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Patti et al. Mini-invasive Surg 2022;6:38 https://dx.doi.org/10.20517/2574-1225.2022.19 Page 3 of 6

instance, a prospective and randomized European trial comparing PD to LHM showed similar results and
excellent 2 and 5 years after the procedure. The only major downside of PD was that 25% to 40% of patients
required repeated interventions to maintain the same level of symptomatic relief [11,12] .

The therapeutic scenario for achalasia was stable until a decade ago. However, in 2010, Dr. Inoue described
a new endoscopic procedure for the treatment of achalasia, named peroral endoscopic myotomy or
[13]
POEM . The procedure consists of the endoscopic creation of a submucosal tunnel, which allows the
myotomy of the circular fibers of the distal esophagus and proximal stomach (the myotomy is usually
started 10-12 cm above the gastroesophageal junction and extended down for 2-3 cm onto the stomach). In
the initial report, Inoue successfully treated 17 patients with esophageal achalasia without serious
[13]
complications related to the procedure . Subsequent studies confirmed the initial experience of Dr. Inoue,
[13]
which showed excellent results similar to those obtained by LHM . For instance, Kumbhari et al. reported
in 2017 the results of a multicenter case-controlled study in 282 patients with achalasia . At a median
[14]
follow-up of 12 months, clinical success (Eckardt score < 3) with POEM was achieved in 94.3% of patients.
A recent study by Campagna et al. in 100 achalasia patients treated by POEM documented clinical success
(88%) at a mean follow-up of 55 months in 88 patients . A multicenter, randomized clinical trial compared
[15]
POEM (112 patients) and LHM with Dor fundoplication (109 patients) . At a follow-up of two years,
[16]
clinical success was attained in 83% and 81.7% of patients, respectively.

Results of POEM seem to be better than LHM in patients with type III achalasia. It has been suggested that
this outcome is probably due to the fact that POEM allows a longer myotomy on the esophageal body. In a
retrospective multicenter study of treatment of patients with type III achalasia, 49 patients underwent
POEM, and 26 patients had an LHM, with the clinical response was better after POEM (98%) than after
LHM (80.8%) . However, a recent study showed that by elongating the myotomy both upward and
[17]
downward, LHM could achieve in Type III patients the same good results as in Type I-II patients .
[18]
Considering these data, should POEM be taken as the primary form of treatment for achalasia? We
strongly believe that this is not the case. Almost all the reports on POEM have focused on the ability of this
procedure to improve emptying of the esophagus and symptoms; however, they have ignored or
downplayed a very serious consequence of performing a myotomy without a concomitant antireflux
operation - gastroesophageal reflux disease (GERD). Interestingly, history repeats itself, as the literature
clearly shows that the incidence of GERD after POEM is around 50%, therefore similar to that of a THM. A
report from the Catholic University in Rome documented an incidence of 54.3% of pathologic reflux by pH
[19]
monitoring . In a study of patients after POEM, Werner et al. documented for the first time the sequelae of
the abnormal reflux after POEM. Among 80 patients followed for 29 months, esophagitis was present in
37.5%, one patient developed a peptic stricture requiring dilation, and 3 developed Barrett’s esophagus . A
[20]
large case-control study after POEM showed pathologic reflux by pH monitoring in 57.8% of 282
patients . Sanaka et al. recently reported on the incidence of GERD after POEM and LHM by pH
[14]
monitoring . Not only the incidence of pathologic reflux was significantly higher after POEM (48.4% vs.
[21]
13.6%), but the DeMeester score was much higher after POEM (54.8% vs. 17.4%), implying a more severe
process. Finally, a recent meta-analysis has confirmed the significant difference in GERD incidence between
POEM and LHM with fundoplication . Schlottmann et al. examined 21 studies about POEM (1958
[10]
[10]
patients) and 53 studies about LHM (5834 patients) . While the success rate of the two procedures was
similar with 93.5% POEM and 91.0% LHM, the incidence of postoperative GERD by pH monitoring was
significantly different, being more than 4 folds higher after POEM (48% vs. 11%). POEM can be performed
in patients with recurrent dysphagia after LHM since GERD is not a problem because a fundoplication is
already in place. Several studies have shown that in this group of patients, POEM effectively relieves