Which factor best informs the choice between POEM and Heller myotomy?

• A. Patient anatomy and motility pattern
• B. Age only
• C. Hospital location
• D. Insurance coverage

Answer: (A)

The choice between POEM and Heller myotomy is driven by how the esophagus and LES are functioning in that patient. The key information comes from anatomy and motility patterns, especially the Chicago classification on high-resolution manometry and the length of the esophageal involvement.

For achalasia, a longer or more distal myotomy may be needed when there are spastic or highly abnormal contractions in the esophageal body (type III), and POEM can tailor a longer myotomy that extends into the esophagus. Heller myotomy, while effective, traditionally targets the LES more specifically and is often paired with a partial fundoplication to reduce reflux. Thus, understanding whether the problem is mainly a tight LES, or a pattern of esophageal body contractions that extend higher up, guides which approach is more likely to relieve symptoms.

Other factors like age, hospital location, or insurance can influence practicality or access, but they do not determine which procedure best matches the patient’s physiology.