Endoscopic Treatment of Achalasia.

Background: Achalasia is the most common major esophageal motility disorder, characterized by impaired lower esophageal sphincter relaxation and absent or ineffective peristalsis. Peroral endoscopic myotomy (POEM), pneumatic dilation, and botulinum toxin injection are the main endoscopic therapies available. This review highlights recent advances, technical variations, and updated evidence on the efficacy and safety of POEM.

Summary: POEM has emerged as a highly effective and minimally invasive treatment for achalasia, with randomized controlled trials demonstrating excellent long-term clinical success and durability. Its safety profile and capacity for a tailored myotomy offer distinct advantages over alternative therapies. However, gastroesophageal reflux disease (GERD) remains a key concern. Ongoing efforts are focused on optimizing procedural techniques, including myotomy length and orientation, sling fiber preservation, and the addition of fundoplication. Additionally, training protocols, patient selection criteria, and strategies to prevent and predict GERD are critical areas of development. Future research should aim to refine follow-up strategies and define objective measures of success to enhance the safety, efficacy, and accessibility of POEM.

Key messages: Endoscopic treatments of achalasia, particularly POEM, offer effective and durable outcomes. Optimizing technique, refining training, and managing GERD are essential for improving safety and long-term success.