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

Elisa C Calabrese^{1

2

3}, Tammy Kindel⁴, Bethany J Slater⁵, Jeffrey Marks⁶, Lee Swanstrom^{7

8}, Payal Saxena⁹, Salvatore Docimo¹⁰, Dimitrios I Athanasiadis¹¹, Nader M Hanna¹², Dimitrios Stefanidis¹³, Ceciel Rooker¹⁴, Guy Maddern^{15

16}, Geoffrey P Kohn^{17

18}

Affiliations

¹ Department of Surgery, University of California-East Bay, 1411 E 31St St, Oakland, CA, 94602, USA. eclbrs@gmail.com.
² Department of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Adelaide, SA, Australia. eclbrs@gmail.com.
³ Research, Audit & Academic Surgery, Royal Australasian College of Surgeons, Adelaide, SA, Australia. eclbrs@gmail.com.
⁴ Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
⁵ Department of Surgery, University of Chicago, Chicago, IL, USA.
⁶ Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
⁷ Oregon Health and Sciences University, Portland, OR, USA.
⁸ IHU-Strasbourg IHU, Strasbourg, France.
⁹ Department of Gastroenterology, Royal Prince Alfred Hospital, Chris O'Brien Lifehouse, University of Sydney, Sydney, Australia.
¹⁰ Department of Surgery, University of South Florida, Tampa, FL, USA.
¹¹ Department of General Surgery, Indiana University, Indianapolis, IN, USA.
¹² Department of Surgery, McMaster University, Hamilton, Canada.
¹³ Department of Surgery, Indiana University, Indianapolis, IN, USA.
¹⁴ International Foundation for Gastrointestinal Disorders, Milwaukee, WI, USA.
¹⁵ Department of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Adelaide, SA, Australia.
¹⁶ Research, Audit & Academic Surgery, Royal Australasian College of Surgeons, Adelaide, SA, Australia.
¹⁷ Eastern Clinical Research Unit, Monash University, Melbourne, Australia.
¹⁸ Melbourne Upper GI Surgical Group, Melbourne, Australia.

PMID: 40399617
DOI: 10.1007/s00464-025-11789-z

Practice Guideline

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

Elisa C Calabrese et al. Surg Endosc. 2025 Jul.

. 2025 Jul;39(7):4027-4037.

doi: 10.1007/s00464-025-11789-z. Epub 2025 May 21.

Authors

Affiliations

¹ Department of Surgery, University of California-East Bay, 1411 E 31St St, Oakland, CA, 94602, USA. eclbrs@gmail.com.
² Department of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Adelaide, SA, Australia. eclbrs@gmail.com.
³ Research, Audit & Academic Surgery, Royal Australasian College of Surgeons, Adelaide, SA, Australia. eclbrs@gmail.com.
⁴ Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
⁵ Department of Surgery, University of Chicago, Chicago, IL, USA.
⁶ Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
⁷ Oregon Health and Sciences University, Portland, OR, USA.
⁸ IHU-Strasbourg IHU, Strasbourg, France.
⁹ Department of Gastroenterology, Royal Prince Alfred Hospital, Chris O'Brien Lifehouse, University of Sydney, Sydney, Australia.
¹⁰ Department of Surgery, University of South Florida, Tampa, FL, USA.
¹¹ Department of General Surgery, Indiana University, Indianapolis, IN, USA.
¹² Department of Surgery, McMaster University, Hamilton, Canada.
¹³ Department of Surgery, Indiana University, Indianapolis, IN, USA.
¹⁴ International Foundation for Gastrointestinal Disorders, Milwaukee, WI, USA.
¹⁵ Department of Surgery, University of Adelaide, The Queen Elizabeth Hospital, Adelaide, SA, Australia.
¹⁶ Research, Audit & Academic Surgery, Royal Australasian College of Surgeons, Adelaide, SA, Australia.
¹⁷ Eastern Clinical Research Unit, Monash University, Melbourne, Australia.
¹⁸ Melbourne Upper GI Surgical Group, Melbourne, Australia.

PMID: 40399617
DOI: 10.1007/s00464-025-11789-z

Abstract

Background: Peroral Endoscopic Myotomy (POEM) is a safe treatment for esophageal achalasia with comparable safety to Heller myotomy plus fundoplication and pneumatic dilatation (PD). More data comparing POEM to Heller Myotomy plus fundoplication and pneumatic dilation are available since the previous Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guideline published on this topic in 2021.

