Clinical and Physiological Outcomes of Peroral Endoscopic Myotomy in Southeast Asia: A Regional Pooled Analysis

Clinical and Physiological Outcomes of Peroral Endoscopic Myotomy in Southeast Asia: A Regional Pooled Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Clinical and Physiological Outcomes of Peroral Endoscopic Myotomy in Southeast Asia: A Regional Pooled Analysis Navapan Issariyakulkarn, Phubordee Bongkotvirawan, Soonthorn Chonprasertsuk, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8715024/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Peroral endoscopic myotomy (POEM) is an established therapy for achalasia, but data from Southeast Asia remain limited. We evaluated the clinical and physiological outcomes of POEM in Thai patients and compared them with regional cohorts from Singapore and Malaysia. We analyzed a pooled Thai cohort of 127 patients who underwent POEM between 2014 and 2024 and compared outcomes with published cohorts from Singapore (n = 58) and Malaysia (n = 65). Clinical success was defined as an Eckardt score ≤ 3 during the follow-up period. A total of 250 patients were included. Clinical success was achieved in 89.9%, 93.0%, and 93.4% of patients in Thailand, Singapore, and Malaysia, respectively. In the Thai cohort, significant improvements were observed in Eckardt scores, integrated relaxation pressure, and timed barium esophagogram parameters (p < 0.05). Post-POEM reflux occurred in 23.1% of Thai, 43.1% of Singaporean, and 37.0% of Malaysian patients. POEM is a safe and effective treatment for achalasia in Thailand, with clinical outcomes comparable to regional benchmarks. Differences in reflux rates suggest potential heterogeneity in practice and follow-up, highlighting the need for standardized regional protocols. Health sciences/Diseases Health sciences/Gastroenterology Health sciences/Medical research Introduction Achalasia is a rare esophageal motility disorder, although its diagnosed incidence has risen following the widespread adoption of the Chicago Classification 1 . The defining features of achalasia are impaired lower esophageal sphincter (LES) relaxation and aperistalsis, which lead to symptoms such as dysphagia, regurgitation, chest pain, and weight loss. Treatment strategies aim to overcome LES outflow obstruction and include pharmacologic therapy, endoscopic procedures, and surgical interventions 2 – 4 . Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic treatment that involves the transection of the muscular fibers in the distal esophagus and gastric cardia 2 . Since its initial introduction in Japan in 2010, POEM has rapidly evolved into a frontline modality 5 . Numerous studies across North America, Europe, and East Asia have consistently validated the safety, efficacy, and durable outcomes of POEM across all achalasia subtypes 6 – 8 , particularly type III achalasia 2 , 3 , 8 – 11 . A recent systematic review reported that POEM achieves higher success rates and shorter procedure times compared to traditional surgical options such as Heller myotomy 12 . However, concerns persist regarding the higher incidence of post-procedural reflux compared to pneumatic balloon 13 . Despite the global proliferation of POEM, there remains a paucity of comprehensive data from Southeast Asia. Although advanced endoscopic facilities are increasingly available in countries such as Thailand, Malaysia, Indonesia, Vietnam, and the Philippines, heterogeneity in regional practice patterns, patient selection criteria, and post-procedural surveillance exists. Furthermore, sociocultural factors, healthcare disparities, and variations in endoscopic training curricula may influence treatment access and clinical outcomes. Currently, comparative regional data are scarce, impeding benchmarking, training evaluation, and the adaptation of international guidelines to this specific population. Therefore, this study aims to evaluate the clinical and physiological outcomes of POEM for achalasia in Thai patients and to benchmark these findings against other ASEAN cohorts through a regional pooled analysis. Materials and Methods Study design and data collection This study employed a regional pooled analysis design to evaluate the clinical outcomes of peroral endoscopic myotomy (POEM) in Thai patients and benchmark them against published outcomes from other ASEAN countries. The Thai pooled cohort was derived from two sources: Primary Data: This cohort comprises patients diagnosed and managed at Thammasat University Hospital. These patients were referred to an external center specifically for the POEM procedure but returned to our institution for standardized pre-operative assessment and long-term post-operative follow-up. Consequently, complete longitudinal clinical and physiological data were available for all included patients. All included patients had at least one year of follow-up. Published Thai cohorts: Aggregate data including demographics, Eckardt scores, high-resolution manometry [HRM] parameters, and timed barium esophagogram [TBE] results were systematically extracted from PubMed and Scopus. The search terms were “POEM,” “achalasia,” and “Thailand,” restricted to English-language articles. Two independent reviewers screened all titles, abstracts, and full texts before data extraction. Data from Thammasat University Hospital and two published cohorts were pooled. When outcomes were reported as median [IQR] or mean (range), values were converted to mean ± standard deviation (SD) using established statistical methods [14] . This integration allowed for a comprehensive multicenter assessment while acknowledging potential heterogeneity. Inclusion criteria: confirmed achalasia diagnosis with available clinical and physiologic data. Exclusion criteria were: incomplete demographic information, missing Eckardt scores, unavailable HRM results (specifically Integrated Relaxation Pressure [IRP]), or lack of post-procedure reflux assessment. Diagnosis and Subtyping Achalasia was diagnosed based on clinical symptoms and HRM findings. Subtypes were classified according to the Chicago Classification v3.0 or v4.0, depending on the guideline effective at the time of diagnosis: Type I (classic), Type II (panesophageal pressurization), and Type III (spastic). Baseline TBE was performed to measure the height and width of the barium column at 5 minutes. Outcome Measures The primary outcome was clinical success, defined as a post-POEM Eckardt score ≤ 3. The Eckardt score (range 0–12) comprises four symptom domains: dysphagia, regurgitation, chest pain, and weight loss. Secondary outcomes included changes in key physiological parameters, specifically Integrated Relaxation Pressure (IRP) and measurements from the Timed Barium Esophagogram (TBE) (barium column height and width at 5 minutes). The incidence of post-POEM gastroesophageal reflux disease (GERD) was also assessed as a secondary outcome. ASEAN Comparative Cohort Selection For regional comparison, PubMed and Scopus were searched using the keywords “POEM” OR “peroral endoscopic myotomy,” AND “achalasia,” combined with geographic filters for ASEAN member states: “Thailand,” “Singapore,” “Vietnam,” “Indonesia,” “Cambodia,” “Malaysia,” “Brunei,” “Myanmar,” and “Timor.” Searches were limited to English-language articles. Two reviewers independently screened titles and abstracts to identify relevant full-text articles containing extractable outcome data. Statistical Analysis Analyses were performed using SPSS version 27.0 (IBM Corp., Armonk, NY, USA). Published data expressed as median (IQR) or mean (range) were converted to mean ± SD using the method of Wan et al. [14] . Continuous variables were compared using independent t-tests (for summary data), applying Welch’s correction if variances were unequal (Levene’s test). A two-tailed p-value < 0.05 was considered statistically significant. These analyses were exploratory in nature due to the use of aggregated published data. No adjustment was made for multiple