rePOEM: Is it Safe and Effective to Repeat POEM in Achalasia After First Failure?
The short answer is yes. But as always, the devil is in the details: when? for whom? what are the risks? Let me walk you through the real data.
Repeating a POEM is technically feasible and clinically effective when properly indicated.
TL;DR (Quick Summary)
The key facts:
- • rePOEM (repeat POEM) works: over 80% success in patients without previous surgery.
- • Complications similar to first POEM: low and manageable.
- • Gastroesophageal reflux may occur, as with primary POEM.
When to consider it:
- • Symptoms return after initial POEM.
- • Incomplete myotomy or localized fibrosis.
- • Patients who responded well to the first POEM.
rePOEM: Is it safe and effective to repeat POEM in Achalasia after first failure? When a patient with achalasia improves after POEM but then symptoms return, one of the most distressing questions is: "Can I have the procedure again?" The good news is yes, and the results are promising. Let's break it down step by step, with data from studies in Asia, Europe, and America.
Quick Index
- • What is rePOEM and when is it considered?
- • Evidence from Asia: the 158-patient multicenter study
- • Evidence from Europe: long-term follow-up
- • American perspective: AGA recommendations
- • Complications: what to expect?
- • The gastroesophageal reflux issue
- • rePOEM vs other rescue options
- • When is rePOEM indicated?
- • What to do if your POEM "didn't work"
- • Quick FAQs
What is rePOEM and when is it considered?
rePOEM simply means "repeating the peroral endoscopic myotomy." In other words, doing a POEM again in a patient who already had one but whose symptoms have reappeared or never fully resolved.
Why might an initial POEM "fail"? The most common reasons are:
- Incomplete myotomy: not enough muscle was cut the first time.
- Fibrosis: muscle scarring that partially "closes" again.
- Type of achalasia: some subtypes (type III) respond worse long-term.
- Technical factors: anatomical difficulties during the first procedure.
The important thing is that "failure" doesn't mean the technique is bad. Even with the best procedures, there's a percentage of patients (around 10–20%) who need something more.1
Evidence from Asia: the multicenter study with 158 patients
Key finding from Asia
A retrospective multicenter Asian study with 158 patients undergoing rePOEM showed that procedure duration, adverse event incidence, and technical difficulty are similar to primary POEM.2
This is one of the largest studies on rePOEM to date. Researchers compared rePOEM with primary POEM and found:
Main findings:
- • Mucosal injuries: slightly more frequent in rePOEM (20.3%) vs primary POEM (13.9%), but not statistically significant.
- • Major complications: low and without significant differences between groups.
- • Technical risk factors: mucosal edema and submucosal fibrosis (more common after previous interventions).
- • Clinical success: comparable to primary POEM.
What does this mean in practice? That if you need a second POEM, it's not technically more dangerous than the first. It may be a bit more "difficult" due to fibrosis (scar tissue makes creating the submucosal tunnel more complex), but this doesn't translate to more serious complications.2
Evidence from Europe: long-term follow-up and patient satisfaction
In Europe, long-term follow-up series (up to 10 years in some centers like Denmark) show that rePOEM maintains a high clinical success rate: exceeding 80% in patients without previous surgical myotomy.1
A recent Danish study (2025) with 10-year follow-up after POEM and rePOEM reported:
European long-term results
- • Sustained clinical success: over 80% of patients without significant symptoms at 10 years.
- • Patient satisfaction: high (most would repeat the procedure).
- • Gastroesophageal reflux: present in up to 33% of cases long-term, but similar to primary POEM.
- • Serious complications: very low (pneumothorax, perforation or bleeding in <2%).
What's interesting about these data is that they demonstrate rePOEM is not just a "temporary patch." The results are maintained over time, which is crucial when we talk about quality of life.1
American perspective: AGA recommendations
The American Gastroenterological Association (AGA) recognizes in its most recent guidelines (2024) that POEM and its variants—including rePOEM—are effective and safe treatments for esophageal motility disorders.3
AGA message:
POEM is a first-line option for achalasia, and rePOEM is a viable and safe alternative when symptoms reappear after a first POEM. However, they note that more studies are needed on modified techniques and very long-term follow-up.3
In the United States, several reference centers have reported rePOEM success rates similar to Asian and European ones, with emphasis on the importance of appropriate patient selection and endoscopist experience.
If you want to learn more about the advanced endoscopy services we offer, including POEM and rePOEM, you can explore our specialized page.
rePOEM complications: what to expect?
Let's talk frankly about the risks. Because a "safe" procedure doesn't mean "without risks," it means the risks are low, predictable, and manageable.
