Per-oral endoscopic myotomy (POEM) in achalasia: why length matters

INTRODUCTION: Per-oral endoscopic myotomy (POEM) is a minimally-invasive, effective treatment option in patients with non-spastic and spastic achalasia, and is continuously evolving toward a personalized, tailored approach for patients. AREAS COVERED: This article reviews the procedural aspects of POEM, its efficacy in the treatment of non-spastic and spastic achalasia, adverse events, and how it compares to other first-line therapies including pneumatic dilation and laparoscopic Heller myotomy with partial fundoplication. It also describes the evolution of tailored therapy in patients, including short-tailored myotomy in non-spastic achalasia and manometry-directed myotomy in spastic achalasia. This review is based on data from randomized controlled trials, systematic reviews, meta-analyses, and comparative studies from PubMed over the past 20 years, and primarily over the past 5-10 years. EXPERT OPINION: POEM has continuously moved toward personalized medicine, offering tailored therapy to a patient's specific phenotype. Delivering effective therapy while minimizing the major disadvantages of POEM (e.g. gastroesophageal reflux, esophagitis, and blown-out myotomy) would be a milestone in achalasia therapy. A movement toward a short-tailored myotomy in non-spastic achalasia and manometry-directed therapy for spastic achalasia may provide these answers.