Comparing peroral endoscopic myotomy and laparoscopic Heller myotomy for esophageal motility disorders: Nationwide cohort study

Abstract

Background and study aims

Peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) are established treatments for esophageal motility disorders. However, previous comparative studies have been limited by small sample sizes, restricting generalizability. This study aimed to evaluate perioperative outcomes of POEM and LHM in the United States using a population-based database.

Patients and methods

We conducted a retrospective cohort study using the Nationwide Inpatient Sample (NIS) from 2016 to 2022. Patients with achalasia or non-achalasia spastic esophageal disorders who underwent POEM or LHM were included. Inverse probability of treatment weighting (IPTW) analysis was applied to enhance comparability across treatments. Trends in the number of procedures and assessed outcomes included serious adverse events (SAEs), reintervention, mortality, length of stay, and cost.

Results

A total of 18,694 patients were identified (6,554 POEM and 12,140 LHM). Overall rates of SAEs, reintervention, and 30-day mortality were 7.9%, 5.0%, and 0.08%, respectively. IPTW analysis revealed significantly lower rates of SAEs (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.70–0.88) and reintervention (OR 0.79, 95% CI 0.68–0.93) in the POEM group. Length of stay and cost were also more favorable in the POEM group. Mortality was not significantly different (P = 0.97). Subgroup analysis supported these findings when considering either achalasia (n = 15,971) or non-achalasia spastic esophageal disorders (n = 2,723) individually.

Conclusions

In this nationwide cohort, LHM remained more commonly performed in the United States. However, our results confirm that POEM demonstrated favorable outcomes in management of esophageal motility disorders.

