Swallowing problems after achalasia dilation: should you consider POEM?

Why treatment changed in the Yulin case

If you have confirmed achalasia and swallowing difficulties return after balloon dilation, peroral endoscopic myotomy (POEM) can be considered during reassessment. Previous dilation does not rule it out, but does not mean you must switch to it. The key is to establish whether the problem is continued tightness at the lower end of the esophagus, impaired emptying, reflux or another issue. The cause affects how much further muscle cutting could help.[2–5]

On June 5, 2026, 玉林市第二人民医院 (Yulin's second people's hospital) reported the treatment of a 49-year-old woman given the pseudonym Ms Zhang. Balloon dilation had relieved her symptoms, but they worsened again about 2 years later. By her admission in May 2026, even plain rice porridge was difficult to swallow. A barium study showed the 'bird-beak' appearance associated with achalasia.[1]

The hospital cited the limited effect of previous dilation and the patient and family's preference for minimally invasive treatment as factors behind choosing POEM. After assessment, she underwent the procedure; the report described smooth eating by postoperative day 4. It did not disclose the manometric subtype, long-term reflux findings or follow-up duration. This establishes only the reported improvement at that time, not another patient's long-term outcome or return-travel date.[1]

Why swallowing problems have returned

Little improvement from the outset is different from eating comfortably for two years and then deteriorating. The former calls for assessing whether the initial treatment was adequate; the latter also requires investigation of recurrence. The European UEG/ESNM guideline lists possible causes including an outlet that still fails to relax, post-treatment scarring, food retention from ineffective esophageal contractions, and gastroesophageal reflux. Recurrence does not automatically mean the lower outlet has tightened again.[5]

This changes the next step. If significant outlet resistance remains, comparing ways to reduce it further becomes a priority. If reflux or food retention is the main problem, difficulty eating alone does not establish that another myotomy will resolve it. Tests are needed to distinguish these situations.[5]

How reassessment guides treatment

A timed barium esophagram shows how well the esophagus empties over set intervals after swallowing barium. High-resolution manometry assesses contractions, relaxation of the lower sphincter and achalasia subtype. Endoscopy examines the lining and looks for narrowing or other obstruction. For recurrent symptoms, the European guideline recommends reassessment with a timed barium study, with manometry as appropriate, and consideration of repeat endoscopy. The AGA's 2024 expert advice also includes these tests in comprehensive assessment before POEM. An old endoscopy report cannot answer every question.[2,5,6]

After dilation, match treatment records with symptom changes: how many procedures you had, when improvement began, what you could eat and how long it lasted. Keep balloon specifications and procedural notes if recorded. Before assessment in China, use the medical-record preparation guide to organize existing information. The receiving doctor decides which additional tests are needed.

Comparing POEM with other options

Balloon dilation stretches the lower esophageal sphincter to reduce resistance and may need repeating. POEM enters through the mouth, creates a tunnel beneath the lining and cuts part of the muscle. There is no external incision, but there is an internal wound, and general anesthesia is usually required.[2,4]

The three approaches involve different trade-offs:

Repeat balloon dilation: this remains an option to discuss; having it once does not exclude it later. Review the degree and duration of previous improvement and the procedure record to discuss expectations and whether you accept the possibility of further interventions. Do not dismiss it solely because you have already tried it.[2,6]

POEM: endoscopic muscle cutting reduces outlet resistance, and previous dilation does not rule it out. For type III achalasia with spastic contractions, expert opinion in the updated SAGES guideline favors POEM. Recurrence itself does not establish type III; manometric classification is still needed.[3,4]

Laparoscopic Heller myotomy with fundoplication: this also cuts muscle, but through an abdominal approach, and can include an anti-reflux procedure. Its difference from POEM is not simply whether there is an external incision; it also includes whether an anti-reflux step is performed.[2,4]

For types I and II, the AGA's 2024 expert advice describes all three as effective treatments, with a shared decision based on disease characteristics, patient preferences and the center's expertise. The updated SAGES recommendation favoring POEM over balloon dilation in adults overall is conditional. It does not mean that recurrence after dilation always requires POEM.[3,6]

If avoiding repeated treatment matters greatly to you, include the possibility of further intervention in the comparison. If reflux and medication are major concerns, compare management after POEM with Heller myotomy plus an anti-reflux procedure. Both concerns are reasonable, but can lead to different preferences about the same option.[3,6]

Managing reflux after swallowing improves

Reducing resistance to food passage with POEM can also make it easier for stomach acid to enter the esophagus. Heller surgery often includes an anti-reflux procedure; standard POEM usually does not. Bleeding, injury to the esophageal lining and pneumothorax are also procedural risks. No external incision does not mean no surgical risk.[4]

Discuss acid-suppressing treatment and follow-up before the procedure. The AGA's 2024 expert advice says acid suppression should be strongly considered early after POEM and all patients should be monitored for gastroesophageal reflux. Persistent esophagitis or reflux-like symptoms despite medication require further investigation, rather than simply increasing medication yourself.[6]

Absence of heartburn does not exclude reflux injury. The updated SAGES guideline notes that significant reflux may be asymptomatic and endoscopic monitoring can be considered, although evidence on exact timing and schedules remains insufficient. Eating again is therefore only part of the outcome: follow-up also considers esophagitis, continued medication needs and changes in swallowing symptoms.[3,6]