POEM Procedure

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Ask which type of achalasia you have before anybody proposes a treatment

Three types exist and they respond differently, which is why the pressure test comes before the decision. Send the manometry report with its type, the barium swallow, the endoscopy report, any record of previous dilation, botulinum toxin or surgery, and your medication list. A gastroenterologist reviews the file and tells you whether this procedure suits your type, what it would do to your swallowing and what it is likely to do to your reflux. No fee, no obligation, and a coordinator replies in your own language.

What the procedure does

Achalasia is a failure of the muscular ring at the bottom of the gullet to relax. Food and liquid sit above it, the gullet widens over years, and swallowing becomes a matter of waiting, standing up, drinking water to push things down and eventually bringing undigested food back. It is not a cancer and it does not go away, and the muscle nerve cells that would normally open that ring do not regrow. Every effective treatment does the same thing. It weakens that ring so gravity and pressure can push food past it. Nothing restores the coordinated squeeze the gullet has lost, which is why no treatment for this condition is a cure and why the word used by careful doctors is always relief. Endoscopy does the same job from inside. A camera passed through the mouth makes a small cut in the inner lining of the gullet, then tunnels down between the layers of the wall for several centimeters, and divides the muscle fibers of the tight ring from within that tunnel before closing the entry point with clips. No cut is made through the skin anywhere. The whole operation happens inside a wall a few millimeters thick, which is both what makes it elegant and why it is done by people who do a lot of them.

The four options

Understanding what this procedure competes against makes the rest of the page easier to read, and the four differ more in what they cost you than in what they achieve.

• Botulinum toxin injection. Paralyzes the ring chemically through an endoscope. Simple and safe, wears off within months, and repeated injections cause scarring that makes later surgery harder. Generally reserved for patients too frail for anything else.
• Pneumatic dilation. A balloon is inflated across the ring to tear the muscle fibers. Quick, no incision, repeated in many patients, and it carries a small risk of perforating the gullet. It remains a reasonable first treatment in many hands.
• Laparoscopic Heller myotomy. Keyhole abdominal surgery cutting the same muscle from outside, almost always combined with wrapping part of the stomach around the gullet to create an anti-reflux valve. Four or five small skin incisions and a hospital stay of a day or two.
• Peroral endoscopic myotomy. The subject of this page. The same muscle, cut from inside, with no skin incision and no anti-reflux wrap, and that missing wrap is why the reflux figures further down look the way they do.

Notice what the last two have in common and where they part. Both divide the same muscle and both achieve similar swallowing. The surgical version adds a valve to protect against acid coming back up and the endoscopic version does not, and that single structural difference explains almost every number in this article.

Which type you have

A pressure study, called manometry, is passed through the nose and measures what the gullet does when you swallow. It sorts achalasia into three types, and the type predicts which treatment works. Ask for yours by number before any treatment is discussed.

Type one, a silent gullet

Contractions in the body of the gullet have stopped altogether and the ring will not open, which is often the late stage of the disease, and it responds to any of the treatments that weaken the ring. In the largest single series published, this type accounted for about a quarter of patients treated.

Type two, pressure building up

Here the gullet squeezes along its whole length against the closed ring, producing a column of pressure. This is the commonest type, at about half of patients in that same series, and it is the one that responds best to every treatment including balloon dilation. If a doctor tells you your type two achalasia should do well, they are right.

Type three, spasm as well as obstruction

Violent uncoordinated spasms run through the gullet on top of the ring failing to open, which is why these patients tend to have chest pain as well as difficulty swallowing. Balloon dilation treats only the ring and leaves the spasm untouched. Pooled results from eight observational studies covering 179 patients with spastic disorders found the endoscopic operation clinically successful in 87 percent overall, and in the 116 patients with type three specifically the figure was 92 percent.

Two honest cautions on that last figure. Those were observational studies rather than trials, and the reason usually given for the advantage, that the cut can be made longer from inside to cover the spastic segment, was not confirmed when somebody tested it. A separate pooled analysis of 210 patients found no difference in success between cuts shorter and longer than ten centimeters, so the advantage in type three is real in the data while the explanation usually offered for it is less settled than it sounds.

Against surgery

Read the last panel with one qualification. Acid testing at five years was done in only 81 of the 221 patients, so those percentages rest on 45 and 36 people, and while the direction is not in doubt the precision is a good deal lower than the numbers suggest.

Against balloon dilation

Balloon dilation is the cheapest and least invasive option, and for patients who have never been treated it was tested head to head against the endoscopic operation in a randomized trial of 133 people.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

That success gap is the largest in this article and it deserves its weight. Balloon dilation failed in nearly half of these patients within two years and many of them then needed something else done, and what the table also shows is that the same trade appears here as against surgery. The treatment that opens the ring most reliably is the one that lets the most acid back up.

