Surgery for achalasia works by cutting the muscle fibers of the lower esophageal sphincter so food can pass into the stomach, and it succeeds in relieving swallowing difficulty in roughly 75 to 90 percent of patients depending on the technique and time frame. Two procedures dominate current practice: laparoscopic Heller myotomy, which has been the standard for decades, and peroral endoscopic myotomy (POEM), a newer approach performed entirely through the mouth with no external incisions. A landmark randomized trial found POEM to be noninferior to Heller myotomy for symptom control, but the choice between them involves real trade-offs that go well beyond short-term success rates.
What Achalasia Does and Why Surgery Helps
Achalasia is a rare motility disorder in which the inhibitory nerve cells in the esophageal wall progressively degenerate, leaving the lower esophageal sphincter unable to relax properly when you swallow.1PubMed. The role of type II esophageal microbiota in achalasia: Activation of macrophages and degeneration of myenteric neurons In healthy people, a wave of nerve signals triggers the sphincter to open briefly, letting food drop into the stomach. In achalasia, the neurons responsible for that signal are drastically reduced. Studies comparing esophageal tissue from achalasia patients and healthy controls have found the number of nitric oxide-producing nerve cells to be nearly absent at the sphincter in affected individuals.2The American Journal of Gastroenterology. Esophageal and gastric nitric oxide synthesizing innervation in primary achalasia The cause likely involves a combination of viral triggers and genetic susceptibility. Evidence points to herpes simplex virus type 1 as a possible initial insult, with chronic inflammation around the nerve plexus driving damage in people whose immune systems respond in a way that sustains the attack.3PubMed Central. Achalasia—An Autoimmune Inflammatory Disease: A Cross-Sectional Study
Because the nerve loss is irreversible with current medicine, no drug restores normal sphincter function. Surgery works around the problem by physically dividing the muscle that the nerves can no longer relax. The muscle cut, called a myotomy, weakens the sphincter enough for food and liquid to pass through by gravity and esophageal pressure, even though the coordinated nerve-driven relaxation never returns.
Laparoscopic Heller Myotomy
Heller myotomy has been performed in one form or another since 1913, evolving from open chest and abdominal operations to the laparoscopic approach that became standard in the 1990s.4PubMed. The Evolution of the Treatment of Esophageal Achalasia: From the Open to the Minimally Invasive Approach The surgeon makes several small incisions in the abdomen, reaches the lower esophagus from the outside, and carefully splits the circular and longitudinal muscle layers of the sphincter while leaving the inner lining intact. This is almost always paired with a partial fundoplication, a procedure in which part of the stomach is wrapped around the lower esophagus to create a valve-like barrier against acid reflux. The most common wrap is the Dor fundoplication, which goes over the front of the exposed esophageal lining.
Adding that wrap matters a great deal. A prospective randomized trial found that nearly half of patients who had Heller myotomy alone developed abnormal acid reflux, compared with about 9 percent of those who also received a Dor fundoplication.5PubMed Central. Heller Myotomy Versus Heller Myotomy With Dor Fundoplication for Achalasia A Prospective Randomized Double-Blind Clinical Trial The wrap also protects the exposed mucosal surface if there is a small perforation during surgery. For these reasons, virtually every center now performs the myotomy with some form of fundoplication.
Peroral Endoscopic Myotomy
POEM, introduced in humans around 2010, achieves the same goal of dividing the sphincter muscle but uses a flexible endoscope passed through the mouth. The endoscopist creates a small opening in the esophageal lining, tunnels between the lining and the muscle for several centimeters, and then cuts the muscle from the inside. There are no abdominal incisions, and patients typically go home the next day.
Short-term results are consistently strong. A systematic review and meta-analysis found that POEM produces large, statistically significant drops in both symptom scores and sphincter pressure.6PubMed. Efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia: a systematic review and meta-analysis A multicenter study from Taiwan reported clinical success in about 96 percent of patients at three months, with only about 4 percent experiencing symptom recurrence over a median follow-up of two years.7PubMed. Clinical efficacy and safety of peroral endoscopic myotomy for esophageal achalasia: A multicenter study in Taiwan Longer data are now available: a study tracking 100 patients beyond four years after POEM found that 95 percent had symptom scores of 3 or below, a threshold considered clinical success, after accounting for a handful who needed additional treatment.8PubMed Central. Outcomes of 100 Patients Greater than 4 Years after POEM for Achalasia – Original Study
Head-to-Head Comparison
The question most patients want answered is whether POEM or Heller myotomy gives better results. The best evidence comes from a multicenter randomized trial comparing the two. At two years, about 83 percent of POEM patients and 82 percent of Heller myotomy patients had good symptom control, establishing POEM as noninferior.9PubMed. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia The five-year follow-up of the same trial showed clinical success in 75 percent after POEM and 71 percent after Heller myotomy, confirming that the two approaches remain comparable over a longer horizon.10The Lancet Gastroenterology & Hepatology. Endoscopic or surgical myotomy in patients with idiopathic achalasia Both procedures lose some effectiveness over time, which is expected given the progressive nature of the disease.
