POEM for Achalasia Not Improved After Surgery?
A real second chance: How POEM treatment can solve your symptoms when Heller surgery didn't work as expected
POEM: An effective solution when traditional surgery hasn't delivered expected results
Quick Summary - What You Need to Know
✅ Hopeful Message:
- • If your symptoms persist after Heller surgery, you DO have options
- • POEM achieves improvement in 80-95% of patients with recurrent achalasia
- • It's a minimally invasive procedure with no external incisions
- • Most recent scientific studies confirm its effectiveness
🎯 Key POEM Data:
- • Clinical success: 80-95% significantly improve
- • Recovery: 2-3 days hospitalization
- • Superior to dilations: 62% vs 27% success
- • Follow-up: Long-term maintained results
If Heller surgery didn't work: There is an effective solution
I know exactly how you feel. You had surgery hoping to get better, but the symptoms came back or never really went away. The frustration is understandable. But I want you to know something important: there is an effective alternative that is changing the lives of many patients in your same situation. The POEM procedure has scientifically demonstrated that it can give you that second chance you need.
Why Can Heller Surgery Fail?
Before talking about solutions, it's important to understand what might have happened. Heller surgery (also called laparoscopic myotomy) has been the standard surgical treatment for achalasia for decades. It's a good procedure that helps many patients, but it doesn't always work perfectly.
What is achalasia? A quick reminder
Achalasia is a problem in the esophagus where the valve muscle connecting to the stomach (lower esophageal sphincter) doesn't relax properly. It's like having a door that won't open correctly, causing food to get stuck.
Typical symptoms include: difficulty swallowing (dysphagia), food regurgitation, chest pain, and weight loss.
Heller surgery attempts to solve this by surgically cutting the sphincter muscle fibers from outside the esophagus. But sometimes:
Technical issues
- • The surgical cut wasn't long enough
- • Scar tissue formed that narrowed again
- • The myotomy was incomplete in some area
- • The muscle closed back up over time
Patient factors
- • More difficult type of achalasia to treat (type III)
- • Very dilated or tortuous esophagus
- • Personal tendency to form fibrosis
- • Natural disease progression
What's important is this: It's not your fault, nor necessarily the surgeon's error. Sometimes the body simply doesn't respond as expected or the disease is more complex than usual.
What Exactly is POEM and Why Does It Work Better in These Cases?
POEM stands for "Peroral Endoscopic Myotomy." It sounds complicated, but let me explain it simply.
POEM explained simply
Imagine your esophagus is like a tube with layers, similar to a multi-layered garden hose. In POEM, we use an endoscope (a flexible tube with a camera) that enters through the mouth to the esophagus. Then:
- 1. We create a small entry in the inner layer of the esophagus
- 2. We move between the esophageal layers (like making a "tunnel")
- 3. We cut the problematic muscle fibers from inside
- 4. We close the entry with clips
All this without any external incision. Everything is done through the mouth, no cuts in the abdomen.
Why Does POEM Work When Heller Failed?
This is the key you need to understand. POEM has important advantages over traditional surgery, especially when you've already been operated on before:
Direct and precise vision
Unlike surgery done from outside, in POEM we directly see the muscle fibers we need to cut. This allows us to be much more precise and complete. If the previous surgery left areas uncut, POEM can identify and treat them.
Longer and customizable myotomy
With POEM we can make a longer myotomy (muscle cut) than in conventional surgery, adapting it exactly to what each patient needs. This is especially useful if you have type III achalasia or a very dilated esophagus.
Avoids scar tissue from previous surgery
When surgery is performed, adhesions and scars form on the outside of the esophagus that can make a second surgery difficult. POEM works from inside, so it can completely avoid these problematic areas, working on healthy tissue.
No abdominal incisions
Since everything is done by endoscopy (through the mouth), there are no external cuts, less postoperative pain, faster recovery, and lower risk of complications related to abdominal surgery.
The importance of specialist experience
POEM is an advanced technique that requires specialized training and significant experience. As an advanced endoscopy specialist, I completed my specific POEM training in Japan, the pioneering country in this technique, and regularly perform these procedures at Hospital Universitario La Paz.
Scientific studies demonstrate that the best results are obtained in centers with extensive POEM experience. The learning curve is important, and performing the procedure in experienced hands makes a significant difference in outcomes.