The day itself

Who it suits

• Type three achalasia and other spastic disorders. The strongest indication. Pooled results put success at 92 percent in type three, and the alternatives address the ring without touching the spasm above it.
• Anybody who has already had surgery on the area. Working from inside avoids the scar tissue left by a previous operation, which is dealt with in its own section below.
• Patients who want the fewest serious complications. The randomized comparison put these at 2.7 percent against 7.3 percent for surgery, which is a meaningful difference for anybody with other health problems.
• Somebody who cannot tolerate abdominal surgery. No skin incision, no wrap around the stomach, and a shorter anesthetic than a laparoscopic operation.
• Anybody in whom balloon dilation has failed. Dilation failed within two years in nearly half of previously untreated patients in the randomized comparison, and those patients need something more durable.

And who should think twice. Somebody who already has significant reflux, since this procedure reliably makes acid worse, and somebody who cannot or will not take an acid-suppressing tablet long term. A patient with a very tortuous end-stage gullet is also a harder case, and in some of those the discussion turns to removing the gullet altogether, which is a much larger undertaking and a different conversation.

If you have been treated before

Previous botulinum toxin or balloon dilation is a different situation again with no randomized evidence about it, so if that describes you, expect a frank answer that the numbers on this page do not exactly fit your case.

Reflux, the price

Read this section twice. Weakening the ring that was refusing to open also weakens the barrier that stops stomach acid coming up, and the endoscopic version does not add a valve to compensate. The result is measurable, common and manageable, and it should be discussed before rather than after.

This table scrolls sideways on a narrow screen. Swipe or drag to see every column.

Three practical consequences follow from that table, and each of them is worth settling in the consultation before the procedure rather than discovering it in the months afterwards. Most patients are started on an acid-suppressing tablet and many stay on one indefinitely, which is a small daily commitment and not a trivial one, particularly for somebody in their thirties who may be taking it for decades. A large share of the acid coming up produces no symptoms at all, which is why an endoscopy at some point after the procedure is recommended rather than waiting to feel heartburn, since feeling nothing is not the same as having nothing. And if acid is already a problem for you before treatment, that is a genuine argument for the surgical route with its wrap instead. Whether you already get heartburn is the single most useful thing you can bring to the consultation about yourself, so answer that question carefully rather than in passing, and answer it about the last year and not about last week.

The honest summary

Put next to each other, the findings on this page are consistent. None of them is a marketing claim.

Swallowing after this procedure matches surgery at two years and at five. Serious complications are fewer. Acid reflux is roughly twice as common, and you are likely to be taking a tablet for it. That is the deal, and for most patients it is a good one.

Where it becomes a poor deal is worth naming. Somebody who already lives with heartburn, somebody unwilling to take a daily tablet indefinitely, and somebody who will not attend an endoscopy some years later to check what the acid has been doing are all better served by the operation with its wrap. None of that is a reason to steer patients away from the endoscopic route, and it is a reason to choose between the two deliberately rather than by whichever specialist you happened to see first. Which department you walked into should not decide which operation you get.

One more piece of context belongs here. Neither treatment cures achalasia, both lose a little ground over five years at the same rate, and a proportion of patients eventually need something further whichever they choose. Being told that at the start makes the years afterwards much easier than discovering it at year six, when swallowing has quietly become difficult again and it feels like a failure rather than a known feature of the disease. Ask what the plan would be if symptoms returned, and you will find there is one.

Eating again

The morning after, a swallow test or a scan confirms the closure is watertight, and then you drink. Clear fluids for a day, thickened liquids and soft food for a week or so, and ordinary food from around the second week, with the exact schedule set by the unit that treated you. Chest discomfort behind the breastbone for a few days is expected and settles, as is a sore throat from the tube and some bloating from the gas used during the procedure. What is not expected is fever, worsening chest or abdominal pain, breathlessness, or swelling in the neck that crackles under the fingers, and any of those needs assessment the same day rather than a wait to see whether it passes. Most patients notice their swallowing change immediately, which is the part people remember and the part that makes the first week feel like a different life. The relief is real and it arrives fast, and that is exactly why the reflux discussion has to happen before the procedure rather than in the glow afterwards. Eat sitting upright, chew properly and take smaller mouthfuls for the first weeks, because the gullet above the treated ring is still the weak one it always was, and eating habits built up over years of difficulty take a while to catch up with the new anatomy. An acid-suppressing tablet starts before you leave and continues. Sleeping with the head of the bed raised, leaving three hours between eating and lying down, and being careful with late meals all matter more after this procedure than they did before it. Ask when your first follow-up endoscopy should be, and put the date in your own calendar rather than trusting a letter to reach you. Flying is cleared at around five to seven days, once you are eating comfortably and any check has been reported. A doctor examines you and writes the date. Avoid a heavy meal before boarding and keep to soft food on the flight.

