Submucosal tunnel endoscopy: Peroral endoscopic myotomy and peroral endoscopic tumor resection

Table 3 Advantages and disadvantages of peroral endoscopic myotomy vs laparoscopic Heller myotomy

	POEM	LHM
Advantages of POEM
Myotomy length	Longer myotomy up to 25 cm	Short myotomy maximum 6 cm
	Minimally invasive method	Invasive (major surgery)
Hospitalization	Less hospitalization (1-5 d)	Longer hospitalization > 5 d
Myotomy depth	Selective circular myotomy possible	Only full-thickness myotomy
Other esophageal motility disorders	Effective for esophageal spasm, nut cracker and jackhammer esophagus	Combined laparoscopic and thoracoscopic approach is necessary to obtain equivalent myotomy
Sigmoid achalasia	Effective in all types of achalasia even in end-stage, sigmoid type (S2) achalasia with megaesophagus	Major surgery such as esophagectomy may be necessary
Elderly patients	Effective in elderly with comorbidities and contraindications	Contra indication for surgery
In failed surgical	POEM after failed surgical myotomy is effective	Redo-surgery often with high rates of failure and complications
Cost	Lower hospitalization and lower cost	Higher cost in combination to surgical procedure
GERD	Less common and lower severity. No antireflux procedure (fundoplication) necessary at the moment. Further study necessary	Fundoplication necessary and routinely performed Complications from fundoplication
	Does not preclude surgery	POEM more difficult after LHM
	Bilateral POEM possible
Disadvantages of POEM
	POEM	Surgery
Follow-up	Short follow-up (novel technique)	Longer follow-up
	POEM restricted to specialized centers	Common surgical or laparoscopic procedure overall available
Training	Difficult (no so many centers)	Overall available

POEM: Peroral endoscopic myotomy; LHM: Laparoscopic Heller myotomy; GERD: Gastroesophageal reflux.