These numbers put POEM and Heller myotomy on essentially equal footing for the primary goal of relieving dysphagia. The differentiator lies in what happens on the reflux side.
The Reflux Trade-Off
Cutting the sphincter muscle inevitably weakens the barrier between the stomach and esophagus, making some degree of acid reflux a predictable side effect of any myotomy. The key difference is that Heller myotomy includes a fundoplication to compensate, while POEM does not. This shows up clearly in pooled data. A meta-analysis found that after POEM, about 39 percent of patients had abnormal acid exposure on pH testing, compared with roughly 17 percent after Heller myotomy with fundoplication. Reflux symptoms were reported by about 19 percent of POEM patients versus about 9 percent after Heller myotomy. The rate of visible esophagitis was about 29 percent after POEM and about 8 percent after Heller myotomy.11PubMed. GERD after per-oral endoscopic myotomy as compared with Heller’s myotomy with fundoplication: a systematic review with meta-analysis
Another systematic review confirmed the pattern, finding that POEM patients were significantly more likely to develop reflux symptoms, erosive esophagitis, and abnormal pH monitoring results.12Annals of Surgery. Laparoscopic Heller Myotomy Versus Peroral Endoscopic Myotomy (POEM) for Achalasia: A Systematic Review and Meta-analysis The five-year data from the randomized trial showed reflux was common in both groups but tended to be higher after POEM.13The Lancet Gastroenterology & Hepatology. Endoscopic or surgical myotomy in patients with idiopathic achalasia Most post-POEM reflux responds well to acid-suppressing medication, but this means many POEM patients end up on a daily proton pump inhibitor indefinitely, something worth factoring into the decision.
How Achalasia Subtypes Influence Results
Not all achalasia behaves the same way, and the subtype diagnosed on manometry testing can influence which procedure a surgeon recommends. The most widely used classification divides achalasia into three types based on the pressure pattern in the esophageal body. Type I involves minimal esophageal pressurization, type II shows panesophageal pressurization with each swallow, and type III has premature or spastic contractions.
Type II achalasia generally responds best to any treatment. Type III is the most difficult: patients tend to have lower rates of good symptom outcomes than other subtypes.14PubMed Central. Comparison of Achalasia Classification Schemes to Predict Treatment Outcomes POEM has a particular advantage in type III, because the endoscopic approach allows the myotomy to be extended further up the esophageal body to address the spastic segment, something that is more difficult to do laparoscopically. Even so, a study comparing type I and type III outcomes found that type I patients had a greater reduction in symptom scores after POEM.15Diseases of the Esophagus. Long-term outcomes of peroral endoscopic myotomy for Chicago classification type I vs type III achalasia in treatment-naive patients Type III achalasia remains harder to treat regardless of approach, and patients should have realistic expectations.
Pneumatic Dilation as a Non-Surgical Alternative
Not everyone with achalasia needs or wants surgery. Pneumatic dilation, in which a large balloon is inflated across the sphincter to forcibly stretch and partially tear the muscle, has been used for over a century. A European randomized trial comparing pneumatic dilation to laparoscopic Heller myotomy found comparable success rates at two years: about 86 percent for dilation and 90 percent for surgery.16PubMed. Pneumatic Dilation versus Laparoscopic Heller’s Myotomy for Idiopathic Achalasia Dilation often requires repeat sessions, though, and its durability appears to fade over longer periods. A separate study tracking patients for six years found success dropping to about 44 percent for pneumatic dilation compared with roughly 57 percent for Heller myotomy.17PubMed. The long-term efficacy of pneumatic dilatation and Heller myotomy for the treatment of achalasia
Pneumatic dilation is most useful for patients who are not surgical candidates, those who prefer a less invasive first step, or as a bridge while deciding on definitive surgery. Botulinum toxin injection into the sphincter is another temporizing option that weakens the muscle chemically, but its effect wears off within months and repeated injections can create scarring that makes a subsequent myotomy more difficult.