Most frequent complications (but minor)
- Mucosal injuries: small "wounds" in the esophageal mucosa during the procedure. Occur in ~20% of rePOEM vs ~14% in primary POEM (non-significant difference). They are closed with clips during the same procedure.2
- Mild chest pain: common in the first 24–48h. Managed with usual analgesics.
- Transient fever: may appear due to local inflammation. Monitored and rarely needs antibiotics.
Major complications (rare but important)
Serious complications (very infrequent)
- • Pneumothorax (air in the chest): <2% of cases. Detected during the procedure and treated.
- • Significant bleeding: very rare (<1%). Almost always controlled endoscopically.
- • Perforation: exceptional in expert hands. Requires specific management (usually endoscopic).
International studies agree: the rate of major complications in rePOEM is low (similar to primary POEM) and does not increase significantly due to being a second procedure.12
The gastroesophageal reflux issue after rePOEM
Here we need to be honest: gastroesophageal reflux is the "price to pay" for any myotomy (surgical or endoscopic). By cutting the muscle that "closes" the esophagogastric junction to treat achalasia, we're also reducing the barrier against reflux.
Data on reflux after rePOEM:
- • Prevalence: up to 33% of patients long-term experience reflux symptoms.1
- • Endoscopic esophagitis: may exceed 40% in some series (similar to primary POEM).4
- • Management: most is controlled with proton pump inhibitors (PPIs) and endoscopic follow-up.
- • Anti-reflux surgery: rarely necessary after POEM/rePOEM.
What does this mean for you? That if you have rePOEM, there's a reasonable probability you'll need to take a stomach protector (omeprazole or similar) long-term, and have control endoscopies every 2–3 years to monitor the esophagus.
But note: most patients prefer to have reflux controlled with medication than continue with dysphagia. Quality of life improves much more by removing difficulty swallowing than by avoiding reflux.5
rePOEM vs other rescue options: which is better?
When a POEM "fails," there are several rescue options. The main ones are:
Rescue options after POEM failure:
- 1. Pneumatic balloon dilation: the sphincter is "opened" with pressure. Less invasive but with perforation risk (~1–2%) and lower long-term efficacy.
- 2. Laparoscopic Heller myotomy: classic surgery. More postoperative pain, slower recovery, but good reflux control if fundoplication is added.
- 3. rePOEM: repeat POEM. Minimally invasive, high efficacy, fast recovery, but reflux risk.
What does comparative evidence say?
Comparative studies show that:
- • Efficacy: rePOEM has success rates comparable to or higher than balloon dilation and similar to Heller myotomy.6
- • Complications: rePOEM has less pain and faster recovery than Heller, and lower perforation risk than pneumatic dilation.7
- • Reflux: more frequent after rePOEM than after Heller with fundoplication, but similar to dilation.4
- • Satisfaction: high in all techniques, but rePOEM stands out for minimal invasiveness.5
In summary: rePOEM is an excellent rescue option, especially in patients without previous surgery, with good initial response to the first POEM, and in centers with experience in the technique.
When is rePOEM indicated instead of other options?
Not all patients with symptoms after POEM are candidates for rePOEM. The decision is based on several factors:
Criteria to consider rePOEM:
- • Good initial response: the patient improved after the first POEM but symptoms reappeared.
- • Evidence of incomplete myotomy or localized fibrosis: seen on manometry or endoscopy.
- • No previous Heller-type surgery: anatomy is "cleaner" and rePOEM is technically simpler.
- • Motivated patient with realistic expectations: understands the risks (especially reflux) and benefits.
- • Center with experience: the learning curve is important in POEM and even more in rePOEM.
If you meet these criteria, rePOEM may be your best option. If not, other alternatives (dilation, Heller) may be more appropriate. The important thing is to evaluate each case individually.3
If your POEM didn't work as expected, we'll evaluate options together: rePOEM, dilation, or other alternatives.
What to do if your POEM "didn't work" (practical plan)
If you had a POEM and symptoms persist or have returned, don't despair. Here's a step-by-step plan:
5-Step Plan
- 1. Confirm there really is a problem: sometimes symptoms are reflux, not persistent achalasia. An endoscopy and manometry clarify this.
- 2. Review the initial POEM report: myotomy length, complications, findings. This guides the next step.
- 3. Rule out other causes: eosinophilic esophagitis, strictures, other motor diseases can mimic persistent achalasia.
- 4. Discuss options with an expert team: rePOEM, dilation, Heller… each case is unique.
- 5. Make an informed decision: with data, not fear. Know the risks and benefits of each option.
And remember: a procedure "not working" 100% doesn't mean you're a "lost case." It means you need an adjustment, and there are tools to achieve it.