What can go wrong

1. Acid reflux. Not a complication so much as an expected consequence, and the reason this page has a section of its own about it. Common, measurable and controlled with a tablet in most people.
2. An accidental hole in the inner lining. The commonest technical mishap, at 10.5 percent in a series of 610 patients, and almost always closed with clips during the same procedure without consequence.
3. Gas escaping into the chest or abdomen. Carbon dioxide used during tunnelling can track into the tissues, the chest cavity or the abdominal cavity. It is usually watched and absorbs on its own, occasionally needing a needle to release pressure.
4. Bleeding. Within the tunnel during the procedure or from the entry site afterwards. Managed endoscopically in nearly all cases.
5. Infection in the space behind the gullet. Rare, and the reason for antibiotics around the procedure and for taking fever seriously in the first week.
6. Serious adverse events overall. These occurred in 2.7 percent of patients in the randomized comparison against 7.3 percent after surgery, and in 3.4 percent of the 610-patient series.
7. The symptoms coming back. Success falls from 83 percent at two years to 75 percent at five in the randomized trial, and recurrence is treatable, sometimes with a further endoscopic cut on the opposite wall of the gullet.

Reading a quote

No figure appears on this page. What this costs depends on whether the diagnostic work has already been done, on whether you have had previous treatment and on how many nights your case is expected to need, none of which is knowable from a description of your symptoms. Six things to settle in writing before anybody books a date. Whether the manometry, the barium swallow and the diagnostic endoscopy are inside the number or billed separately, since a patient arriving without a typed manometry report will need one before anything else can happen and that adds both a day and a line to the bill. How many nights are budgeted and what an extra one costs. Whether the check performed the morning after, whether a swallow study or a scan, is included. What happens financially if the assessment concludes the surgical route with its wrap suits you better, which is a real outcome for patients who already have reflux. Whether the follow-up endoscopy some months later is covered or is expected to happen at home. And whether the acid-suppressing medication you leave on is included.

Your own file moves the total less here than in most procedures, because a straightforward case is short and the stay is one night. Previous surgery in the area, a very dilated gullet and previous repeated botulinum toxin are the three things that most often turn a routine case into a longer one.

Packages published by Turkish hospitals and medical travel agencies for endoscopic procedures generally include the airport transfer, pre-procedure testing, the operator and anesthesia fees, the endoscopy suite, the planned nights, an interpreter and the review before departure. They generally exclude flights, insurance, treatment of a complication, extra nights and hotel stays past an agreed number. Compare what you receive against both lists.

Coming to Istanbul

Seven to ten days covers a straightforward case. Assessment fills the first days, the procedure takes an afternoon, one night in hospital follows, and the rest is a short recovery while you work back up to solid food. Somebody who has been treated before, or whose gullet is very dilated, should allow a few days more, because the assessment takes longer and the procedure itself usually does too. Tell the coordinator at the outset if either applies to you, so the booking is made against a realistic timetable instead of an optimistic one. The manometry report is the document that matters most, and specifically the type it assigns. Send it with the barium swallow images, the endoscopy report, and a clear account of anything already done to you, including how many balloon dilations, how many botulinum toxin injections and any operation with its date. That history changes both the recommendation and the numbers you will be quoted. An approximate memory is not enough.

Say in your first message how long you have had symptoms, how much weight you have lost and whether you already have heartburn. That last question decides more than patients expect. One coordinator holds your file from the first message to discharge, and the international patients team works in English, Arabic, French, Russian, Serbian, Romanian and Spanish, with other languages arranged on request. Ask in your first message if you would prefer a female physician.

Someone can stay overnight with you on the ward, where the rooms carry a companion bed. Meals from the hospital kitchen cover halal, vegetarian and diabetic diets, and the liquid and soft diets you will be on immediately afterwards are prepared to the same standards, which matters more here than in most treatments because the first week is defined by what you can swallow. A prayer room is available, and the ward staff are used to patients working their way back through liquids and soft food in the days after this particular procedure. The international patients office books accommodation for both of you, arranges the airport transfer and daily transport, and prepares the appointment confirmation and the invitation letter naming the hospital and your treating doctor for a medical visa application, around ten days before travel.

Take home a written file rather than a discharge slip, because the follow-up for this procedure happens elsewhere and depends entirely on what you can hand over. It should state the type of achalasia treated, the length and orientation of the cut made, the findings of the check performed the morning after, the acid-suppressing tablet with its dose, the eating schedule week by week, and the date the follow-up endoscopy should happen. Address it to a gastroenterologist and arrange that appointment before you fly, because the reflux this procedure causes is often silent, and the endoscopy some months after you are back home is how it gets found. Your coordinator stays reachable on the same WhatsApp number afterwards, so a question about food sticking or a tablet reaches somebody holding your notes. Get in touch about fever, chest or abdominal pain that is getting worse, vomiting blood, black stools, or swallowing that becomes difficult again after having been easy.

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