comparisons because the analyses were exploratory and hypothesis-generating. Ethical Considerations This study was approved by the Institutional Review Board of Thammasat University (IRB approval number: 220/2568). Informed consent was waived due to the retrospective design and minimal risk to participants. All data were de-identified in accordance with the Declaration of Helsinki and Good Clinical Practice (GCP) guidelines. This study followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) reporting guidelines. Results A total of 250 patients were included in the final analysis. The pooled Thai cohort (n=127) comprised 9 patients from Thammasat University Hospital and 118 patients from previously published studies 14,15 . The comparative ASEAN groups consisted of 58 patients from Singapore 16 , and 65 patients from Malaysia 17 . A comprehensive search yielded no eligible data from other ASEAN member states. Baseline demographics and clinical characteristics The demographic and baseline clinical characteristics of the pooled Thai cohort, and the comparative Singaporean and Malaysian cohorts were summarized in Table 1. Table 1: Baseline characteristics of patients who underwent POEM in Thailand, Singapore, and Malaysia. Characteristic Thai (n=127) Singapore (n=58) 16 Malaysia (n=65) 17 Demographic Age mean±SD (years) Male n(%) BMI mean±SD (kg/m²) 46.5 ± 16.6 42 (35.4) 21.4 ± 5.2 51.4 ± 14.3 30 (51.7) NR 41.7 ± 15.1 29 (44.6) NR Achalasia subtype n (%) 1 2 3 Unclassified subtype Prior Procedures n (%) 32 (27.6) 56 (47.2) 8 (7.1) 22 (18.1) 10 (8.3) 16 (27.6) 34 (58.6) 3 (5.2) 4 (6.9) 20 (34.5) 26 (40.0) 33 (50.7) 2 (3.1) 4 (6.2) NR Baseline clinical/physiological Baseline Eckardt Scores Pre-procedure IRP (mmHg) TBE height at 5 minutes(cm) TBE width at 5 minutes (cm) 6.5±2.2 34.30 ± 15.53 11.9±6.1 4.2±2 6.09±2.43 23.5±33.1 NR NR 7.9±2.5 NR NR NR Values are mean ± standard deviation (SD) unless otherwise stated. NR = not reported; IRP = integrated relaxation pressure; TBE = timed barium esophagogram. The mean age differed across cohorts: 46.5 ± 16.6 years in Thailand, 51.4 ± 14.3 years in Singapore, and 41.7 ± 15.1 years in Malaysia. The proportion of male patients was lowest in the Thai cohort (35.4%), compared with Singapore (51.7%) and Malaysia (44.6%). Baseline BMI was available only for Thai patients (21.4 ± 5.2 kg/m²) precluding a comparative analysis of obesity-related technical difficulty across all groups. Achalasia type II was the most frequent subtype across all countries, accounting for 47.2% of Thai, 58.6% of Singaporean, and 50.7% of Malaysian patients. The Singaporean cohort had the highest rate of prior interventions (34.5%), whereas the Thai cohort reported 8.3%. This information was not reported for Malaysia. Baseline symptom severity, as reflected by the Eckardt scores, was high in all groups: 6.5 ± 2.2 (Thailand), 6.09 ± 2.43 (Singapore), and 7.9 ± 2.5 (Malaysia). Pre-procedure IRP was available for Thailand (34.3 ± 15.5 mmHg) and Singapore (23.5 ± 33.1 mmHg). TBE parameters were reported only for the Thai cohort. The mean barium height was 11.9 ± 6.1 cm and the width was 4.2 ± 2.0 cm at 5 minutes. Table 2: Clinical and physiological outcomes post-POEM in Thailand, Singapore, and Malaysia Outcome Thailand (n=127) Singapore (n=58) 16 Malaysia (n=65) 17 Eckardt Scores Baseline (mean±SD) Post-POEM Clinical success (%) 6.5±2.2 * 2.4±2.7 * (6 mo) 89.9 6.09±2.43 * 1.16±1.70 * (12 mo) 93 7.9±2.5 * 1.1±1.9 * (2 mo) 93.4 Integrated relaxation pressure (IRP) Pre-POEM (mmHg) Post-POEM (mmHg) 34.30 ± 15.53* 26.24±8.48* 23.5±33.1 * * 13.4±7.71 * * NR NR Timed barium esophagogram (TBE) Height of barium at 5 minutes Pre-POEM (cm) Post-POEM (cm) Width at 5 minutes Pre-POEM (cm) Post-POEM (cm) 11.9±6.1 * 6.9 ± 4.1* 4.2±2** 3.5±2.4** NR NR NR NR NR NR NR NR Post-procedure reflux after 2-12 months (%) 23.1 (6 mo) 43.1 (12 mo) 37 (2 mo) * P-value < 0.01, ** P-value < 0.05 Values are mean ± SD unless otherwise stated. NR = not reported. Follow-up durations vary across cohorts: Thailand (6 months), Singapore (12 months), and Malaysia (2 months). Across all cohorts, POEM resulted in a significant improvement in symptoms. In Thai patients, the mean Eckardt scores decreased from 6.5 ± 2.2 to 2.4 ± 2.7 (p < 0.01), the IRP from 34.3 ± 15.5 to 26.2 ± 8.5 mmHg (p < 0.01), and the TBE height from 11.9 ± 6.1 to 6.9 ± 4.1 cm (p < 0.01). Clinical success was achieved in 89.9%, 93.0%, and 93.4% of Thai, Singaporean, and Malaysian patients, respectively. Post-POEM reflux was reported in 23.1% (Thailand), 43.1% (Singapore), and 37.0% (Malaysia). Discussion Peroral endoscopic myotomy (POEM) has firmly established itself as a standard therapeutic option for achalasia, demonstrating high efficacy and safety across diverse populations. In this first regionally integrated ASEAN analysis, POEM yielded consistent symptomatic and physiological improvements among patients from Thailand, Singapore, and Malaysia. Clinical success rates exceeded 89% in all cohorts, aligning with benchmarks set by large-scale studies in East Asia and Western countries 6 , 18 – 22 . Consequently, this study provides a crucial dataset validating the real-world effectiveness of POEM within the specific healthcare context of Southeast Asia. Comparison with global and regional benchmarks Our findings corroborate prior meta-analyses showing that POEM achieves symptom control in more than 90% of achalasia cases 12 , 13 . Specifically, POEM proved to be a highly effective treatment for the Thai population, with outcomes comparable to those reported in Singapore and Malaysia. Interestingly, demographic heterogeneity was observed across the region; Thai and Malaysian patients were generally younger than their Singaporean counterparts. This discrepancy may reflect variations in healthcare systems, referral pathways, or potentially distinct disease phenotypes in different ethnic groups, warranting further epidemiological investigation. Post-procedural Reflux Reflux was observed in 23.1% of Thai patients, which is lower than in Singapore (43.1%) and Malaysia (37%). These differences likely reflect heterogeneity in follow-up duration and diagnostic methods—particularly whether reflux was defined symptomatically or by pH-impedance testing. Additionally, temporal factors may play a role; as the Singaporean and Malaysian cohorts represent earlier experiences, their higher reflux rates may partially reflect the initial learning curve phase of POEM implementation. Previous prospective studies have demonstrated reflux rates ranging from 30% to 50% when objective pH testing is applied 16 , 23 . Therefore, standardized reflux assessment and consistent reporting of PPI use will be essential in future ASEAN studies to better quantify this adverse outcome. Regional Gaps and Future Directions This study adds pivotal data to the limited literature on POEM outcomes in Southeast Asia. The absence of published studies from countries such as Indonesia, Vietnam, and the Philippines underscores the need for greater regional collaboration and multicenter registries. Differences in healthcare systems, specialist training, and access to diagnostic tools such as manometry likely contribute to the current evidence gaps. Reducing these disparities will be crucial for improving achalasia management across ASEAN. Limitations Several limitations should be acknowledged. First, the retrospective design and reliance on published aggregate data may have introduced selection and reporting biases. Second, heterogeneity in follow-up duration, particularly the short two-month follow-up in the Malaysian cohort, limited direct comparison of long-term outcomes. Third, the conversion of medians or ranges into estimated means and standard deviations, though necessary for pooled analysis, may have reduced precision relative to patient-level data. Statistical comparisons were performed using estimated means derived from reported medians, which serves as an exploratory comparison