INTRODUCTION: Per-oral endoscopic myotomy (POEM) is a less invasive therapy for 
achalasia with a shorter hospitalization but with similar short- and long-term 
outcomes as a laparoscopic Heller myotomy (LHM). Previous literature comparing 
POEM to LHM has focused primarily on postoperative outcome parameters such as 
complications, dysphagia scores and gastro-esophageal reflux severity. This 
study specifically compares postoperative pain following POEM to pain following 
LHM, the current gold-standard operation.
METHODS: A retrospective review of all patients undergoing POEM or LHM for 
achalasia was performed from 2006 to 2015. Data collection included 
demographics, comorbidities, length of stay (LOS) and pain scores (arrival to 
the recovery room, 1 h postoperative, average first 24 h and upon discharge). 
Statistical analysis was performed using Student's t test and Chi-square test.
RESULTS: Forty-four POEM patients and 122 LHM patients were identified. The 
average age (52.2 ± 20.75 vs 50.9 ± 17.89 years, p = 0.306) and BMI (28.1 ± 7.62 
vs 27.6 ± 7.07 kg/m2, p = 0.824) did not differ between the POEM and LHM groups, 
respectively; however, the American Society of Anesthesiology scores were higher 
in the POEM patients (2.43 ± 0.62 vs 2.11 ± 0.71, p = 0.011). There were no 
differences in rates of smoking, diabetes, cardiac disease or pulmonary disease. 
The average pain scores upon arrival to the recovery room and 1 h 
postoperatively were lower in the POEM group (2.3 ± 3.014 vs 3.61 ± 3 0.418, 
p = 0.025 and 2.2 ± 2.579 vs 3.46 ± 3.063, p = 0.034, respectively). There was 
no difference in the average pain score over the first 24 h (2.7 ± 2.067 vs 
3.29 ± 1.980, p = 0.472) or at the time of discharge (1.6 ± 2.420 vs 
2.09 ± 2.157, p = 0.0657) between the POEM and LHM groups. After standardizing 
opioid administration against 10 mg of oral morphine, the POEM group used 
significantly less narcotics that the LHM group (35.8 vs 101.8 mg, p < 0.001) 
while hospitalized. The average LOS for the POEM group was 31.2 h and 55.79 for 
the LHM group (p < 0.0001). At discharge, fewer POEM patients required a 
prescription for a narcotic analgesic (6.81 vs 92.4 %, p < 0.0001).
CONCLUSION: POEM demonstrated significantly less postoperative pain upon arrival 
to the recovery room and 1 h postoperatively. To achieve similar pain scores 
during the first 24 h and at discharge, LHM patients required more narcotic 
analgesic administration. Despite a significantly shorter LOS, fewer POEM 
patients require a prescription for narcotic analgesics compared to LHM. POEM is 
a less painful procedure for achalasia than LHM, permitting earlier hospital 
discharge with little need for home narcotic use.