If you need a second opinion or evaluation for rePOEM, you can book an appointment here. You can also read more about recommendations before and after POEM intervention.
Related readings that may help you
POEM for Achalasia: Before and After Recommendations
Everything you need to know to prepare and recover well.
Read article →
POEM for Achalasia After Failed Heller Surgery
What options you have when Heller surgery didn't work.
Read article →
Esophageal Achalasia: What It Is, Symptoms, and Treatments
Complete guide on achalasia for patients.
Read article →A personal touch (because this matters)
I've had the privilege of being part of teams that have performed hundreds of POEMs and rePOEMs. Each patient is different, and each case needs personalized evaluation. My job is to give you clear data, real options, and accompany you in the decision. There are no magic solutions, but there are good solutions.
Ready for an advanced endoscopy procedure at Hospital La Paz.
FAQ: Quick questions about rePOEM
What exactly is rePOEM?
rePOEM is repeating the peroral endoscopic myotomy (POEM) procedure in patients whose achalasia symptoms return or persist after the first POEM. It is a minimally invasive rescue procedure.
Is rePOEM as effective as the first POEM?
Yes. International evidence shows that rePOEM has clinical success rates comparable to primary POEM, exceeding 80% in patients without previous surgery, with similar long-term symptom control.12
Is it more dangerous to do a second POEM?
Not significantly. Major complications are low and similar to primary POEM. There may be slightly more mucosal injuries due to fibrosis, but without increasing the risk of serious complications.2
What about reflux after rePOEM?
Gastroesophageal reflux can occur in up to 33% of cases long-term, similar to primary POEM. It is usually managed with medical treatment (PPIs) and endoscopic follow-up every 2–3 years.1
When is rePOEM indicated instead of other options?
rePOEM is considered when symptoms reappear after initial POEM and there is evidence of incomplete myotomy or fibrosis. It is especially useful in patients without previous Heller surgery and with good initial response to the first POEM.3
How long should I wait between the first POEM and rePOEM?
There's no fixed time. It's evaluated based on clinical evolution, findings on endoscopy and manometry. Generally, at least 3–6 months is waited to allow complete healing and properly evaluate the response to the first procedure.
Is rePOEM better than balloon dilation after POEM failure?
It depends on the case. rePOEM has greater long-term efficacy in many studies, but dilation is less invasive. The decision is based on individual factors: anatomy, achalasia type, patient preferences, and center experience.6
Does health insurance cover rePOEM?
In most private insurance plans and Spanish public healthcare (when available), yes. It's important to check beforehand, as policies may vary by insurer and clinical indication.
Scientific references (clickable)
- Pedersen MH, Bjerregaard NC, Hvid-Jensen F, Kjaer DW. Peroral Endoscopic Myotomy: A Danish Single Center 10-Year Follow-Up Study. Surgical Endoscopy. 2025. PubMed: 39773327
- Ma LY, Guo KY, Liu ZQ, et al. Repeat Peroral Endoscopic Myotomy: Technical Difficulty and Risk Factors. Gastrointestinal Endoscopy. 2025. PubMed: 39551373
- Yang D, Bechara R, Dunst CM, Konda VJA. AGA Clinical Practice Update on Advances in Per-Oral Endoscopic Myotomy (POEM) and Remaining Questions—What We Have Learned in the Past Decade: Expert Review. Gastroenterology. 2024;166(5):815-827. PubMed: 38494033
- Ponds FA, Fockens P, Lei A, et al. Effect of Peroral Endoscopic Myotomy vs Pneumatic Dilation on Symptom Severity and Treatment Outcomes Among Treatment-Naive Patients With Achalasia: A Randomized Clinical Trial. JAMA. 2019;322(2):134-144. PubMed: 31305925
- 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;165(5):1264-1275. PubMed: 37532087
- Dirks RC, Kohn GP, Slater B, et al. Is Peroral Endoscopic Myotomy (POEM) More Effective Than Pneumatic Dilation and Heller Myotomy? A Systematic Review and Meta-Analysis. Surgical Endoscopy. 2021;35(5):2259-2271. PubMed: 32440747
- D'Angelo A, Pioche M, Barret M, et al. RedoPOEM: Efficacy and Safety After Failure of a First POEM for Esophageal Motility Disorders. Surgical Endoscopy. 2026 [Epub ahead of print]. PubMed: 39820536
- Zhang H, Pu X, Huang S, et al. Comparing Clinical Outcomes of Peroral Endoscopic Myotomy for Achalasia Between Eastern and Western Countries: A Systematic Review and Meta-Analysis. Diseases of the Esophagus. 2024;37(3):doae002. PubMed: 38305184
Your POEM didn't work as expected?
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