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PubMed This is a summary of 16 peer-reviewed journal articles Updated
Gastroenterology · Achalasia

Standard of Care Treatments for Achalasia

At a Glance

Standard achalasia treatments aim to relieve symptoms by reducing pressure at the lower esophageal sphincter. The three definitive options are POEM (best for Type III, higher reflux risk), Heller Myotomy (includes an anti-reflux valve), and pneumatic dilation (less invasive but often needs repeats).

Because the underlying nerve damage in achalasia cannot be reversed, the goal of all standard treatments is palliative—meaning they focus on relieving symptoms by reducing the pressure at the “trap door” (lower esophageal sphincter or LES). By effectively “breaking” the tight muscle at the bottom of the esophagus, food can pass into the stomach using gravity [1][2].

The Three Definitive Treatments

Today, patients generally choose between three highly effective, long-term options. Each has a success rate of roughly 80% to 90%, but they differ in how they are performed and their side-effect profiles [2][3].

1. POEM (Peroral Endoscopic Myotomy)

POEM is a “scarless” procedure performed entirely through the mouth using an endoscope.

  • The Procedure: The doctor creates a tunnel in the lining of the esophagus to reach the muscle and cut it from the inside [4].
  • Best For: This is the preferred treatment for Type III (spastic) achalasia because the doctor can cut a longer segment of muscle to neutralize the painful spasms that occur higher up in the esophagus [5].
  • The Trade-off: Because no anti-reflux valve is created during POEM, it has the highest rate of post-procedure acid reflux (GERD). Many patients will need to take daily acid-blocking medication (PPIs) indefinitely [6][7].

2. Laparoscopic Heller Myotomy (LHM)

LHM is a “keyhole” surgery performed through several small incisions in the abdomen.

  • The Procedure: The surgeon cuts the LES muscle from the outside. Crucially, they also perform a fundoplication—wrapping part of the stomach around the esophagus to create a new, one-way valve [7].
  • Best For: Patients with Type I or II achalasia who want to minimize the risk of long-term acid reflux [5].
  • The Trade-off: While highly effective at preventing reflux, it is a more invasive surgery than POEM and involves a standard surgical recovery period [8][9].

3. Pneumatic Dilation (PD)

This is a non-surgical approach performed during a routine endoscopy.

  • The Procedure: A specialized, high-pressure balloon is inflated across the LES to “stretch” (and slightly tear) the muscle fibers [10].
  • Best For: Often highly successful for Type II achalasia [11].
  • The Trade-off: It has a higher “relapse” rate than surgery. Many patients require a second or third dilation over several years to maintain symptom relief [10][12]. It also carries a slightly higher risk of esophageal perforation (a tear in the wall) compared to LHM [13].

What to Expect: Recovery and Diet

While exact recovery timelines vary, procedures like POEM and LHM do not typically involve long-term feeding tubes. You will likely wake up able to swallow much more easily.

  • Diet Progression: Post-surgery, you will start on a clear liquid diet for a few days, progress to full liquids, and then soft foods over the course of 2 to 4 weeks before returning to a regular diet.
  • Red Flags: Immediately following any of these procedures, you must watch for signs of serious complications, such as an esophageal perforation (a leak or tear). Seek immediate emergency care if you experience sudden, severe chest pain, fever, or shortness of breath.

Temporary and Secondary Measures

  • Botulinum Toxin (Botox): A doctor may inject Botox into the LES to temporarily paralyze and relax the muscle. The effect usually lasts only 6 to 12 months [14][15]. Crucially, repeated Botox injections cause submucosal fibrosis (scarring) at the sphincter. This scarring makes future definitive procedures (like LHM or POEM) technically more difficult and increases the risk of surgical complications. Therefore, Botox is typically reserved only for elderly or frail patients who cannot safely undergo surgery [16].
  • Medications: Oral medications (like nitrates or calcium channel blockers) can help relax the LES, but they are generally far less effective than the procedures above and are used only as a bridge to more definitive care [14].

Treatment Comparison Table

Feature POEM Heller Myotomy (LHM) Pneumatic Dilation
Invasiveness Minimal (Endoscopic) Moderate (Surgical) Minimal (Endoscopic)
Reflux Risk Highest Low (due to “wrap”) Low
Type III Success Best Good Lower
One-and-Done? Usually Usually Often needs repeats
Recovery 1-3 days 1-2 weeks 1-2 days