rather than a direct patient-level meta-analysis. Fourth, physiological outcome data (TBE and HRM) were unavailable for several external cohorts. Finally, the maximum follow-up across all cohorts did not exceed one year, precluding evaluation of long-term durability. Despite these limitations, this study provides valuable insight into the performance of POEM across an understudied region and establishes a foundation for collaborative ASEAN registries. Conclusion POEM is a safe and effective therapeutic option for achalasia in Thailand, demonstrating clinical outcomes comparable to regional benchmarks in Singapore and Malaysia. As the first regionally integrated analysis, these findings highlight the importance of harmonizing outcome reporting and fostering collaborative research efforts in Southeast Asia to ensure equitable access to high-quality care. Future prospective, longitudinal studies incorporating standardized reflux evaluation (e.g., pH impedance monitoring) will be essential to validate long-term efficacy, optimize patient selection, and minimize adverse effects such as post-POEM reflux. Declarations Competing Interests The authors declare no competing interests. Declarations of Generative AI and AI-assisted technologies in the writing process. During the preparation of this work, the author(s) used Gemini (Google) to improve language and readability. After using this tool/service, the author(s) reviewed and edited the content as needed and take full responsibility for the content of the publication. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Author Contribution N.I. conceived and designed the study, collected and analyzed the data, and drafted the manuscript.P้h.B. performed the statistical analysis and data validation.S.C., B.P., S.S., Pa.B., A.W. and N.A. supervised the project and provided critical revision of the manuscript for important intellectual content.R.K.V. provided critical revision and important intellectual input.All authors reviewed and approved the final manuscript. Acknowledgements This study was supported by the Thailand Science Research and Innovation Fundamental Fund 2025, the Gastroenterological Association of Thailand (GAT), and the Center of Excellence in Digestive Diseases, Thammasat University. Data Availability The datasets generated and/or analyzed during the current study are not publicly available due to ethical and privacy restrictions but are available from the corresponding author on reasonable request. References Lee, K. et al. Global trends in incidence and prevalence of achalasia, 1925–2021: A systematic review and meta-analysis. United Eur. Gastroenterol. J. 12 , 504–515. 10.1002/ueg2.12555 (2024). Vaezi, M. F., Pandolfino, J. E., Yadlapati, R. H., Greer, K. B. & Kavitt, R. T. ACG Clinical Guidelines: Diagnosis and Management of Achalasia. Am. J. Gastroenterol. 115 , 1393–1411. 10.14309/ajg.0000000000000731 (2020). Jung, H. K. et al. Seoul Consensus on Esophageal Achalasia Guidelines. Journal of neurogastroenterology and motility 26, 180–203, (2019). 10.5056/jnm20014 (2020). Oude Nijhuis, R. A. B. et al. European guidelines on achalasia: United European Gastroenterology and European Society of Neurogastroenterology and Motility recommendations. United Eur. Gastroenterol. J. 8 , 13–33. 10.1177/2050640620903213 (2020). Inoue, H. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 42 , 265–271. 10.1055/s-0029-1244080 (2010). Andolfi, C. & Fisichella, P. M. Meta-analysis of clinical outcome after treatment for achalasia based on manometric subtypes. Br. J. Surg. 106 , 332–341. 10.1002/bjs.11049 (2019). Kim, W. H. et al. Comparison of the Outcomes of Peroral Endoscopic Myotomy for Achalasia According to Manometric Subtype. Gut liver . 11 , 642–647. 10.5009/gnl16545 (2017). Kohn, G. P. et al. SAGES guidelines for the use of peroral endoscopic myotomy (POEM) for the treatment of achalasia. Surg. Endosc. 35 , 1931–1948. 10.1007/s00464-020-08282-0 (2021). Yang, D., Bechara, R., Dunst, C. M. & Konda, V. J. A. AGA Clinical Practice Update on Advances in Per-Oral Endoscopic Myotomy (POEM) and Remaining Questions-What We Have Learned in the Past Decade: Expert Review. Gastroenterology 167 , 1483–1490. 10.1053/j.gastro.2024.08.038 (2024). Calabrese, E. C. et al. 2024 Update to SAGES guidelines for the use of peroral endoscopic myotomy (POEM) in the treatment of achalasia. Surg. Endosc. 10.1007/s00464-025-11789-z (2025). Khashab, M. A. et al. ASGE guideline on the management of achalasia. Gastrointest. Endosc. 91 , 213–227e216. 10.1016/j.gie.2019.04.231 (2020). Kasapoglu, M., Noor Us Saba, S., Hashemi, A., Panchal, M. & Khan, S. Comparative Effectiveness of Peroral Endoscopic Myotomy (POEM) Versus Traditional Treatment Modalities for Achalasia: A Systematic Review. Cureus 16 , e71917. 10.7759/cureus.71917 (2024). Dirks, R. C. et al. Is peroral endoscopic myotomy (POEM) more effective than pneumatic dilation and Heller myotomy? A systematic review and meta-analysis. Surg. Endosc. 35 , 1949–1962. 10.1007/s00464-021-08353-w (2021). Suwatthanarak, T. et al. Timed barium esophagography to predict recurrent achalasia after peroral endoscopic myotomy: a retrospective study in Thailand. Clin. endoscopy . 57 , 610–619. 10.5946/ce.2023.236 (2024). Laohavichitra, K., Wannaprasert, J. & Ratanachu-ek, T. Outcomes of per-oral endoscopic myotomy in the treatment of esophageal achalasia: over one hundred cases in a single tertiary center. Siriraj Med. J. 75 , 629–637. 10.33192/smj.v75i9.263612 (2023). Teh, J. L. et al. Gastro-esophageal reflux disease (GERD) after peroral endoscopic myotomy (POEM). Surg. Endosc. 36 , 3308–3316. 10.1007/s00464-021-08644-2 (2022). Ho, S. H., Nik Arsyad, N. M. A., Lau, P. C., Jamaludin, F. H. & Mahadeva, S. Acquiring new complex endoscopic skills: Experience from the development of peroral endoscopic myotomy (POEM) in Malaysia. JGH open: open. access. J. Gastroenterol. Hepatol. 5 , 729–733. 10.1002/jgh3.12598 (2021). Campagna, R. A. J. et al. Outcomes of 100 Patients More Than 4 Years After POEM for Achalasia. Ann. Surg. 273 , 1135–1140. 10.1097/sla.0000000000004830 (2021). Brewer Gutierrez, O. I. et al. Long-term outcomes of per-oral endoscopic myotomy in achalasia patients with a minimum follow-up of 4 years: a multicenter study. Endoscopy Int. open. 8 , E650–e655. 10.1055/a-1120-8125 (2020). Gu, L. et al. Safety and efficacy of peroral endoscopic myotomy with standard myotomy versus short myotomy for treatment-naïve patients with type II achalasia: a prospective randomized trial. Gastrointest. Endosc. 93 , 1304–1312. 10.1016/j.gie.2020.10.006 (2021). Shiwaku, H. et al. Peroral endoscopic myotomy for achalasia: a prospective multicenter study in Japan. Gastrointestinal endoscopy 91, 1037–1044.e1032, (2020). 10.1016/j.gie.2019.11.020 Shieh, T. Y. et al. Clinical efficacy and safety of peroral endoscopic myotomy for esophageal achalasia: A multicenter study in Taiwan. J. Formos. Med. Association = Taiwan. yi zhi . 121 , 1123–1132. 10.1016/j.jfma.2021.10.016 (2022). Shiwaku, H. et al. A prospective analysis of GERD after POEM on anterior myotomy. Surg. Endosc. 30 , 2496–2504. 10.1007/s00464-015-4507-0 (2016). