This systematic review shows that Heller’s myotomy and peroral endoscopic myotomy (POEM) outperform botulinum toxin for long-term symptom relief in primary achalasia.

• At 5 years, Heller’s myotomy and POEM have a treatment success rate that is significantly greater than botulinum toxin (odds ratios of 6.39 and 6.33, respectively).
• Botulinum toxin showed less treatment success at one year (odds ratio of 0.10).
• Pneumatic dilatation resulted in higher lower esophageal sphincter pressure and greater abnormal acid exposure, indicating potential complications.

Patient selection should be individualized based on clinical factors and available expert techniques, as further high-quality trials are warranted.