference, endoscopic and surgical expertise, and access to follow-up. In Australia, this pathway may involve a gastroenterologist in a metropolitan centre and a surgeon at a regional hospital, with coordinated referral.

Matching the myotomy to physiology

Manometry helps distinguish achalasia subtypes. Type I generally involves impaired sphincter relaxation without marked panesophageal pressurisation; type II includes substantial pressurisation; type III features premature or spastic contractions that may require a longer, more targeted myotomy.

Durable oesophageal emptying matters more than removing the greatest possible length of muscle. Excessively long cuts may increase reflux or perforation risk, while an inadequate cut leaves obstruction behind. Newer practice favours a length based on manometry, barium study and endoscopic findings, rather than treating every patient with the same division.

Refining technique and reducing risk

Technical developments include changes in entry site, tunnel direction and closure of the mucosal incision. Posterior tunnel entry has been investigated for difficult anatomy, and closure methods continue to evolve. The aim is better control at the junction and fewer leaks, rather than novelty for its own sake.

Long myotomy is particularly valuable in type III achalasia, where spasm extends beyond the junction. Cutting only the junction may fail to relieve chest pain or dysphagia caused higher in the oesophagus. A longer operation demands careful interpretation of motility testing and advanced endoscopic dissection.

Measuring outcomes beyond symptoms

Relief of dysphagia and regurgitation is important, but it does not prove that the junction opens normally. Timed barium esophagrams can show persistent narrowing or delayed emptying, while EndoFLIP assesses opening and compliance at the gastro-oesophageal junction. Follow-up may include endoscopy to check the tunnel and pH monitoring when reflux is suspected.

Access shapes this pathway. Patients around Sydney, Melbourne, Brisbane, Perth and Adelaide often travel for endoscopy or imaging, while people in regional and remote areas may rely on local services and telehealth review. Repeated travel can affect adherence, so follow-up must account for distance, work, family commitments and fasting before tests.

Managing reflux and complications

Perforation, pneumomediastinum, pneumothorax and mucosal injury are recognised complications. Small injuries may be managed endoscopically or conservatively, but significant leakage can require intervention. Reflux deserves attention because POEM does not add the partial wrap used in some Heller procedures. Proton-pump inhibitors are often used initially, with dietary advice and later testing for persistent symptoms.

For some Australians, dining out, takeaway meals and long social lunches can make reflux harder to distinguish from recurrent oesophageal problems. A dietitian can identify meal size, timing and triggers; dietary changes cannot correct an incomplete myotomy. Device regulation adds another local requirement: the Therapeutic Goods Administration oversees product safety, and equipment used in Australia must meet device requirements, commonly through inclusion on the Australian Register of Therapeutic Goods.

Recognising failure and considering salvage treatment

Persistent dysphagia after POEM may reflect an incomplete or incorrectly positioned myotomy, scarring, an alternative motor disorder or a structural lesion rather than recurrent achalasia. Reviewing the original report, repeat manometry and objective tests is essential before another procedure. In selected patients, a second POEM can extend the myotomy or revise the tunnel.

Surgery remains an option after failed endoscopic therapy, although altered anatomy makes it more demanding. The ISDE’s salvage surgery overview explains the role of Heller myotomy, partial fundoplication and, rarely, oesophagectomy in selected cases. These decisions belong in experienced multidisciplinary teams, with nutrition and reflux management weighed against the likelihood of durable success.

Training evidence and international collaboration

POEM requires a distinct skill set: safe tunnel creation, controlled muscle division, recognition of complications and appropriate closure. Video-based teaching, proctoring, credentialing and outcome registries translate technical success into consistent patient benefit. Congress abstracts help identify common complications and questions needing prospective studies.

ISDE 2021 brought these discussions into a virtual format during the Australian spring, with a programme that could be followed from different Australian time zones. An adjacent example is the procedural research forum, which shows how specialist meetings circulate new research and refine evaluation methods. Continuing education credits and local peer review can then support the audited adoption of new techniques.

What should remain with clinicians is that POEM is not a standardised operation. Its value depends on accurate subtype classification, a myotomy matched to the physiology, objective assessment and a prepared response to reflux or incomplete treatment. For Australian patients, access to experienced multidisciplinary care and equitable follow-up matter as much as technical refinement.