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 08 Apr, 2026 Reviews received at journal 31 Mar, 2026 Reviewers agreed at journal 11 Mar, 2026 Reviews received at journal 11 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviewers invited by journal 04 Feb, 2026 Editor invited by journal 02 Feb, 2026 Editor assigned by journal 30 Jan, 2026 Submission checks completed at journal 30 Jan, 2026 First submitted to journal 27 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8715024","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":587422034,"identity":"4f9a675b-b76d-4fe4-9703-010984c8d13d","order_by":0,"name":"Navapan Issariyakulkarn","email":"","orcid":"","institution":"Thammasart University","correspondingAuthor":false,"prefix":"","firstName":"Navapan","middleName":"","lastName":"Issariyakulkarn","suffix":""},{"id":587422035,"identity":"5ecd2e6e-fb9a-467d-8415-0a0288694471","order_by":1,"name":"Phubordee Bongkotvirawan","email":"","orcid":"","institution":"Thammasart University","correspondingAuthor":false,"prefix":"","firstName":"Phubordee","middleName":"","lastName":"Bongkotvirawan","suffix":""},{"id":587422036,"identity":"b5f3afd4-c208-46d9-89a1-ff59a6e39530","order_by":2,"name":"Soonthorn Chonprasertsuk","email":"","orcid":"","institution":"Thammasart University","correspondingAuthor":false,"prefix":"","firstName":"Soonthorn","middleName":"","lastName":"Chonprasertsuk","suffix":""},{"id":587422037,"identity":"08fda809-f0f8-4b15-8c35-0455ca4a0b01","order_by":3,"name":"Bubpha Pornthisarn","email":"","orcid":"","institution":"Thammasart University","correspondingAuthor":false,"prefix":"","firstName":"Bubpha","middleName":"","lastName":"Pornthisarn","suffix":""},{"id":587422038,"identity":"9b9bde9a-3ffe-4448-87ff-2642e5163fa2","order_by":4,"name":"Sith Siramolpiwat","email":"","orcid":"","institution":"Thammasart University","correspondingAuthor":false,"prefix":"","firstName":"Sith","middleName":"","lastName":"Siramolpiwat","suffix":""},{"id":587422039,"identity":"9405dcff-03c2-470a-aaca-4c6511c3af4f","order_by":5,"name":"Patommatat Bhanthumkomol","email":"","orcid":"","institution":"Thammasart University","correspondingAuthor":false,"prefix":"","firstName":"Patommatat","middleName":"","lastName":"Bhanthumkomol","suffix":""},{"id":587422040,"identity":"584e022b-2667-4dbc-b517-6e8112b55ccb","order_by":6,"name":"Arti Wongcha-um","email":"","orcid":"","institution":"Thammasart University","correspondingAuthor":false,"prefix":"","firstName":"Arti","middleName":"","lastName":"Wongcha-um","suffix":""},{"id":587422041,"identity":"b830219a-42c2-4c00-a38e-6d7b3cb6294a","order_by":7,"name":"Natsuda Aumpan","email":"","orcid":"","institution":"Thammasart University","correspondingAuthor":false,"prefix":"","firstName":"Natsuda","middleName":"","lastName":"Aumpan","suffix":""},{"id":587422042,"identity":"ee22f2a3-755c-497a-9037-8f0be9ee857c","order_by":8,"name":"Ratha-Korn Vilaichone","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYDACZuYGhgSGAyDWMbAAGztEIgG3FkaYFrY0sDo2ZrC4AW4tDEAtDGAtPGYQowlpMTjO2PjhQc0dOXP2nm8PPv7YJs/HzMD44QPDnzycWg4zNkskHHtmbNlzdrvhjITbhm3MDMySMxgMinFpkWxmbJBIbDicuOFG7jZpnoTbjEAtbMw8DAaJDbi1NP8Aa7n/5hlIiz1BLfzMjG1QW3jYQFoSidJikXDssLHBmTQzyRlpt5PbmBmbJWcYGOPUwsZ/+PDNHzWH5QyOH34m8cHmtu389uaDHz5UyOHUgg2AYsqABPWjYBSMglEwCjAAAPWxVZtFNjA5AAAAAElFTkSuQmCC","orcid":"","institution":"Thammasart University","correspondingAuthor":true,"prefix":"","firstName":"Ratha-Korn","middleName":"","lastName":"Vilaichone","suffix":""}],"badges":[],"createdAt":"2026-01-28 01:08:35","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8715024/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8715024/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102312029,"identity":"7550a55b-094f-4d8b-90c1-722271d94393","added_by":"auto","created_at":"2026-02-10 11:59:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":606221,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8715024/v1/f8dfaa44-94a4-4fde-94d4-56f3493664f4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical and Physiological Outcomes of Peroral Endoscopic Myotomy in Southeast Asia: A Regional Pooled Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAchalasia is a rare esophageal motility disorder, although its diagnosed incidence has risen following the widespread adoption of the Chicago Classification \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The defining features of achalasia are impaired lower esophageal sphincter (LES) relaxation and aperistalsis, which lead to symptoms such as dysphagia, regurgitation, chest pain, and weight loss. Treatment strategies aim to overcome LES outflow obstruction and include pharmacologic therapy, endoscopic procedures, and surgical interventions \u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePeroral endoscopic myotomy (POEM) is a minimally invasive endoscopic treatment that involves the transection of the muscular fibers in the distal esophagus and gastric cardia \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Since its initial introduction in Japan in 2010, POEM has rapidly evolved into a frontline modality \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Numerous studies across North America, Europe, and East Asia have consistently validated the safety, efficacy, and durable outcomes of POEM across all achalasia subtypes \u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e, particularly type III achalasia \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. A recent systematic review reported that POEM achieves higher success rates and shorter procedure times compared to traditional surgical options such as Heller myotomy \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. However, concerns persist regarding the higher incidence of post-procedural reflux compared to pneumatic balloon \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite the global proliferation of POEM, there remains a paucity of comprehensive data from Southeast Asia. Although advanced endoscopic facilities are increasingly available in countries such as Thailand, Malaysia, Indonesia, Vietnam, and the Philippines, heterogeneity in regional practice patterns, patient selection criteria, and post-procedural surveillance exists. Furthermore, sociocultural factors, healthcare disparities, and variations in endoscopic training curricula may influence treatment access and clinical outcomes. Currently, comparative regional data are scarce, impeding benchmarking, training evaluation, and the adaptation of international guidelines to this specific population.\u003c/p\u003e \u003cp\u003e Therefore, this study aims to evaluate the clinical and physiological outcomes of POEM for achalasia in Thai patients and to benchmark these findings against other ASEAN cohorts through a regional pooled analysis.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eStudy design and data collection\u003c/p\u003e \u003cp\u003e This study employed a regional pooled analysis design to evaluate the clinical outcomes of peroral endoscopic myotomy (POEM) in Thai patients and benchmark them against published outcomes from other ASEAN countries.\u003c/p\u003e \u003cp\u003eThe Thai pooled cohort was derived from two sources:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePrimary Data: This cohort comprises patients diagnosed and managed at Thammasat University Hospital. These patients were referred to an external center specifically for the POEM procedure but returned to our institution for standardized pre-operative assessment and long-term post-operative follow-up. Consequently, complete longitudinal clinical and physiological data were available for all included patients. All included patients had at least one year of follow-up.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePublished Thai cohorts: Aggregate data including demographics, Eckardt scores, high-resolution manometry [HRM] parameters, and timed barium esophagogram [TBE] results were systematically extracted from PubMed and Scopus. The search terms were \u0026ldquo;POEM,\u0026rdquo; \u0026ldquo;achalasia,\u0026rdquo; and \u0026ldquo;Thailand,\u0026rdquo; restricted to English-language articles. Two independent reviewers screened all titles, abstracts, and full texts before data extraction.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eData from Thammasat University Hospital and two published cohorts were pooled. When outcomes were reported as median [IQR] or mean (range), values were converted to mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) using established statistical methods \u003csup\u003e[14]\u003c/sup\u003e. This integration allowed for a comprehensive multicenter assessment while acknowledging potential heterogeneity.\u003c/p\u003e \u003cp\u003eInclusion criteria: confirmed achalasia diagnosis with available clinical and physiologic data.