POEM for achalasia: Looking good, but the final verses are yet to be penned

Choice of therapy will be determined by the compromises and uncertainties most acceptable for the patient and their clinician

Achalasia is an uncommon oesophageal motor disorder (annual incidence in North America: 1.6 per 100 000 population1) of unknown aetiology. Its hallmarks are failure of peristalsis and failed deglutitive relaxation of the lower oesophageal sphincter, the result of the loss of inhibitory neurons in the oesophagus. Treatment for achalasia focuses on mechanical disruption of the integrity of the lower oesophageal sphincter, usually by laparoscopic Heller myotomy (LHM) or endoscopic pneumatic dilatation (PD).2,3 The short term response rates for a third, novel option, per‐oral endoscopic myotomy (POEM), have been impressive since its introduction ten years ago.4 However, as achalasia is a chronic relapsing condition, treatment decisions must be based on long term outcomes (5‒10 years). The long term durability of POEM is unknown; more importantly, how the long term symptom relapse rate compares with the substantial rates following PD or LHM has not yet been established.