Common questions in this guide

Which treatment is best for Type III achalasia?
POEM (Peroral Endoscopic Myotomy) is generally the preferred treatment for Type III achalasia. This endoscopic procedure allows the doctor to cut a longer segment of the esophageal muscle to effectively neutralize the painful spasms that occur higher up in the esophagus.
Will I get acid reflux after achalasia surgery?
Acid reflux is a common side effect of achalasia treatments, especially after the POEM procedure, because it does not create an anti-reflux valve. Laparoscopic Heller Myotomy carries a much lower risk of reflux because the surgeon performs a fundoplication, wrapping part of the stomach to build a one-way valve.
Is Botox a good long-term treatment for achalasia?
Botox is only a temporary measure that usually lasts six to twelve months. Repeated injections cause permanent scarring in the esophageal sphincter, making future permanent surgeries much more difficult and risky. Botox is typically reserved for elderly or frail patients who cannot safely undergo surgery.
How many times will I need to undergo pneumatic dilation?
Pneumatic dilation has a higher relapse rate compared to definitive surgeries like POEM or Heller Myotomy. Many patients will require a second or third balloon dilation over the course of several years to maintain their symptom relief.
What is the diet and recovery like after achalasia surgery?
Recovery involves starting on a clear liquid diet for a few days, then progressing to full liquids and soft foods over two to four weeks. Most patients wake up from the procedure able to swallow much more easily and do not require long-term feeding tubes.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Based on my achalasia subtype, which of these three treatments do you recommend as the first-line option for me?
  2. 2.How many POEM or Heller Myotomy procedures have you personally performed?
  3. 3.If we proceed with POEM, how will we monitor for 'silent' acid reflux afterward?
  4. 4.If we choose Heller Myotomy, which type of fundoplication (Dor or Toupet) do you perform to prevent reflux?
  5. 5.What are your personal success and complication rates (specifically perforation and reflux) for the procedure you are recommending?
  6. 6.If I choose pneumatic dilation, what is the likelihood that I will need a second or third procedure within the next few years?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (16)
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    Achalasia: Current therapeutic options.

    Rolland S, Paterson W, Bechara R

    Neurogastroenterology and motility 2023; (35(1)):e14459 doi:10.1111/nmo.14459.

    PMID: 36153803
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    Durability and reflux outcomes of peroral endoscopic myotomy compared to laparoscopic heller myotomy in achalasia: a meta-analysis of long-term studies.

    Abosheisha M, Nasr E, Kandeel M, et al.

    Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus 2025; (38(6)) doi:10.1093/dote/doaf111.

    PMID: 41348606
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    Comparative long-term outcomes of Heller myotomy and peroral endoscopic myotomy.

    Semaan S, Kassab C, Naselsky WC, et al.

    Surgical endoscopy 2026; (40(5)):4427-4433 doi:10.1007/s00464-026-12837-y.

    PMID: 42377529
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    Multicenter collaborative retrospective evaluation of peroral endoscopic myotomy for esophageal achalasia: analysis of data from more than 1300 patients at eight facilities in Japan.

    Shiwaku H, Inoue H, Onimaru M, et al.

    Surgical endoscopy 2020; (34(1)):464-468 doi:10.1007/s00464-019-06833-8.

    PMID: 31183791
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    2024 Update to SAGES guidelines for the use of peroral endoscopic myotomy (POEM) in the treatment of achalasia.

    Calabrese EC, Kindel T, Slater BJ, et al.

    Surgical endoscopy 2025; (39(7)):4027-4037 doi:10.1007/s00464-025-11789-z.

    PMID: 40399617
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    Per-oral endoscopic myotomy versus laparoscopic Heller's myotomy plus Dor fundoplication in patients with idiopathic achalasia: 5-year follow-up of a multicentre, randomised, open-label, non-inferiority trial.

    Hugova K, Mares J, Hakanson B, et al.

    The lancet. Gastroenterology & hepatology 2025; (10(5)):431-441 doi:10.1016/S2468-1253(25)00012-3.

    PMID: 40112837
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    Comparison of the Clinical Efficacy, Safety, and Postoperative Outcomes Between Peroral Esophageal Myotomy and Laparoscopic Heller's Myotomy With Fundoplication: A Systematic Review.

    Latha Kumar A, Sadagopan A, Mahmoud A, et al.

    Cureus 2023; (15(9)):e44877 doi:10.7759/cureus.44877.

    PMID: 37818506
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    Perioperative outcomes of inpatient laparoscopic Heller myotomy and per-oral endoscopic myotomy in the United States.

    Khoraki J, Campos GM, Alwatari Y, et al.

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    PMID: 34774290
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    Surgical and per-oral endoscopic myotomy (POEM) for the treatment of primary esophageal motility disorders: A systematic analysis of current trends in Germany between 2011 and 2019.

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    PloS one 2024; (19(1)):e0297265 doi:10.1371/journal.pone.0297265.

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    POEM is a cost-effective procedure: cost-utility analysis of endoscopic and surgical treatment options in the management of achalasia.

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    PMID: 27534662
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    Achalasia: A syndrome.

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    PMID: 33506560
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    Peroral endoscopic myotomy versus pneumatic dilation in treatment-naive patients with achalasia: 5-year follow-up of a randomised controlled trial.

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    Pneumatic dilation versus laparoscopic Heller's myotomy in the treatment of achalasia: systematic review and meta-analysis based on randomized controlled trials.

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This page explains standard achalasia treatment options for informational purposes only. Always discuss with your gastroenterologist or thoracic surgeon to determine the safest and most effective procedure for your specific achalasia subtype.

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