\u003c/p\u003e \u003cp\u003eExclusion criteria were: incomplete demographic information, missing Eckardt scores, unavailable HRM results (specifically Integrated Relaxation Pressure [IRP]), or lack of post-procedure reflux assessment.\u003c/p\u003e \u003cp\u003eDiagnosis and Subtyping\u003c/p\u003e \u003cp\u003eAchalasia was diagnosed based on clinical symptoms and HRM findings. Subtypes were classified according to the Chicago Classification v3.0 or v4.0, depending on the guideline effective at the time of diagnosis: Type I (classic), Type II (panesophageal pressurization), and Type III (spastic). Baseline TBE was performed to measure the height and width of the barium column at 5 minutes.\u003c/p\u003e \u003cp\u003eOutcome Measures\u003c/p\u003e \u003cp\u003eThe primary outcome was clinical success, defined as a post-POEM Eckardt score\u0026thinsp;\u0026le;\u0026thinsp;3. The Eckardt score (range 0\u0026ndash;12) comprises four symptom domains: dysphagia, regurgitation, chest pain, and weight loss.\u003c/p\u003e \u003cp\u003eSecondary outcomes included changes in key physiological parameters, specifically Integrated Relaxation Pressure (IRP) and measurements from the Timed Barium Esophagogram (TBE) (barium column height and width at 5 minutes). The incidence of post-POEM gastroesophageal reflux disease (GERD) was also assessed as a secondary outcome.\u003c/p\u003e \u003cp\u003eASEAN Comparative Cohort Selection\u003c/p\u003e \u003cp\u003eFor regional comparison, PubMed and Scopus were searched using the keywords \u0026ldquo;POEM\u0026rdquo; OR \u0026ldquo;peroral endoscopic myotomy,\u0026rdquo; AND \u0026ldquo;achalasia,\u0026rdquo; combined with geographic filters for ASEAN member states: \u0026ldquo;Thailand,\u0026rdquo; \u0026ldquo;Singapore,\u0026rdquo; \u0026ldquo;Vietnam,\u0026rdquo; \u0026ldquo;Indonesia,\u0026rdquo; \u0026ldquo;Cambodia,\u0026rdquo; \u0026ldquo;Malaysia,\u0026rdquo; \u0026ldquo;Brunei,\u0026rdquo; \u0026ldquo;Myanmar,\u0026rdquo; and \u0026ldquo;Timor.\u0026rdquo; Searches were limited to English-language articles. Two reviewers independently screened titles and abstracts to identify relevant full-text articles containing extractable outcome data.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eAnalyses were performed using SPSS version 27.0 (IBM Corp., Armonk, NY, USA). Published data expressed as median (IQR) or mean (range) were converted to mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD using the method of Wan et al. \u003csup\u003e[14]\u003c/sup\u003e. Continuous variables were compared using independent t-tests (for summary data), applying Welch\u0026rsquo;s correction if variances were unequal (Levene\u0026rsquo;s test). A two-tailed p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. These analyses were exploratory in nature due to the use of aggregated published data. No adjustment was made for multiple comparisons because the analyses were exploratory and hypothesis-generating.\u003c/p\u003e \u003cp\u003eEthical Considerations\u003c/p\u003e \u003cp\u003e This study was approved by the Institutional Review Board of Thammasat University (IRB approval number: 220/2568). Informed consent was waived due to the retrospective design and minimal risk to participants. All data were de-identified in accordance with the Declaration of Helsinki and Good Clinical Practice (GCP) guidelines.\u003c/p\u003e \u003cp\u003e This study followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) reporting guidelines.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 250 patients were included in the final analysis. The pooled Thai cohort (n=127) comprised 9 patients from Thammasat University Hospital and 118 patients from previously published studies\u003csup\u003e\u0026nbsp;\u0026nbsp;\u003c/sup\u003e\u003csup\u003e14,15\u003c/sup\u003e. \u0026nbsp;The comparative ASEAN groups consisted of 58 patients from Singapore \u003csup\u003e16\u003c/sup\u003e, and 65 patients from Malaysia \u003csup\u003e17\u003c/sup\u003e. A comprehensive search yielded no eligible data from other ASEAN member states.\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003e\u0026nbsp;Baseline demographics and clinical characteristics\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe demographic and baseline clinical characteristics of the pooled Thai cohort, and the comparative Singaporean and Malaysian cohorts were summarized in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 1: Baseline characteristics of patients who underwent POEM in Thailand, Singapore, and Malaysia.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;Thai (n=127)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eSingapore (n=58) \u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003eMalaysia (n=65) \u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDemographic\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAge mean\u0026plusmn;SD (years)\u003c/p\u003e\n \u003cp\u003eMale n(%)\u003c/p\u003e\n \u003cp\u003eBMI mean\u0026plusmn;SD (kg/m\u0026sup2;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e46.5 \u0026plusmn; 16.6\u003c/p\u003e\n \u003cp\u003e42 (35.4)\u003c/p\u003e\n \u003cp\u003e21.4 \u0026plusmn; 5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e51.4 \u0026plusmn; 14.3\u003c/p\u003e\n \u003cp\u003e30 (51.7)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e41.7 \u0026plusmn; 15.1\u003c/p\u003e\n \u003cp\u003e29 (44.6)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAchalasia subtype\u003c/strong\u003e n (%)\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003eUnclassified subtype\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePrior Procedures n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32 (27.6)\u003c/p\u003e\n \u003cp\u003e56 (47.2)\u003c/p\u003e\n \u003cp\u003e8 (7.1)\u003c/p\u003e\n \u003cp\u003e22 (18.1)\u003c/p\u003e\n \u003cp\u003e10 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 (27.6)\u003c/p\u003e\n \u003cp\u003e34 (58.6)\u003c/p\u003e\n \u003cp\u003e3 (5.2)\u003c/p\u003e\n \u003cp\u003e4 (6.9)\u003c/p\u003e\n \u003cp\u003e20 (34.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e26 (40.0)\u003c/p\u003e\n \u003cp\u003e33 (50.7)\u003c/p\u003e\n \u003cp\u003e2 (3.1)\u003c/p\u003e\n \u003cp\u003e4 (6.2)\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline clinical/physiological\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eBaseline Eckardt Scores\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePre-procedure IRP (mmHg)\u003c/p\u003e\n \u003cp\u003eTBE height at 5 minutes(cm)\u003c/p\u003e\n \u003cp\u003eTBE width at 5 minutes (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6.5\u0026plusmn;2.2\u003c/p\u003e\n \u003cp\u003e34.30 \u0026plusmn; 15.53\u003c/p\u003e\n \u003cp\u003e11.9\u0026plusmn;6.1\u003c/p\u003e\n \u003cp\u003e4.2\u0026plusmn;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6.09\u0026plusmn;2.43\u003c/p\u003e\n \u003cp\u003e23.5\u0026plusmn;33.1\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 156px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.9\u0026plusmn;2.5\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eValues are mean \u0026plusmn; standard deviation (SD) unless otherwise stated. NR = not reported; IRP = integrated relaxation pressure; TBE = timed barium esophagogram.\u003c/p\u003e\n\u003cp\u003eThe mean age differed across cohorts: 46.5 \u0026plusmn; 16.6 years in Thailand, 51.4 \u0026plusmn; 14.3 years in Singapore, and 41.7 \u0026plusmn; 15.1 years in Malaysia. The proportion of male patients was lowest in the Thai cohort (35.4%), compared with Singapore (51.7%) and Malaysia (44.6%). Baseline BMI was available only for Thai patients (21.4 \u0026plusmn; 5.2 kg/m\u0026sup2;) precluding a comparative analysis of obesity-related technical difficulty across all groups.