Background Peroral endoscopic myotomy (POEM) is con-sidered a primary treatment modality for achalasia. It canbe performed using either the anterior or posterior ap-proach. A previous randomized clinical trial (RCT) showedthat the posterior approach was noninferior to the anteriorapproach at 1 year post-POEM in terms of clinical success,rate of adverse event, and risk of gastroesophageal refluxdisease (GERD). The aim of this post-RCT study was to com-pare outcomes at ⥠2 years post-POEM.Methods Patients who previously completed the 1-yearfollow-up were contacted and their Eckardt, dysphagia,and GERD questionnaire (GERDQ) scores and frequency ofproton pump inhibitor use were recorded. Clinical successwas defined as an Eckardt score < 3.Results 150 patients were initially randomized and 138completed the 1-year follow-up. Of the 138, 111 (anteriorgroup 54, posterior group 57) also completed ⥠2 years offollow-up, with an overall clinical success decrease from89 % to 82 %. At ⥠2 years post-POEM, clinical success wasachieved in 46/54 (85 %) and 45/57 (79 %) in the anteriorand posterior groups, respectively (P = 0.43). A similardecrease in clinical success was noted in both groups at ⥠2years (anterior: 90 % to 85 %; posterior 89 % to 79 %; P =0.47). GERDQ score was 6 (interquartile range 6 â 8; P =0.08) in both treatment groups.Conclusions The anterior and posterior POEM techniquesremained equally effective at 2 years and decreases in effi-cacy were similar between the two approaches over time.GERD outcomes were also similar in both groups duringmedium-term follow-up.