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Treatment aims to make swallowing easier.
- Achalasia affects how the esophagus moves food and how its lower muscle opens.
- Manometry helps confirm the diagnosis and identify the subtype.
- Heller myotomy, POEM, and other treatments have different benefits and tradeoffs, including reflux risk.
What is achalasia?
Swallowing normally depends on coordinated muscle contractions in the esophagus and relaxation of the lower esophageal sphincter, the ring of muscle at the entrance to the stomach.
In achalasia, the lower sphincter does not relax properly and the esophagus loses its normal coordinated contractions. The condition is associated with loss of the nerve cells that normally help the muscles relax. Food and liquid therefore have difficulty passing into the stomach.
How is achalasia recognized and diagnosed?
Symptoms can include difficulty swallowing both solids and liquids, regurgitation, chest pain, weight loss, and aspiration into the airway.
- Upper endoscopy
- Examines the esophagus and the junction with the stomach. It is important for excluding a tumor or another process that can mimic achalasia, called pseudoachalasia.
- Barium esophagram
- Shows how swallowed contrast passes through the esophagus. It may show enlargement, retained contents, and narrowing at the bottom described as a “bird’s beak.”
- High-resolution manometry
- Measures pressures during swallowing and is the diagnostic standard. It also identifies the achalasia subtype.
A timed barium study and EndoFLIP may provide additional information about emptying or the esophageal junction in the broader evaluation of swallowing disorders.
What are the three subtypes?
Manometry distinguishes three patterns. The subtype can help guide treatment rather than serving only as a diagnostic label.
| Subtype | Pattern and treatment relevance |
|---|---|
| Type I: classic | Little or no pressure generation through the esophagus, which is often enlarged. A good response to treatment is possible. |
| Type II | Pressure builds throughout the esophagus during some swallows. This pattern has the best overall response to treatment. |
| Type III: spastic | Premature, spastic contractions are present. A longer myotomy may be helpful, making POEM particularly relevant. |
What treatments are available?
The choice depends on the subtype, patient factors, and the expertise available. All of the treatments below aim to improve passage through the lower sphincter rather than restore normal esophageal muscle function.
Botulinum toxin injections can provide relief for months and are generally discussed for patients who are poor candidates for an operation. Nitrates or calcium channel blockers are the least effective options and are used as a temporary bridge. Esophagectomy is reserved for selected end-stage cases with a severely enlarged or distorted esophagus.
How do Heller myotomy and POEM compare?
Both divide muscle to reduce resistance to swallowing. An important difference is how reflux is addressed after the muscle has been divided.
A randomized trial found similar symptom relief with POEM and Heller myotomy plus Dor fundoplication at two years, with more esophagitis after POEM. Esophagitis means inflammation of the esophageal lining.[7] However, more esophagitis does not necessarily mean more heartburn or other reflux symptoms.[9]
Heller/Dor and POEM at a glance
Both procedures aim to improve swallowing by releasing the tight muscle at the lower end of the esophagus. Neither restores normal esophageal muscle contractions. The choice depends on your test results and priorities.
Recovery ranges below are general planning estimates. Dr. Servais and your care team will give you instructions for your procedure.
| What matters to you | Heller myotomy + Dor fundoplication | POEM |
|---|---|---|
| How it is performed | The tight muscle is divided through small abdominal incisions. A Dor fundoplication is a partial stomach wrap added to reduce reflux. Dr. Servais uses a robotic minimally invasive approach.[6] | The muscle is divided through a tunnel created with an endoscope passed through the mouth. There are no skin incisions and no fundoplication.[6][5] |
| Symptom relief | About 82% at 2 years and 71% at 5 years met the trial’s definition of treatment success.[7][9] | About 83% at 2 years and 75% at 5 years met the same definition. The trial found comparable effectiveness.[7][9] |
| Reflux and heartburn | The Dor wrap lowers reflux risk but does not eliminate it. Acid-suppressing medicine or reflux testing may still be needed.[6][8] | Acid reflux and esophagitis are more common after POEM. Heartburn symptoms may still be similar to those after Heller/Dor. Acid-suppressing medicine and follow-up testing are often part of care.[6][9][2] |
| Hospital stay | Often 1–2 nights after an uncomplicated minimally invasive operation; a longer stay may be needed.[1] | Often one overnight stay, although some patients go home the same day and others need additional observation.[2][5] |
| Pain and comfort | Small abdominal incisions can cause soreness. Short-term pain medicine may be needed as activity gradually increases.[1][4] | Discomfort is usually mild and short-lived, with no abdominal incisions. Temporary throat or chest soreness may occur.[2][5] |
| Eating after treatment | Dr. Servais typically recommends a full-liquid diet for one week, followed by soft solid foods. | Dr. Servais typically recommends a full-liquid diet for one week, followed by soft solid foods. |