\u003c/p\u003e\n\u003cp\u003eAchalasia type II was the most frequent subtype across all countries, accounting for 47.2% of Thai, 58.6% of Singaporean, and 50.7% of Malaysian patients. The Singaporean cohort had the highest rate of prior interventions (34.5%), whereas the Thai cohort reported 8.3%. This information was not reported for Malaysia.\u003c/p\u003e\n\u003cp\u003eBaseline symptom severity, as reflected by the Eckardt scores, was high in all groups: 6.5 \u0026plusmn; 2.2 (Thailand), 6.09 \u0026plusmn; 2.43 (Singapore), and 7.9 \u0026plusmn; 2.5 (Malaysia). Pre-procedure IRP was available for Thailand (34.3 \u0026plusmn; 15.5 mmHg) and Singapore (23.5 \u0026plusmn; 33.1 mmHg). TBE parameters were reported only for the Thai cohort. The mean barium height was 11.9 \u0026plusmn; 6.1 cm and the width was 4.2 \u0026plusmn; 2.0 cm at 5 minutes.\u003c/p\u003e\n\u003cp\u003eTable 2: Clinical and physiological outcomes post-POEM in Thailand, Singapore, and Malaysia\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;Thailand\u003c/strong\u003e\u0026nbsp; (n=127)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSingapore\u003c/strong\u003e (n=58)\u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMalaysia\u0026nbsp;\u003c/strong\u003e(n=65) \u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEckardt Scores\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eBaseline (mean\u0026plusmn;SD)\u003c/p\u003e\n \u003cp\u003ePost-POEM\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eClinical success (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6.5\u0026plusmn;2.2\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e2.4\u0026plusmn;2.7\u003csup\u003e*\u003c/sup\u003e(6\u0026nbsp;mo)\u003c/p\u003e\n \u003cp\u003e89.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6.09\u0026plusmn;2.43\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e1.16\u0026plusmn;1.70\u003csup\u003e*\u003c/sup\u003e(12 mo)\u003c/p\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e7.9\u0026plusmn;2.5\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e1.1\u0026plusmn;1.9\u003csup\u003e*\u003c/sup\u003e(2 mo)\u003c/p\u003e\n \u003cp\u003e93.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntegrated relaxation pressure (IRP)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003ePre-POEM (mmHg)\u003c/p\u003e\n \u003cp\u003ePost-POEM (mmHg)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e34.30 \u0026plusmn; 15.53*\u003c/p\u003e\n \u003cp\u003e26.24\u0026plusmn;8.48*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e23.5\u0026plusmn;33.1\u003csup\u003e*\u003c/sup\u003e\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e13.4\u0026plusmn;7.71\u003csup\u003e*\u003c/sup\u003e\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003cp\u003eNR\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTimed barium esophagogram (TBE)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eHeight of barium at 5 minutes\u003c/p\u003e\n \u003cp\u003ePre-POEM (cm)\u003c/p\u003e\n \u003cp\u003ePost-POEM (cm)\u003c/p\u003e\n \u003cp\u003eWidth at 5 minutes\u003c/p\u003e\n \u003cp\u003ePre-POEM (cm)\u003c/p\u003e\n \u003cp\u003ePost-POEM (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11.9\u0026plusmn;6.1\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003e6.9 \u0026plusmn; 4.1*\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4.2\u0026plusmn;2**\u003c/p\u003e\n \u003cp\u003e3.5\u0026plusmn;2.4**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003cp\u003eNR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-procedure reflux\u003c/strong\u003e after 2-12 months (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e23.1 (6 mo)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e43.1 (12 mo)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e37 (2 mo)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003eP-value \u0026lt; 0.01, \u003csup\u003e**\u003c/sup\u003eP-value \u0026lt; 0.05\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eValues are mean \u0026plusmn; SD unless otherwise stated. NR = not reported. Follow-up durations vary across cohorts: Thailand (6 months), Singapore (12 months), and Malaysia (2 months).\u003c/p\u003e\n\u003cp\u003eAcross all cohorts, POEM resulted in a significant improvement in symptoms. In Thai patients, the mean Eckardt scores decreased from 6.5 \u0026plusmn; 2.2 to 2.4 \u0026plusmn; 2.7 (p \u0026lt; 0.01), the IRP from 34.3 \u0026plusmn; 15.5 to 26.2 \u0026plusmn; 8.5 mmHg (p \u0026lt; 0.01), and the TBE height from 11.9 \u0026plusmn; 6.1 to 6.9 \u0026plusmn; 4.1 cm (p \u0026lt; 0.01). Clinical success was achieved in 89.9%, 93.0%, and 93.4% of Thai, Singaporean, and Malaysian patients, respectively. Post-POEM reflux was reported in 23.1% (Thailand), 43.1% (Singapore), and 37.0% (Malaysia).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePeroral endoscopic myotomy (POEM) has firmly established itself as a standard therapeutic option for achalasia, demonstrating high efficacy and safety across diverse populations. In this first regionally integrated ASEAN analysis, POEM yielded consistent symptomatic and physiological improvements among patients from Thailand, Singapore, and Malaysia. Clinical success rates exceeded 89% in all cohorts, aligning with benchmarks set by large-scale studies in East Asia and Western countries \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan additionalcitationids=\"CR19 CR20 CR21\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Consequently, this study provides a crucial dataset validating the real-world effectiveness of POEM within the specific healthcare context of Southeast Asia.\u003c/p\u003e \u003cp\u003eComparison with global and regional benchmarks\u003c/p\u003e \u003cp\u003eOur findings corroborate prior meta-analyses showing that POEM achieves symptom control in more than 90% of achalasia cases \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Specifically, POEM proved to be a highly effective treatment for the Thai population, with outcomes comparable to those reported in Singapore and Malaysia. Interestingly, demographic heterogeneity was observed across the region; Thai and Malaysian patients were generally younger than their Singaporean counterparts. This discrepancy may reflect variations in healthcare systems, referral pathways, or potentially distinct disease phenotypes in different ethnic groups, warranting further epidemiological investigation.\u003c/p\u003e \u003cp\u003ePost-procedural Reflux\u003c/p\u003e \u003cp\u003eReflux was observed in 23.1% of Thai patients, which is lower than in Singapore (43.1%) and Malaysia (37%). These differences likely reflect heterogeneity in follow-up duration and diagnostic methods\u0026mdash;particularly whether reflux was defined symptomatically or by pH-impedance testing. Additionally, temporal factors may play a role; as the Singaporean and Malaysian cohorts represent earlier experiences, their higher reflux rates may partially reflect the initial learning curve phase of POEM implementation. Previous prospective studies have demonstrated reflux rates ranging from 30% to 50% when objective pH testing is applied \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Therefore, standardized reflux assessment and consistent reporting of PPI use will be essential in future ASEAN studies to better quantify this adverse outcome.\u003c/p\u003e \u003cp\u003eRegional Gaps and Future Directions\u003c/p\u003e \u003cp\u003eThis study adds pivotal data to the limited literature on POEM outcomes in Southeast Asia. The absence of published studies from countries such as Indonesia, Vietnam, and the Philippines underscores the need for greater regional collaboration and multicenter registries. Differences in healthcare systems, specialist training, and access to diagnostic tools such as manometry likely contribute to the current evidence gaps. Reducing these disparities will be crucial for improving achalasia management across ASEAN.