Endoscopic Treatment of Esophageal Motility Disorders in the Era of POEM: Current Perspectives and Future Directions

The therapeutic landscape of esophageal motility disorders has changed substantially over the past decade with the emergence of third-space endoscopy. Peroral endoscopic myotomy (POEM), initially developed as an endoscopic treatment for achalasia, has evolved into a standard therapeutic modality with excellent clinical efficacy and durable long-term outcomes. Accumulating evidence demonstrates that POEM provides clinical outcomes comparable to or superior to pneumatic dilation and laparoscopic Heller myotomy, while offering the advantages of a minimally invasive endoscopic approach. Technical refinements of POEM, including optimizing myotomy length, tailoring myotomy to disease phenotype, and implementing anti-reflux strategies, have further improved procedural safety and therapeutic outcomes. In addition, the indications for POEM have expanded beyond achalasia to selected patients with esophagogastric junction outflow obstruction and spastic esophageal motility disorders, such as distal esophageal spasm and hypercontractile esophagus. The development of diverticular POEM, including Zenker-POEM and diverticular-POEM, has also highlighted POEM's evolution from a disease-specific intervention to a versatile third-space endoscopic therapeutic platform. This review summarizes current evidence regarding the endoscopic treatment of esophageal motility disorders in the era of POEM, focusing on established indications, expanding applications, technical evolution, and future perspectives. Continued advances in endoscopic technology and physiology-guided therapeutic strategies are expected to broaden POEM's role further and expand personalized endoscopic treatment for esophageal motility disorders.