What Does Science Say? The Numbers You Should Know
It's not just my opinion or experience. There are multiple scientific studies published in the world's best medical journals that have specifically analyzed how POEM works in patients who have already been operated on with Heller surgery. Let's look at the real data:
Success rates: The numbers speak for themselves
Translation: Out of every 10 patients who undergo POEM after failed Heller surgery, between 8 and 9 experience significant symptom improvement that is maintained over time. This is scientifically proven in multiple independent studies.
Key Scientific Studies Supporting POEM
Randomized Clinical Trial (Saleh et al., Gastroenterology 2023)
This is the most important study to date: a randomized clinical trial (the highest level of scientific evidence) that compared POEM vs pneumatic dilation as rescue treatment after Heller.
Results at one year follow-up:
- • POEM: 62% success (significant symptom improvement)
- • Dilation: 27% success
- • Conclusion: POEM is superior as rescue treatment
Meta-analysis of Multiple Studies (Huang et al., GIE 2021)
This study jointly analyzed all published studies on POEM in patients with prior Heller, including data from hundreds of patients from different countries.
Main findings:
- • Overall clinical success rate: 89%
- • Significant improvement in Eckardt score
- • Low rate of serious complications (< 3%)
- • Procedure is feasible and safe in experienced hands
Long-term Follow-up (Nabi et al., J Gastroenterol Hepatol 2023)
A crucial aspect: Are results maintained over time? This study followed patients for a median of 5 years after POEM following failed Heller.
5-year results:
- • Symptom improvement is maintained over time
- • Benefits are not lost over the years
- • Most patients continue to do well
- • Durable and consistent results
What does all this mean for you?
That we're not talking about an experimental technique or anecdotal results. POEM for achalasia after Heller surgery is a treatment backed by solid scientific evidence, with studies published in the best medical journals, consistently demonstrating its effectiveness, safety, and durability. You have real reasons to have hope.
Have achalasia symptoms returned after your surgery?
As an expert in POEM for achalasia, I can evaluate your specific case and determine if you're a candidate for this effective rescue treatment.
Book an AppointmentReal Testimony: A Patient's Experience After POEM
Our patients' words are more powerful than any statistic. Below you can watch the testimony of a patient who underwent the POEM procedure and shares their experience:
Why these testimonies matter
Seeing and hearing real people who have been through the same thing as you helps us understand that behind the statistics and scientific studies are real people who have recovered their quality of life. You're not alone in this.
What is the Procedure Like? From Start to Finish
I understand that when facing a new treatment you want to know exactly what will happen. Let me explain step by step what the complete process is like:
Evaluation and preoperative preparation
Before the procedure we perform a complete evaluation that includes:
- • Detailed medical consultation to review your medical history
- • Upper digestive endoscopy to assess current esophageal status
- • Esophageal manometry (measuring esophageal pressures)
- • Routine blood tests
- • Detailed procedure explanation and doubt resolution
The day of the POEM procedure
POEM is performed in the operating room under general anesthesia (you'll be completely asleep and pain-free):
- • Duration: Usually 1-2 hours depending on complexity
- • A flexible endoscope is introduced through the mouth to the esophagus
- • We create a tunnel between the esophageal layers
- • We cut the problematic muscle fibers
- • We close the tunnel entrance with endoscopic clips
- • All without external incisions
Immediate postoperative recovery
After the procedure:
- • Wake up in the recovery room
- • Observation for 24-48 hours in the hospital
- • Liquid diet the next day if all goes well
- • Gradual progression to soft and normal diet in following days
- • Hospital discharge usually at 2-3 days
- • Mild discomfort controllable with usual painkillers
Medium and long-term follow-up
After discharge we continue monitoring your progress:
- • Follow-up consultation 2-4 weeks after discharge
- • Control endoscopy at 3-6 months
- • Evaluation of reflux symptoms
- • Treatment with proton pump inhibitors (omeprazole)
- • Annual long-term follow-up
When will I notice improvement?
Most patients notice improvement in dysphagia (difficulty swallowing) very quickly, even in the first days after the procedure. Complete improvement and symptom stabilization usually occurs in the first weeks. It's important to follow the dietary and medication instructions we will provide.
Important Aspects You Should Know
As a physician, my obligation is to be completely honest with you about all aspects of the treatment, including possible complications and special considerations:
The issue of gastroesophageal reflux
A side effect to monitor: Reflux
Honesty is fundamental here: After POEM, there is an increased risk of developing gastroesophageal reflux (when stomach acid rises to the esophagus). This occurs because by relaxing the tight achalasia muscle, we also reduce part of the mechanism that prevents reflux.
