Peroral endoscopic myotomy (POEM) has become a first-line therapeutic option for achalasia and other esophageal motility disorders, offering high effectiveness and a favorable safety profile. Most adverse events are identified and managed intraprocedurally, while severe post-procedural complications such as leak, perforation or bleeding are uncommon, occur in ≤1% of cases. Despite this, post-POEM care lacks standardization. Current ESGE guidelines advise against routine esophagram in asymptomatic patients and recommend gradual diet advancement - fluids on day 1, soft diet on day 3, and normal diet on day 7 - along with single-dose prophylactic antibiotics and empiric acid suppression. AGA acknowleges that same-day discharge may be feasible and supports early initiation of oral fluids in clinically stable patients without intraprocedural complications, hours after the procedure, although no uniform post-procedure diet protocol exists. Growing clinical experience suggests that early oral intake is safe in appropriately selected patients, as most complications are detected during POEM and early feeding does not appear to increase adverse events. 

Our aim was to describe our post-procedural management protocol and demonstrate the safety of introducing a soft diet as early as 48 hours after POEM.

This retrospective single-center study included all patients undergoing POEM at a tertiary Portuguese referral center between January 2017 and October 2025. All procedures were performed by a single experienced endoscopist. The primary outcome was perioperative adverse events (AEs). AEs were classified according to the AGREE system. 

A total of 204 patients underwent 211 POEM procedures, 51% were male (n=104) with a median age of 55 years. Most patients had achalasia (n=195), including 101 with type II, 52 with type I, 24 with type III and 18 unclassified. Six patients had other esophageal motility disorders, most commonly esophageal spasm (n=4).

Technical success was achieved in 209 of the 211 procedures. Intra-procedural adverse events occurred in seven cases (some with more than one event): six minor bleedings and two perforations, all endoscopically managed, three pneumoperitoneums drained during the procedure, and two anesthetic complications (aspiration and pneumonia). One aspiration pneumonia required ICU admission, constituting a grade IV adverse event according to the AGREE classification.

Most patients were admitted for 48-hour surveillance, during which prophylactic ceftriaxone was administered. Thirty-eight patients reported post-procedural pain controlled with analgesics (grade I), and two experienced fever requiring one additional day of hospitalization (grade II).

A barium swallow was performed on day one in 146 patients, with no clinically significant findings. Since September 2024, this examination is no longer performed routinely and is now reserved for technically complex procedures with higher perceived risk.

A liquid diet was initiated on day 1 (24 hours after POEM) in 200 patients, followed by a soft diet on day 2 in 198 patients, with no diet-related complications observed. Patients maintained a soft diet for six days, progressing to a light general diet from day 7 onward. All patients received double-dose PPI therapy during admission, continued until at least the first outpatient follow-up. Aside from GERD and symptomatic failure, no other late complications were recorded.

POEM remains a highly safe therapeutic modality, with most adverse events occurring intraprocedurally and effectively managed endoscopically. Post-procedural clinical surveillance is sufficient to guide patient management, without the need for routine contrast studies in asymptomatic individuals. Our data indicate that early diet advancement is feasible and safe, supporting the initiation of a soft diet on day 2 after POEM.