Peroral Endoscopic Myotomy Versus Laparoscopic Heller Myotomy for Achalasia: A Meta-Analysis of Randomized Controlled Trials

Introduction: Achalasia is a rare primary esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and dysphagia. Laparoscopic Heller myotomy (LHM) has long been the standard treatment, while peroral endoscopic myotomy (POEM) has emerged as a minimally invasive alternative. Comparative evidence from randomized controlled trials (RCTs) remains limited, and outcomes such as gastroesophageal reflux disease (GERD) and clinical remission require clarification. Methods: We systematically searched PubMed, Embase, Cochrane CENTRAL, and Web of Science to September 2025 for RCTs comparing POEM and LHM in adult patients with achalasia. Data on demographics, previous treatment, dysphagia improvement, GERD incidence, clinical remission, and mortality were extracted. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model in Stata 18. Results: Seven RCTs involving 900 patients (465 POEM; 465 LHM) were included. Dysphagia improvement was similar between groups (log OR 0.14; 95% CI −0.32 to 0.59; p = 0.55). GERD incidence was higher after POEM but not statistically significant (log OR 0.59; 95% CI −0.08 to 1.25; p = 0.08). Clinical remission showed a non-significant trend favoring POEM (log OR 0.39; 95% CI −0.06 to 0.84; p = 0.09). Reduction in pH levels significantly favored LHM (log OR 0.75; 95% CI 0.18 to 1.33; p = 0.01). No mortality was reported. Conclusion: POEM and LHM provide comparable dysphagia relief and clinical remission in achalasia. However, POEM is associated with higher GERD risk, particularly on pH monitoring. Treatment choice should balance efficacy against reflux risk, with careful long-term follow-up.