When Surgery Fails
No achalasia treatment is permanent for everyone. When symptoms return after an initial Heller myotomy, options include repeat myotomy, pneumatic dilation, or POEM performed as a rescue procedure. Redo Heller myotomy is technically more challenging because of scar tissue from the first operation, but reported success rates range from about 69 to 100 percent.18PubMed. What to do when Heller myotomy fails: pneumatic dilation, redo Heller, or peroral endoscopic myotomy? POEM has increasingly become the preferred salvage option. Because it approaches the muscle from the inside of the esophagus, it can work through a plane of tissue that was not disturbed by the original external surgery. A comparison at a single institution found that rescue POEM was associated with better surgical outcomes than redo laparoscopic Heller myotomy in patients whose first operation had failed.19PubMed. Redo laparoscopic Heller myotomy and Dor fundoplication versus rescue peroral endoscopic myotomy for esophageal achalasia after failed Heller myotomy
Revisional therapy, whether by POEM or redo Heller, can produce significant improvements in dysphagia, regurgitation, and chest pain. One study found sustained symptom improvement at a median follow-up of about three and a half years after revisional surgery.20PubMed Central. Revisional Therapy for Recurrent Symptoms After Heller Myotomy for Achalasia
End-Stage Achalasia and Esophagectomy
If achalasia goes untreated for many years, the esophagus can become massively dilated and tortuous, sometimes described as a sigmoid esophagus because of its S-shaped curve. At this stage, standard myotomy may not be enough because the esophagus has lost all functional muscle tone and essentially acts as a floppy, food-collecting sac.
Esophagectomy, or surgical removal of the esophagus, may be considered in these cases. International guidelines still recommend trying a less invasive approach first, even in advanced disease.21PubMed. Surgical Options for End-Stage Achalasia A systematic review of advanced megaesophagus found that Heller myotomy could be performed even in these patients with lower complication and mortality rates compared with major surgeries like esophagectomy, though the long-term results are less certain.22Arquivos Brasileiros de Cirurgia Digestiva. Advanced Megaesophagus Treatment: Which Technique Offers the Best Results? A Systematic Review Esophagectomy is typically reserved for patients who have failed all other treatments or who have a severely damaged esophagus with a high risk of cancer.
Achalasia Surgery in Children
Achalasia in children is even rarer than in adults, but the treatment principles are similar. POEM has been increasingly adopted in pediatric practice. The largest single-institution report, covering 101 children over ten years, concluded that POEM is safe, effective, and durable in this population, with outcomes that were superior to those of Heller myotomy at that center.23PubMed. Pediatric achalasia and peroral endoscopic myotomy (POEM): Ten-year outcomes for 101 children at a single institution Additional long-term follow-up data confirmed that POEM achieves significant symptom relief and quality-of-life improvement in children.24PubMed Central. Per-oral endoscopic myotomy is safe and effective for pediatric patients with achalasia: A long-term follow-up study The same reflux considerations apply: children undergoing POEM will likely need monitoring and possibly acid suppression therapy, just as adults do.
Recovery and Quality of Life
One of the most reassuring findings in achalasia research is how dramatically quality of life improves after treatment. Before surgery, patients with achalasia score significantly worse than the general population across nearly every quality-of-life measure. Twelve months after POEM, those scores recover to levels similar to those of healthy people. A study found clinically meaningful improvements in at least half the patients for most quality-of-life dimensions, with the exception of basic physical functioning, which was already relatively preserved before treatment.25PubMed Central. Quality of life in patients with achalasia: Associations with Eckardt score and objective treatment outcomes after peroral endoscopic myotomy The emotional and social burden of achalasia is often underappreciated: difficulty swallowing affects meals, social eating, sleep, and weight. Surgery relieves most of that.
Physical recovery from POEM is generally quicker than from Heller myotomy because there are no abdominal incisions. Most POEM patients resume a soft diet within a day or two and return to normal activities within a week. Heller myotomy, while still minimally invasive, involves small abdominal wounds and intra-abdominal dissection, so most surgeons recommend limiting activity for two to four weeks.
Measuring Success During the Operation
One of the trickier aspects of achalasia surgery is knowing, in real time, whether you have cut enough muscle. An incomplete myotomy is the most common reason for treatment failure. Surgeons have started using a tool called the functional lumen imaging probe (FLIP) to assess the sphincter’s openness during the procedure. FLIP uses a balloon catheter to measure how easily the sphincter stretches under controlled distension.