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eSeveral limitations should be acknowledged. First, the retrospective design and reliance on published aggregate data may have introduced selection and reporting biases. Second, heterogeneity in follow-up duration, particularly the short two-month follow-up in the Malaysian cohort, limited direct comparison of long-term outcomes. Third, the conversion of medians or ranges into estimated means and standard deviations, though necessary for pooled analysis, may have reduced precision relative to patient-level data. Statistical comparisons were performed using estimated means derived from reported medians, which serves as an exploratory comparison rather than a direct patient-level meta-analysis. Fourth, physiological outcome data (TBE and HRM) were unavailable for several external cohorts. Finally, the maximum follow-up across all cohorts did not exceed one year, precluding evaluation of long-term durability. Despite these limitations, this study provides valuable insight into the performance of POEM across an understudied region and establishes a foundation for collaborative ASEAN registries.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e POEM is a safe and effective therapeutic option for achalasia in Thailand, demonstrating clinical outcomes comparable to regional benchmarks in Singapore and Malaysia. As the first regionally integrated analysis, these findings highlight the importance of harmonizing outcome reporting and fostering collaborative research efforts in Southeast Asia to ensure equitable access to high-quality care. Future prospective, longitudinal studies incorporating standardized reflux evaluation (e.g., pH impedance monitoring) will be essential to validate long-term efficacy, optimize patient selection, and minimize adverse effects such as post-POEM reflux.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting Interests\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eDeclarations\u003c/h2\u003e \u003cp\u003eof Generative AI and AI-assisted technologies in the writing process. During the preparation of this work, the author(s) used Gemini (Google) to improve language and readability. After using this tool/service, the author(s) reviewed and edited the content as needed and take full responsibility for the content of the publication.\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eN.I. conceived and designed the study, collected and analyzed the data, and drafted the manuscript.P้h.B. performed the statistical analysis and data validation.S.C., B.P., S.S., Pa.B., A.W. and N.A. supervised the project and provided critical revision of the manuscript for important intellectual content.R.K.V. provided critical revision and important intellectual input.All authors reviewed and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThis study was supported by the Thailand Science Research and Innovation Fundamental Fund 2025, the Gastroenterological Association of Thailand (GAT), and the Center of Excellence in Digestive Diseases, Thammasat University.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to ethical and privacy restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLee, K. et al. Global trends in incidence and prevalence of achalasia, 1925\u0026ndash;2021: A systematic review and meta-analysis. \u003cem\u003eUnited Eur. Gastroenterol. J.\u003c/em\u003e \u003cb\u003e12\u003c/b\u003e, 504\u0026ndash;515. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ueg2.12555\u003c/span\u003e\u003cspan address=\"10.1002/ueg2.12555\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaezi, M. F., Pandolfino, J. E., Yadlapati, R. H., Greer, K. B. \u0026amp; Kavitt, R. T. ACG Clinical Guidelines: Diagnosis and Management of Achalasia. \u003cem\u003eAm. J. Gastroenterol.\u003c/em\u003e \u003cb\u003e115\u003c/b\u003e, 1393\u0026ndash;1411. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.14309/ajg.0000000000000731\u003c/span\u003e\u003cspan address=\"10.14309/ajg.0000000000000731\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJung, H. K. et al. Seoul Consensus on Esophageal Achalasia Guidelines. \u003cem\u003eJournal of neurogastroenterology and motility\u003c/em\u003e 26, 180\u0026ndash;203, (2019). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5056/jnm20014\u003c/span\u003e\u003cspan address=\"10.5056/jnm20014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOude Nijhuis, R. A. B. et al. European guidelines on achalasia: United European Gastroenterology and European Society of Neurogastroenterology and Motility recommendations. \u003cem\u003eUnited Eur. Gastroenterol. J.\u003c/em\u003e \u003cb\u003e8\u003c/b\u003e, 13\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/2050640620903213\u003c/span\u003e\u003cspan address=\"10.1177/2050640620903213\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInoue, H. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. \u003cem\u003eEndoscopy\u003c/em\u003e \u003cb\u003e42\u003c/b\u003e, 265\u0026ndash;271. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-0029-1244080\u003c/span\u003e\u003cspan address=\"10.1055/s-0029-1244080\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2010).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndolfi, C. \u0026amp; Fisichella, P. M. Meta-analysis of clinical outcome after treatment for achalasia based on manometric subtypes. \u003cem\u003eBr. J. Surg.\u003c/em\u003e \u003cb\u003e106\u003c/b\u003e, 332\u0026ndash;341. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/bjs.11049\u003c/span\u003e\u003cspan address=\"10.1002/bjs.11049\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim, W. H. et al. Comparison of the Outcomes of Peroral Endoscopic Myotomy for Achalasia According to Manometric Subtype. \u003cem\u003eGut liver\u003c/em\u003e. \u003cb\u003e11\u003c/b\u003e, 642\u0026ndash;647. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5009/gnl16545\u003c/span\u003e\u003cspan address=\"10.5009/gnl16545\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2017).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKohn, G. P. et al. SAGES guidelines for the use of peroral endoscopic myotomy (POEM) for the treatment of achalasia. \u003cem\u003eSurg. Endosc.\u003c/em\u003e \u003cb\u003e35\u003c/b\u003e, 1931\u0026ndash;1948. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-020-08282-0\u003c/span\u003e\u003cspan address=\"10.1007/s00464-020-08282-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang, D., Bechara, R., Dunst, C. M. \u0026amp; Konda, V. J. A. AGA Clinical Practice Update on Advances in Per-Oral Endoscopic Myotomy (POEM) and Remaining Questions-What We Have Learned in the Past Decade: Expert Review. \u003cem\u003eGastroenterology\u003c/em\u003e \u003cb\u003e167\u003c/b\u003e, 1483\u0026ndash;1490. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/j.gastro.2024.08.038\u003c/span\u003e\u003cspan address=\"10.1053/j.gastro.2024.08.038\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCalabrese, E. C. et al. 2024 Update to SAGES guidelines for the use of peroral endoscopic myotomy (POEM) in the treatment of achalasia. \u003cem\u003eSurg. Endosc.\u003c/em\u003e \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-025-11789-z\u003c/span\u003e\u003cspan address=\"10.1007/s00464-025-11789-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2025).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhashab, M. A. et al. ASGE guideline on the management of achalasia. \u003cem\u003eGastrointest. Endosc.\u003c/em\u003e \u003cb\u003e91\u003c/b\u003e, 213\u0026ndash;227e216. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.gie.2019.04.231\u003c/span\u003e\u003cspan address=\"10.1016/j.gie.2019.04.231\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKasapoglu, M., Noor Us Saba, S., Hashemi, A., Panchal, M. \u0026amp; Khan, S. Comparative Effectiveness of Peroral Endoscopic Myotomy (POEM) Versus Traditional Treatment Modalities for Achalasia: A Systematic Review. \u003cem\u003eCureus\u003c/em\u003e \u003cb\u003e16\u003c/b\u003e, e71917. