A POEM procedure, short for peroral endoscopic myotomy, is a minimally invasive treatment for achalasia, a condition where the muscles of the esophagus fail to relax properly and make it difficult to swallow food and liquids. During the procedure, a doctor uses a flexible endoscope passed through the mouth to cut the tight muscle fibers at the junction of the esophagus and stomach, allowing food to pass through normally again. No external incisions are made.
Why POEM Is Performed
The primary reason for a POEM procedure is achalasia, which comes in three subtypes based on how the esophageal muscles behave. POEM works for all three types and is particularly effective for type III achalasia, where the esophagus contracts in uncoordinated spasms. It’s also used for other motility disorders where the esophagus squeezes too forcefully, such as diffuse esophageal spasm and jackhammer esophagus.
POEM is an option both as a first-line treatment and for people who’ve already tried other approaches that didn’t work. That includes prior Botox injections into the esophageal muscle, balloon dilation (stretching the tight muscle with an inflatable device), or even a previous surgical myotomy performed through the abdomen.
How the Procedure Works
The entire procedure happens through the mouth using an endoscope, a thin flexible tube with a camera and small tools at the tip. It follows four main steps.
First, the surgeon makes a small incision (about 2 centimeters) in the inner lining of the esophagus, roughly 10 to 15 centimeters above where the esophagus meets the stomach. Before cutting, they inject a mixture of saline and blue dye beneath the lining to create a cushion of space between the inner lining and the muscle layer underneath.
Next, they create a tunnel in that space between the lining and the muscle, working downward toward the stomach. The blue dye helps the surgeon see exactly where to work, and larger blood vessels can be sealed off individually to prevent bleeding. This tunnel extends about 3 centimeters past the junction of the esophagus and stomach.
Once the tunnel is complete, the surgeon cuts the tight circular muscle fibers. The cut spans at least 7 centimeters, with about 2 centimeters extending onto the stomach side to ensure the lower esophageal sphincter (the valve-like muscle causing the blockage) is fully released. For spastic types of achalasia, the cut may be even longer.
Finally, the surgeon inspects the tunnel for any accidental damage to the lining, then closes the original entry point with endoscopic clips or sutures.
Pre-Procedure Testing
Before scheduling a POEM, your doctor will need to confirm your diagnosis with specific tests. High-resolution manometry is the key diagnostic tool. It involves swallowing a thin catheter that measures the pressure and coordination of your esophageal muscles in real time, which determines whether you have achalasia and which subtype. An upper gastrointestinal series (a type of X-ray where you swallow contrast liquid) is also typically part of the workup. Getting the right diagnosis matters: without manometry, achalasia is sometimes mistaken for acid reflux, leading patients down the wrong treatment path for months or years.
How POEM Compares to Traditional Surgery
The traditional surgical alternative is a laparoscopic Heller myotomy, which cuts the same muscle but through small incisions in the abdomen, often combined with a partial stomach wrap to prevent reflux. In a multicenter study comparing the two approaches for type III achalasia, POEM patients had a clinical success rate of 98% compared to 80.8% for the surgical approach. POEM also took significantly less time: an average of 102 minutes versus 264 minutes for the traditional surgery. Hospital stays were essentially the same at about 3 days for both.
Over longer follow-up periods, the gap narrows somewhat. A meta-analysis looking at outcomes five years after treatment found POEM had a long-term clinical success rate of 83%. At the two-year mark, randomized trial data showed POEM and traditional surgery performing comparably, with success rates around 83% and 82% respectively.
Acid Reflux After POEM
The most significant tradeoff with POEM is acid reflux. Because the procedure cuts through the lower esophageal sphincter without adding an anti-reflux barrier (which traditional surgery can include), reflux is common afterward. About half of POEM patients show objective evidence of reflux on testing, and roughly 39% experience reflux symptoms. Nearly one in five develops severe reflux. Notably, about a quarter of patients with measurable reflux don’t feel any symptoms, which is why post-procedure monitoring is important even if you feel fine.
Most post-POEM reflux responds well to acid-reducing medications. Your doctor will likely recommend follow-up testing to check for reflux even in the absence of symptoms, since untreated acid exposure over time can damage the esophageal lining.
Recovery and Diet After POEM
Most patients stay in the hospital for about three days after the procedure. The recovery diet follows a gradual progression designed to let the internal incision site heal before you challenge it with solid foods.
For the first two weeks, everything you eat needs to be blenderized to a completely smooth consistency. You can technically eat any food you want during this phase as long as it’s been pureed and strained to remove seeds or clumps.
After two weeks, if you’ve been tolerating the pureed diet without problems, you begin reintroducing solid foods one at a time. The process is methodical: you add one new food per day, starting with a small amount (a couple of tablespoons) in the morning. If that goes well, you double the portion later in the day. Foods are grouped into categories, and you work through them in order, from easiest to digest to most challenging, before moving to the next group. The full transition back to a normal diet takes several weeks.
Most people notice a dramatic improvement in swallowing relatively quickly after the procedure. The gradual diet isn’t because swallowing is still difficult; it’s to protect the healing tissue inside the esophagus while your body recovers from the tunnel and muscle cut.