Studies have shown that the sphincter’s distensibility increases substantially after myotomy, from about 1.4 to about 4.7 on a standardized index, giving the surgeon a real-time confirmation that the cut was adequate.26PubMed Central. Intraoperative assessment of esophageal motility using FLIP during myotomy for achalasia Early experience suggests FLIP can help predict outcomes after both Heller myotomy and POEM.27Journal of Gastrointestinal Surgery. Using Impedance Planimetry (EndoFLIP) to Evaluate Myotomy and Predict Outcomes After Surgery for Achalasia That said, the technology is still being validated, and its real-world usefulness remains debated.28PubMed Central. EndoFLIP system for the intraoperative evaluation of peroral endoscopic myotomy More centers are incorporating it, and if your surgeon uses FLIP, it is a reasonable indicator that the team is current with best practices.
Long-Term Cancer Risk After Surgery
Achalasia itself increases the risk of esophageal cancer, primarily squamous cell carcinoma. The chronic stasis of food and saliva in the esophagus exposes the lining to irritants for years, and the chronic inflammation from the disease itself plays a role. A critical point for patients to understand is that surgery does not eliminate this elevated cancer risk. Even after successful myotomy that resolves swallowing symptoms, the esophageal lining has already sustained years of damage, and the underlying motility disorder persists.
One long-term follow-up study found that four patients developed squamous cell esophageal cancer at intervals ranging from 2 to 18 years after surgery, with the standardized mortality ratio for esophageal cancer significantly higher than expected in men.29British Journal of Surgery. Long-term outcome and risk of oesophageal cancer after surgery for achalasia In a separate prospective study, about 18 percent of patients in an endoscopic surveillance program developed esophageal cancer despite regular monitoring, with cancers appearing on average more than 14 years after surgery.30PubMed Central. Achalasia and esophageal cancer: risks and links The potential for cancer persists even after surgery improves passage symptoms.31PubMed Central. Incidence of Esophageal Carcinomas After Surgery for Achalasia: Usefulness of Long-Term and Periodic Follow-Up
This means periodic endoscopic surveillance is recommended for life after achalasia surgery. There is no universal consensus on exactly how often to scope, but many experts suggest surveillance endoscopy every one to three years starting around 10 to 15 years after diagnosis, with earlier or more frequent checks for patients who had long-standing disease before treatment. The goal is to catch any malignancy at an early, treatable stage.
Cost Considerations
If you are weighing POEM against Heller myotomy and insurance coverage or out-of-pocket cost is a concern, the financial picture is nuanced. One cost-effectiveness analysis found that the index hospital admission for POEM was actually more expensive than for Heller myotomy (about $8,500 versus about $6,700), but the quality-of-life improvement was slightly larger after POEM, yielding a cost per quality-adjusted life year that, while high, was within the range many health systems consider acceptable.32Journal of the American College of Surgeons. Cost-Effectiveness of Per Oral Endoscopic Myotomy Relative to Laparoscopic Heller Myotomy for Treatment of Achalasia Other analyses have found the reverse, with Heller myotomy admission costing more, likely reflecting differences in operating room time and institutional practices.33PubMed Central. Direct cost variance analysis of peroral endoscopic myotomy vs heller myotomy for management of achalasia: A tertiary referral center experience Overall, the cost-effectiveness of the two procedures appears to be roughly equivalent.34PubMed. POEM is a cost-effective procedure: cost-utility analysis of endoscopic and surgical treatment options in the management of achalasia The bigger financial variable for most patients is whether their insurance covers POEM at all, since some payers still classify it as investigational, and whether the procedure is available at a nearby center with adequate volume and expertise.
How Surgeons Evaluate You Before and After Surgery
Before any surgical intervention, the diagnosis of achalasia has to be confirmed, and the specifics of your esophageal function need to be characterized. High-resolution manometry is the gold standard for diagnosis and subtyping. A timed barium swallow, in which you drink a barium solution and X-rays are taken at set intervals to see how quickly the esophagus empties, provides complementary information about the degree of stasis and esophageal dilation. Research shows that combining manometry with a timed barium swallow gives the most complete picture of the disease, because the two tests capture different aspects of esophageal dysfunction.35Diseases of the Esophagus. Timed barium esophagram in achalasia types
After treatment, the same tests are used to evaluate success. A rapid drinking challenge during manometry can reliably predict esophageal emptying and measure treatment response to a degree comparable to a timed barium swallow, offering a simpler post-treatment assessment option.36PubMed. Rapid drinking challenge during high-resolution manometry is complementary to timed barium esophagogram for diagnosis and follow-up of achalasia Your surgeon or gastroenterologist will typically repeat one or more of these tests at intervals after surgery to confirm that the myotomy is holding and to catch any early signs of treatment failure before symptoms become severe again.