Data on reflux after POEM:
- • Between 30-50% of patients may develop reflux esophagitis
- • Most are mild to moderate cases
- • It's well controlled with medication (proton pump inhibitors)
- • Some patients already have prior reflux from previous surgery
- • If you had fundoplication (anti-reflux technique) in Heller surgery, it may reduce this risk
What's important: This possible side effect does NOT cancel the benefits of POEM. For the vast majority of patients, it's much better to be able to eat without choking even if they need to take a daily pill for reflux, than to continue with the disabling dysphagia of achalasia.
Reflux management and prevention
Strategies we use:
During the procedure:
- • Preserve the anti-reflux mechanism as much as possible
- • Adjust the length of the myotomy
- • Meticulous surgical technique
After the procedure:
- • Treatment with omeprazole or other protectors
- • Surveillance endoscopies
- • Hygienic-dietary measures
- • Medication adjustment according to symptoms
Factors that can affect POEM success
Scientific evidence has taught us that some factors can make POEM more challenging or influence results:
Presence of fibrosis or scars
Previous surgery may have caused tissue scarring. This can make creating the submucosal tunnel more difficult, but in experienced hands it remains completely feasible. It may slightly lengthen the procedure time.
Previous fundoplication
If your Heller surgery also included fundoplication (anti-reflux technique), this can modify the anatomy. Studies show that POEM remains effective, although it may require a slightly different technical approach.
Type of achalasia
Patients with type III achalasia (spastic) may have slightly less predictable results, but they still benefit from POEM. Type I and II achalasia usually respond especially well.
Degree of esophageal dilation
If your esophagus is very dilated (megaesophagus), results may be somewhat less favorable than in cases without severe dilation. Even so, POEM offers a real opportunity for symptom improvement.
Personalized evaluation is key
Each patient is unique. That's why individualized evaluation is fundamental to determine if POEM is the best option in your specific case, considering all these factors along with your complete medical history, your expectations, and your personal situation.
Why Consider POEM in Your Situation?
If you've made it this far in the reading, you're probably wondering: "Is POEM really for me?" Let me summarize the main reasons why POEM is currently considered the treatment of choice when Heller surgery hasn't worked:
Scientifically proven efficacy
It's not an experimental technique. It's backed by high-level studies, including randomized clinical trials, with 80-95% success rates. It's real evidence-based medicine.
Minimally invasive
No abdominal incisions, no major surgery, much faster recovery than a new operation. Lower risk of complications related to open or laparoscopic surgery.
Superior precision
Direct vision of the muscle fibers we need to cut. We can see exactly what was left untreated in the previous surgery and complete the work precisely.
Lasting results
Long-term follow-up studies (5 years) demonstrate that improvement is maintained over time. It's not temporary relief, but a lasting solution for most patients.
Favorable safety profile
Very low rate of serious complications (< 3%). The most common side effects (like reflux) are manageable with medication. Very favorable risk-benefit balance.
Quality of life improvement
In the end, what matters: being able to eat without fear, enjoying social meals, not feeling anxiety with every bite. POEM restores these simple but essential things in life.
A real and effective second chance
If your Heller surgery didn't work or symptoms have returned, POEM offers you a real second chance to recover your quality of life. It's not just theory or hope: it's a reality backed by solid science and proven clinical experience in patients like you.
Want to know if POEM can help you?
As a specialist in advanced endoscopy with specific POEM experience, I can evaluate your case and offer you personalized expert opinion.
Book an AppointmentFrequently Asked Questions from My Patients
How long will I need to stay in the hospital?
Usually 1 day. The procedure is done in one day, we observe you that night and the next day, if all goes well, you go home with progressive soft diet.
Does POEM hurt?
During the procedure you don't feel anything because you're under general anesthesia. Afterward, some chest discomfort or mild pain is normal in the first days, but it's well controlled with usual painkillers. It's not comparable to the pain of abdominal surgery.
When can I eat normally again?
Progressively. We start with liquids the next day, then soft diet, and usually within 1-2 weeks you can start incorporating more normal foods. We'll give you specific dietary instructions.
Is it possible it could fail again like the previous surgery?
No medical treatment guarantees 100% success, but studies show that POEM has very high long-term success rates (80-95%) and results are maintained over time. It's significantly superior to other alternatives like dilations.
Will I have reflux forever?
Not all patients develop problematic reflux. If it appears, it's usually manageable with medication (omeprazole or similar). For the vast majority, it's a small price to pay for being able to eat without choking again.
When can I return to work?