Keywords

Endoscopy Upper GI Tract - POEM - Motility / achalasia

Publikationsverlauf

Eingereicht: 14. Juni 2025

Angenommen nach Revision: 02. August 2025

Accepted Manuscript online:
04. August 2025

Artikel online veröffentlicht:
27. August 2025

• References

• 1 Yang D, Bechara R, Dunst CM. et al. AGA Clinical Practice Update on Advances in Per-Oral Endoscopic Myotomy (POEM) and Remaining Questions-What We Have Learned in the Past Decade: Expert Review. Gastroenterology 2024; 167: 1483-1490
• 2 Ramchandani M, Nabi Z, Inavolu P. et al. Recent advancements and future perspectives of per oral endoscopic myotomy. Clin Gastroenterol Hepatol 2024; 22: 1983-1996 e2
• 3 Onimaru M, Inoue H, Fujiyoshi Y. et al. Long-term clinical results of per-oral endoscopic myotomy (POEM) for achalasia: First report of more than 10-year patient experience as assessed with a questionnaire-based survey. Endosc Int Open 2021; 9: E409-e416
• 4 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
• 5 Inoue H, Shiwaku H, Kobayashi Y. et al. Statement for gastroesophageal reflux disease after peroral endoscopic myotomy from an international multicenter experience. Esophagus 2020; 17: 3-10
• 6 Ponds FA, Fockens P, Lei A. et al. Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: A randomized clinical trial. JAMA 2019; 322: 134-144
• 7 Khashab MA, Vela MF, Thosani N. et al. ASGE guideline on the management of achalasia. Gastrointest Endosc 2020; 91: 213-227 e6
• 8 Vaezi MF, Pandolfino JE, Yadlapati RH. et al. ACG Clinical Guidelines: Diagnosis and Management of Achalasia. Am J Gastroenterol 2020; 115: 1393-1411
• 9 Weusten B, Barret M, Bredenoord AJ. et al. Endoscopic management of gastrointestinal motility disorders - part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 498-515
• 10 Inoue H, Shiwaku H, Iwakiri K. et al. Clinical practice guidelines for peroral endoscopic myotomy. Dig Endosc 2018; 30: 563-579
• 11 Ali AB, Khan NA, Nguyen DT. et al. Robotic and per-oral endoscopic myotomy have fewer technical complications compared to laparoscopic Heller myotomy. Surg Endosc 2020; 34: 3191-3196
• 12 Werner YB, Hakanson B, Martinek J. et al. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia. N Engl J Med 2019; 381: 2219-2229
• 13 de Moura ETH, Jukemura J, Ribeiro IB. et al. Peroral endoscopic myotomy vs laparoscopic myotomy and partial fundoplication for esophageal achalasia: A single-center randomized controlled trial. World J Gastroenterol 2022; 28: 4875-4889
• 14 Bhayani NH, Kurian AA, Dunst CM. et al. A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia. Ann Surg 2014; 259: 1098-1103
• 15 Chan SM, Wu JC, Teoh AY. et al. Comparison of early outcomes and quality of life after laparoscopic Heller's cardiomyotomy to peroral endoscopic myotomy for treatment of achalasia. Dig Endosc 2016; 28: 27-32
• 16 Schneider AM, Louie BE, Warren HF. et al. A matched comparison of per oral endoscopic myotomy to laparoscopic Heller myotomy in the treatment of achalasia. J Gastrointest Surg 2016; 20: 1789-1796
• 17 Peng L, Tian S, Du C. et al. Outcome of peroral endoscopic myotomy (POEM) for treating achalasia compared with laparoscopic Heller myotomy (LHM). Surg Laparosc Endosc Percutan Tech 2017; 27: 60-64
• 18 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 19 Xu P, Liu Z, Zhang J. et al. Peroral endoscopic myotomy is an effective treatment for achalasia combined with hiatal hernia. Surg Endosc 2024; 38: 4543-4549
• 20 Charlson ME, Pompei P, Ales KL. et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40: 373-383
• 21 Zhao CY, Xu N, Dong H. et al. Effect of sex on the outcomes of peroral endoscopic myotomy for the treatment of achalasia. World J Gastroenterol 2025; 31: 104579
• 22 Lois AW, Oelschlager BK, Wright AS. et al. Use and safety of per-oral endoscopic myotomy for achalasia in the US. JAMA Surg 2022; 157: 490-497
• 23 Attaar M, Su B, Wong HJ. et al. Comparing cost and outcomes between peroral endoscopic myotomy and laparoscopic heller myotomy. Am J Surg 2021; 222: 208-213
• 24 Inoue H, Sato H, Ikeda H. et al. Per-oral endoscopic myotomy: A series of 500 patients. J Am Coll Surg 2015; 221: 256-264
• 25 Quénéhervé L, Vauquelin B, Berger A. et al. Risk factors for clinical failure of peroral endoscopic myotomy in achalasia. Front Med (Lausanne) 2022; 9: 1099533
• 26 Fujiyoshi Y, Fujiyoshi MRA, Khalaf K. et al. Association of gastric myotomy length in peroral endoscopic myotomy (POEM) with gastro-esophageal junction distensibility measured by Endoluminal Functional Lumen Imaging Probe (EndoFLIP). Esophagus 2024; 21: 563-570
• 27 Shah ED, Chang AC, Law R. Valuing innovative endoscopic techniques: per-oral endoscopic myotomy for the management of achalasia. Gastrointest Endosc 2019; 89: 264-273 e3
• 28 Shiwaku H, Sato H, Shimamura Y. et al. Risk factors and long-term course of gastroesophageal reflux disease after peroral endoscopic myotomy: A large-scale multicenter cohort study in Japan. Endoscopy 2022; 54: 839-847
• 29 Ichkhanian Y, Sanaei O, Canakis A. et al. Esophageal peroral endoscopic myotomy (POEM) for treatment of esophagogastric junction outflow obstruction: results from the first prospective trial. Endosc Int Open 2020; 8: E1137-e1143
• 30 Morley TJ, Mikulski MF, Rade M. et al. Per-oral endoscopic myotomy for the treatment of non-achalasia esophageal dysmotility disorders: experience from a single high-volume center. Surg Endosc 2023; 37: 1013-1020
• 31 Khashab MA, Familiari P, Draganov PV. et al. Peroral endoscopic myotomy is effective and safe in non-achalasia esophageal motility disorders: an international multicenter study. Endosc Int Open 2018; 6: E1031-e1036
• 32 Puri R, Giri S, Panigrahi SC. et al. Efficacy and safety of per-oral endoscopic myotomy in non-achalasia esophageal motility disorders: a systematic review and meta-analysis. Esophagus 2024; 21: 419-429