Peroral endoscopic myotomy (POEM) is emerging as a minimally invasive therapeutic option for achalasia. Data are limited in pediatric population. Aim: To compare the efficacy and safety of POEM between pediatric and adult patients with achalasia diagnosis

A prospective study was conducted, including all patients who underwent POEM, since August/2022-October/2025, in a tertiary centre from Portugal. Patients aged under 18yo were included in the pediatric group and above 18yo in adult group. Procedural-related parameters, adverse advents, pre- and post-intervention clinical, manometric and radiologic outcomes were evaluated

Sixty-four consecutive patients underwent POEM, including six pediatric patients aged 13–16 years (mean age: 14.5 ± 1.2 vs. 53.1 ± 18.6 years; male gender: 83.3% (n=5) vs. 50.0% (n=29); p=0.12). According to Chicago classification v4.0, five children had type II achalasia and one had type I achalasia (adults: type I 6.9% (n=4), type II 86.2% (n=50), type III 6.9% (n=4)).

No significant differences were observed between groups regarding pre-procedure Eckardt score (7.2 ± 1.7 vs. 8.0 ± 2.1; p=0.39), symptom duration (26.2 ± 16.8 vs. 71.8 ± 95.3 months; p=0.17), pre-POEM IRP (38.5 ± 6.5 vs. 27.1 ± 11.9 mmHg; p=0.08), EGJ-CI or barium column height at 1/5 minutes (5.2/4.8 vs. 12.1/10.2 cm; p=0.12/0.21). Technical success was 100% with comparable procedure duration (82.5 ± 18.3 vs. 90.2 ± 39.1 min; p=0.48) and exclusive posterior approach. At a mean follow-up of 8.3 in pediatric patients vs. 10.8 months in adults, clinical success was achieved in 100% of pediatric and 94.8% of adult patients (post-POEM Eckardt 0.3 ± 0.5 vs. 1.2 ± 1.5; p=0.31). Minor intraprocedural adverse events occurred in 50% vs. 32.8% (p=0.41); No major adverse events, perforation, or mortality occurred in either group. Symptomatic gastroesophageal reflux disease was significantly less frequent in pediatric patients (0/6, 0%) than adults (10/58, 17.2%) (p=0.021, Fisher’s exact test), all managed with proton pump inhibitors.

POEM proved to be effective and safe for achalasia both in adults and pediatric patients, with no statistically significant differences regarding technical, clinical, manometric and imaging success or complications. Symptomatic post-POEM GERD was significantly lower in children. Early POEM appears to be equally effective and safe compared to late POEM, with less long-term symptomatic post-POEM GERD.