S2265 POEM vs Heller Myotomy: A Nationwide 30-Day Outcomes and Procedural Equity in Achalasia

Introduction: Peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) are definitive treatments for achalasia. However, real-world data comparing short-term safety outcomes and utilization patterns remain limited, and disparities in procedural access are not well characterized. We aimed to evaluate 30-day outcomes and demographic representation among patients undergoing POEM versus LHM. Methods: We used the TriNetX U.S. Collaborative Network to identify adults with achalasia who underwent POEM or Heller myotomy between January 2022 and May 2025. A 1:1 propensity score match (n = 1,963 per group) was performed using baseline variables including age, sex, race/ethnicity, and clinical comorbidities. We then compared 30-day mortality, complications, medication use, and diagnostic resource utilization. Risk ratios (RR) were calculated. Kaplan–Meier analysis evaluated survival. Racial and ethnic distributions were compared prior to matching to assess potential disparities in procedural access. Results: POEM patients were slightly more racially and ethnically diverse than those undergoing Heller (White: 70.7% vs 75.2%; Black: 7.0% vs 6.1%; Hispanic: 4.1% vs 3.8%; Other/Unknown: 15.7% vs 12.6%). After matching, POEM was associated with significantly lower 30-day mortality (0% vs 0.5%; P = 0.002) and a reduced risk of pneumothorax (0.8% vs 2.0%; RR 0.38; P = 0.001). ICU admissions were lower in POEM, though not statistically significant (1.2% vs 1.9%; P = 0.073). POEM patients had markedly reduced need for opioids (38.8% vs 79.7%; RR 0.49), non-opioid analgesics (36.6% vs 74.9%; RR 0.49), antiemetics (27.6% vs 39.4%; RR 0.70), and diagnostic radiology (55.2% vs 65.4%; RR 0.84), all P < 0.001. Rates of GI bleeding, perforation, AKI, respiratory failure, and emergency intubation were similar. GERD (4.5% vs 5.3%) and dysphagia (3.2% vs 3.8%) were also comparable. Kaplan–Meier survival curves revealed statistically significant survival benefits in the POEM cohort (log-rank P = 0.017). Conclusion: POEM was associated with lower short-term mortality, fewer complications, and decreased supportive care utilization compared to Heller myotomy. Pre-matching data revealed modestly greater racial and ethnic diversity among POEM recipients. This highlights the importance of preserving and expanding procedural accessibility to ensure equitable adoption of advanced endoscopic therapies nationwide.