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Peroral endoscopic myotomy (POEM) is an alternative to laparoscopic Heller myotomy (LHM) for treatment of achalasia. In the current randomized trial involving 221 patients, both POEM and LHM were very effective in achieving a primary endpoint of symptom-based dysphagia control at 2 years (83% and 82%, respectively). Manometry results and quality-of-life scores were not different between the groups. Patients undergoing POEM were more likely to have esophagitis at 3 months (57% vs. 20%) and at 2 years (44% vs. 29%) and, per a post hoc analysis, were more likely to be on proton-pump inhibitors (PPIs) at these follow-ups.