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.71917\u003c/span\u003e\u003cspan address=\"10.7759/cureus.71917\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDirks, R. C. et al. Is peroral endoscopic myotomy (POEM) more effective than pneumatic dilation and Heller myotomy? A systematic review and meta-analysis. \u003cem\u003eSurg. Endosc.\u003c/em\u003e \u003cb\u003e35\u003c/b\u003e, 1949\u0026ndash;1962. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-021-08353-w\u003c/span\u003e\u003cspan address=\"10.1007/s00464-021-08353-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSuwatthanarak, T. et al. Timed barium esophagography to predict recurrent achalasia after peroral endoscopic myotomy: a retrospective study in Thailand. \u003cem\u003eClin. endoscopy\u003c/em\u003e. \u003cb\u003e57\u003c/b\u003e, 610\u0026ndash;619. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5946/ce.2023.236\u003c/span\u003e\u003cspan address=\"10.5946/ce.2023.236\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2024).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaohavichitra, K., Wannaprasert, J. \u0026amp; Ratanachu-ek, T. Outcomes of per-oral endoscopic myotomy in the treatment of esophageal achalasia: over one hundred cases in a single tertiary center. \u003cem\u003eSiriraj Med. J.\u003c/em\u003e \u003cb\u003e75\u003c/b\u003e, 629\u0026ndash;637. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.33192/smj.v75i9.263612\u003c/span\u003e\u003cspan address=\"10.33192/smj.v75i9.263612\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTeh, J. L. et al. Gastro-esophageal reflux disease (GERD) after peroral endoscopic myotomy (POEM). \u003cem\u003eSurg. Endosc.\u003c/em\u003e \u003cb\u003e36\u003c/b\u003e, 3308\u0026ndash;3316. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-021-08644-2\u003c/span\u003e\u003cspan address=\"10.1007/s00464-021-08644-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHo, S. H., Nik Arsyad, N. M. A., Lau, P. C., Jamaludin, F. H. \u0026amp; Mahadeva, S. Acquiring new complex endoscopic skills: Experience from the development of peroral endoscopic myotomy (POEM) in Malaysia. \u003cem\u003eJGH open: open. access. J. Gastroenterol. Hepatol.\u003c/em\u003e \u003cb\u003e5\u003c/b\u003e, 729\u0026ndash;733. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jgh3.12598\u003c/span\u003e\u003cspan address=\"10.1002/jgh3.12598\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampagna, R. A. J. et al. Outcomes of 100 Patients More Than 4 Years After POEM for Achalasia. \u003cem\u003eAnn. Surg.\u003c/em\u003e \u003cb\u003e273\u003c/b\u003e, 1135\u0026ndash;1140. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/sla.0000000000004830\u003c/span\u003e\u003cspan address=\"10.1097/sla.0000000000004830\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrewer Gutierrez, O. I. et al. Long-term outcomes of per-oral endoscopic myotomy in achalasia patients with a minimum follow-up of 4 years: a multicenter study. \u003cem\u003eEndoscopy Int. open.\u003c/em\u003e \u003cb\u003e8\u003c/b\u003e, E650\u0026ndash;e655. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/a-1120-8125\u003c/span\u003e\u003cspan address=\"10.1055/a-1120-8125\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGu, L. et al. Safety and efficacy of peroral endoscopic myotomy with standard myotomy versus short myotomy for treatment-na\u0026iuml;ve patients with type II achalasia: a prospective randomized trial. \u003cem\u003eGastrointest. Endosc.\u003c/em\u003e \u003cb\u003e93\u003c/b\u003e, 1304\u0026ndash;1312. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.gie.2020.10.006\u003c/span\u003e\u003cspan address=\"10.1016/j.gie.2020.10.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShiwaku, H. et al. Peroral endoscopic myotomy for achalasia: a prospective multicenter study in Japan. \u003cem\u003eGastrointestinal endoscopy\u003c/em\u003e 91, 1037\u0026ndash;1044.e1032, (2020). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.gie.2019.11.020\u003c/span\u003e\u003cspan address=\"10.1016/j.gie.2019.11.020\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShieh, T. Y. et al. Clinical efficacy and safety of peroral endoscopic myotomy for esophageal achalasia: A multicenter study in Taiwan. \u003cem\u003eJ. Formos. Med. Association = Taiwan. yi zhi\u003c/em\u003e. \u003cb\u003e121\u003c/b\u003e, 1123\u0026ndash;1132. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jfma.2021.10.016\u003c/span\u003e\u003cspan address=\"10.1016/j.jfma.2021.10.016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShiwaku, H. et al. A prospective analysis of GERD after POEM on anterior myotomy. \u003cem\u003eSurg. Endosc.\u003c/em\u003e \u003cb\u003e30\u003c/b\u003e, 2496\u0026ndash;2504. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-015-4507-0\u003c/span\u003e\u003cspan address=\"10.1007/s00464-015-4507-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2016).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8715024/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8715024/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePeroral endoscopic myotomy (POEM) is an established therapy for achalasia, but data from Southeast Asia remain limited. We evaluated the clinical and physiological outcomes of POEM in Thai patients and compared them with regional cohorts from Singapore and Malaysia. We analyzed a pooled Thai cohort of 127 patients who underwent POEM between 2014 and 2024 and compared outcomes with published cohorts from Singapore (n\u0026thinsp;=\u0026thinsp;58) and Malaysia (n\u0026thinsp;=\u0026thinsp;65). Clinical success was defined as an Eckardt score\u0026thinsp;\u0026le;\u0026thinsp;3 during the follow-up period. A total of 250 patients were included. Clinical success was achieved in 89.9%, 93.0%, and 93.4% of patients in Thailand, Singapore, and Malaysia, respectively. In the Thai cohort, significant improvements were observed in Eckardt scores, integrated relaxation pressure, and timed barium esophagogram parameters (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Post-POEM reflux occurred in 23.1% of Thai, 43.1% of Singaporean, and 37.0% of Malaysian patients. POEM is a safe and effective treatment for achalasia in Thailand, with clinical outcomes comparable to regional benchmarks. Differences in reflux rates suggest potential heterogeneity in practice and follow-up, highlighting the need for standardized regional protocols.\u003c/p\u003e","manuscriptTitle":"Clinical and Physiological Outcomes of Peroral Endoscopic Myotomy in Southeast Asia: A Regional Pooled Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-10 11:54:39","doi":"10.21203/rs.3.rs-8715024/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-08T05:50:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-31T15:58:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"116007186274022199828379665581766280948","date":"2026-03-11T04:33:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-11T08:56:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"274300703031726569443350227879208964434","date":"2026-02-06T01:57:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-04T14:44:56+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-02T17:25:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-30T12:51:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-30T12:50:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2026-01-28T00:55:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cbb7b9ff-6b11-4377-8324-9c74b8fea13d","owner":[],"postedDate":"February 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":62505290,"name":"Health sciences/Diseases"},{"id":62505291,"name":"Health sciences/Gastroenterology"},{"id":62505292,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-05-11T06:09:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-10 11:54:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8715024","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8715024","identity":"rs-8715024","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}