| Returning to work | Light or desk work is often possible in about 1–2 weeks. Physical work and full recovery may take longer.[1] | A quick return to routine activities is typical. Many patients can resume light or desk work within about one week, as they feel ready.[3] |
| Exercise, lifting, and driving | Begin walking early and build up gradually. Lifting limits and return to strenuous exercise depend on healing and Dr. Servais’s instructions. Avoid driving while taking sedating pain medicine.[1][4] | Walking and light daily activities can resume early. Lifting restrictions are generally brief, with heavy lifting and strenuous exercise limited during the first week unless Dr. Servais advises otherwise. Avoid driving while taking sedating pain medicine.[3][5] |
| What may favor this option? | An effective option for many patients, particularly when adding reflux protection is a priority. The plan depends on subtype, anatomy, previous treatment, and overall health.[6] | Useful for all types of achalasia, especially when a longer muscle division is needed for type III (spastic) achalasia. POEM can extend the muscle division farther up the esophagus than is typically accessible with Heller myotomy. It may also be an option after a previous Heller myotomy.[6] |
Symptoms and reflux testing measure different things. Esophagitis or excess acid exposure can be present even without heartburn. Follow-up and treatment may still be appropriate after either procedure.[6][9][2]
Evidence behind the options
Werner 2019: POEM and Heller myotomy with Dor fundoplication had similar treatment success at two years; esophagitis was more frequent after POEM.[7]
Hugova 2025: Five-year follow-up found similar control of achalasia symptoms. Abnormal acid exposure was more frequent after POEM among those tested, while reported reflux symptoms were similar.[9]
Richards 2004: Adding a Dor fundoplication to Heller myotomy reduced pathologic reflux compared with Heller myotomy alone.[8]
Ponds 2019: POEM had greater treatment success than pneumatic dilation at two years in that trial, but more esophagitis. These comparisons inform a discussion of the options; they are not personal outcome predictions.[8]
Planning ahead
Recovery after achalasia treatment
Instructions differ after Heller myotomy, POEM, or dilation. Discuss when and how to restart eating, how symptoms will be reassessed, and whether reflux treatment or testing may be needed after the procedure.
Before you go home, ask about
- Eating and drinking: the recommended diet, hydration, and when to advance foods.
- Medicines: pain control and which usual medicines to resume or continue.
- Activity and help at home: walking, lifting, work, driving, and whether you will need assistance.
- Follow-up: when to be seen, which symptoms should prompt a call, and how to reach the team.
Your care team will provide instructions for your procedure and health needs. The information here is a planning checklist, not a postoperative protocol.
Questions to bring to your consultation
- Have the tests confirmed achalasia and excluded a condition that mimics it?
- Which subtype do I have, and how does that affect the treatment options?
- What are the reasons to favor dilation, Heller myotomy, or POEM in my case?
- How would reflux after treatment be addressed?
- How do any previous procedures or changes in the shape of my esophagus affect the plan?
Source & further reading
About this guide
Patient education based on teaching materials by Elliot Servais, MD, FACS, and the references below. This information supports a discussion with your care team and does not determine an individual treatment plan.
Patient resources, references & image credits
Patient resources
- Baylor Medicine. Robot-Assisted Laparoscopic Heller Myotomy and Fundoplication. Patient information; used for general recovery expectations.
- UCLA Health. Per-oral Endoscopic Myotomy (POEM): recovery, complications, and follow-up. Patient information; used for general recovery expectations.
- Memorial Sloan Kettering Cancer Center. About Your Per Oral Endoscopic Myotomy (POEM) Procedure. Patient information; used for general recovery expectations.
- Cleveland Clinic. Heller Myotomy: procedure, risks, and recovery. Patient information; used for general recovery expectations.
- Johns Hopkins Medicine. Peroral Endoscopic Myotomy (POEM). Patient information; used for general recovery expectations.
Research, clinical guidance & lectures
- Vaezi MF, et al. ACG Clinical Guidelines: Diagnosis and Management of Achalasia. American Journal of Gastroenterology. 2020;115:1393–1411.
- Werner YB, et al. Endoscopic or Surgical Myotomy in Patients with Idiopathic Achalasia. New England Journal of Medicine. 2019;381:2219–2229.
- Richards WO, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Annals of Surgery. 2004;240:405–412. Ponds FA, et al. Effect of peroral endoscopic myotomy versus pneumatic dilation in treatment-naive patients with achalasia: a randomized clinical trial. JAMA. 2019;322:134–144.
- Hugova K, et al. Per-oral endoscopic myotomy versus laparoscopic Heller’s myotomy plus Dor fundoplication: 5-year follow-up of a randomised trial. Lancet Gastroenterology & Hepatology. 2025;10:431–441.
Image credits
- Esophagram illustration: © 2006 The McGraw-Hill Companies, Inc., as credited in Benign Esophageal Diseases, slide 23.
Updated October 4, 2026. This guide is general information; your care team can explain which recommendations apply to you.