It depends on your type of work. For office or sedentary jobs, usually 1-2 weeks. For more demanding physical work, it may be 3-4 weeks. We'll give you specific recommendations for your case.
Is this procedure covered by health insurance?
POEM is a recognized and established procedure for achalasia treatment. However up to this day most health insurances do not cover it. We can help you verify coverage with your specific insurance.
Final Message: You're Not Out of Options
There is real and grounded hope
If your Heller surgery didn't work as expected, I perfectly understand your frustration and possible discouragement. But I want you to take this message with you: You're not out of options. POEM represents an effective, scientifically proven solution that is restoring quality of life to patients in your same situation.
The numbers speak for themselves: 8-9 out of every 10 patients who undergo POEM after Heller failure experience significant improvement. These aren't empty promises, they're results published in the world's best medical journals.
You deserve to be able to eat without fear, enjoy a family meal, travel without anxiety. POEM can help you recover these simple but fundamental things in life.
My experience in POEM
As an advanced endoscopy specialist, I completed my POEM training in Japan, the pioneering country in this technique, and have performed numerous procedures at Hospital Universitario La Paz, including complex cases of recurrent achalasia after surgery.
I've seen firsthand how patients who had disabling symptoms for years have recovered their normal life. That's the motivation that drives me every day: giving people back the ability to enjoy something as basic as eating without suffering.
The first step: A consultation
If you identify with this situation, I invite you to talk. In a consultation we can review your medical history, understand exactly what happened with your previous surgery, evaluate if you're a candidate for POEM, and resolve all your doubts. There's no commitment, just honest and professional information so you can make the best decision for yourself.
Scientific References
- 1. Huang Z, Cui Y, Li Y, Chen M, Xing X. Peroral Endoscopic Myotomy for Patients With Achalasia With Previous Heller Myotomy: A Systematic Review and Meta-Analysis. Gastrointestinal Endoscopy. 2021;93(1):47-56.e5. doi:10.1016/j.gie.2020.05.056
- 2. Saleh CMG, Familiari P, Bastiaansen BAJ, et al. The Efficacy of Peroral Endoscopic Myotomy vs Pneumatic Dilation as Treatment for Patients With Achalasia Suffering From Persistent or Recurrent Symptoms After Laparoscopic Heller Myotomy: A Randomized Clinical Trial. Gastroenterology. 2023;164(7):1108-1118.e3. doi:10.1053/j.gastro.2023.02.048
- 3. Nabi Z, Ramchandani M, Basha J, et al. Per-Oral Endoscopic Myotomy in Cases With Prior Heller's Myotomy: Outcomes at a Median Follow-Up of 5 years. Journal of Gastroenterology and Hepatology. 2023;38(11):2035-2039. doi:10.1111/jgh.16320
- 4. Zhang X, Modayil RJ, Friedel D, et al. Per-Oral Endoscopic Myotomy in Patients With or Without Prior Heller's Myotomy: Comparing Long-Term Outcomes in a Large U.S. Single-Center Cohort. Gastrointestinal Endoscopy. 2018;87(4):972-985. doi:10.1016/j.gie.2017.10.039
- 5. Ngamruengphong S, Inoue H, Ujiki MB, et al. Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy. Clinical Gastroenterology and Hepatology. 2017;15(10):1531-1537.e3. doi:10.1016/j.cgh.2017.01.031
- 6. Zhang ZC, Xu JQ, Liu XY, et al. Salvage Peroral Endoscopic Myotomy Is a Promising Treatment for Achalasia After Myotomy Failure. Gastrointestinal Endoscopy. 2023;98(4):543-551.e1. doi:10.1016/j.gie.2023.04.2093
- 7. Conner A, Jain N, Barron J, et al. When the Gold Standard Fails: Propensity-Matched Comparison of Peroral Endoscopic Myotomy After Heller Myotomy vs. Index Peroral Endoscopic Myotomy. The Journal of Thoracic and Cardiovascular Surgery. 2025. doi:10.1016/j.jtcvs.2025.10.012
- 8. DeWitt J, Stainko S, Perkins A, Rosenheck M, Al-Haddad M. Impact of Prior Endoscopic or Surgical Interventions on Clinical Outcomes After Peroral Endoscopic Myotomy for Achalasia. Surgical Endoscopy. 2025. doi:10.1007/s00464-025-12258-3
Dr. Pedro de María Pallarés
Digestive Disease Specialist • Advanced Endoscopy Expert
Hospital Universitario La Paz • INMEQ
🏆 TopDoctors Awards 2024 • Member SEPD, SEED, ESGE