Objective: This guideline provides an update to the evidence-based guideline from SAGES published in 2021. It is intended to support clinicians, surgeons, and patients in decisions about the use of POEM for the treatment of achalasia.

Results: The panel agreed on 3 recommendations for adults with achalasia. A conditional recommendation for the use of POEM over PD was issued. Conditional recommendations included the option of using either POEM with appropriate use of proton pump inhibitors (PPIs) or HM with fundoplication to treat achalasia. POEM was favored over HM with fundoplication for achalasia subtype III. No new literature was found for children, and the previous recommendation from 2021 should be referred to for this population.

Conclusions: POEM is a safe and effective treatment for achalasia in adults. It demonstrates greater efficacy than PD, though there are specific situations where PD may be the more appropriate choice. POEM has previously been compared to Heller myotomy, but this comparison is less relevant to modern surgical practice. Shifting the paradigm, POEM plus appropriate use of PPIs should be compared to Heller plus fundoplication. This reflection of current practice allows for a conditional recommendation for either approach in the treatment of achalasia subtypes 1 and 2, and for a preference of POEM for subtype 3.

Keywords: Achalasia; Endoscopy; Guideline; Heller myotomy; Per-oral endoscopic myotomy (POEM); Recommendations; Surgery.

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Conflict of interest statement

Declarations. Disclosures: All conflicts of interest disclosures were assessed as not having influenced the construction of these Guidelines. Dr. Elisa Calabrese is a research fellow whose salary is supported by SAGES. Dr. Tammy Kindel has contracts with NHLBI, NIA, and American College of Surgeons. She also has consulting fees with Ethicon J&J (to MCW), a patent (No. 63/505,036) and has a board/fiduciary role for the Treo Foundation. Dr. Bethany Slater is the Chair of the Guidelines Committee for SAGES and a consultant for Cook Medical and Hologic. Dr. Jeffrey Marks is a consultant for Boston Scientific and Steris Endoscopy. Dr. Geoffrey Kohn receives payment for expert opinion from Avant Law. Dr. Guy Maddern is the Surgical Director of Research, Audit and Academic Surgery of the Royal Australasian College of Surgeons. Professor Lee Swanstrom is on the Board of Directors for American Foregut Society and has a patent for Taurus. Dr. Payal Saxena has a contract with ERBE and received payment for this and received Fujifilm support for attending meeting/travel. Dr. Salvatore does expert testimony for Docimo and received honorarium from BD, Medtronic, Boston Scientific. Dr. Dimitrios Stefanidis has contracts with Intuitive surgical, Beckton Dickinson, and Cook medical (payment to institution). He receives consulting fees from Applied Medical and Johnson and Johnson. He was reimbursed for meeting travel expenses by Intuitive 360 and is the Chair at SAGES robotic committee and a board member Association for Surgical Education Board member and the Institute of Surgical Excellence (unpaid). Ceciel Rooker is on the Advisory Board Member for the NIDDK (NIH), she is the President and Executive Director (paid) for the International Foundation for Gastrointestinal Disorders and the Treasurer (unpaid) for the Digestive Disease Coalition. Dr. Nader M Hanna and Dr. Dimitrios Athanasiadis have no conflict of interest or financial ties disclose.

References

1. Haisley KR, Swanström LL (2021) The modern age of POEM: The past, present and future of per-oral endoscopic myotomy. J Gastrointest Surg 25:551–557 - DOI - PubMed
1. Kohn GP, Dirks RC, Ansari MT, Clay J, Dunst CM, Lundell L et al (2021) SAGES guidelines for the use of peroral endoscopic myotomy (POEM) for the treatment of achalasia. Surg Endosc 35:1931–1948 - DOI - PubMed
1. Calabrese EC, Kumar SS, Kohn GP, Maddern G, Babidge W, Slater BJ et al (2025) Society of American Gastrointestinal and Endoscopic Surgeons guidelines development: clinical practice guideline update standard operating procedure. Surg Endosc 39:716–720 - DOI - PubMed
1. Andrews JC, Schünemann HJ, Oxman AD, Pottie K, Meerpohl JJ, Coello PA et al (2013) GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation’s direction and strength. J Clin Epidemiol 66:726–735 - DOI - PubMed
1. Pohl D, Tutuian R (2007) Achalasia: an overview of diagnosis and treatment. J Gastrointestin Liver Dis 16:297–303 - PubMed

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

Affiliations

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

Authors

Affiliations

Abstract

Conflict of interest statement

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources