Management of Recurrent Dysphagia after POEM and Heller Myotomy: Current Strategies and Future Directions

Dysphagia recurrence after myotomy for achalasia presents a complex clinical challenge. This review highlights causes of recurrent dysphagia, diagnostic strategies, and management options following laparoscopic Heller myotomy (LHM) or per-oral endoscopic myotomy (POEM). Both POEM and LHM demonstrate durable efficacy, but recurrence arises from incomplete myotomy, blown-out myotomy (BOM), fundoplication-related obstruction, anatomic esophageal body abnormalities, esophageal dysmotility, or gastroesophageal reflux disease (GERD). In the diagnostic evaluation, functional lumen imaging probe (FLIP) and high-resolution manometry (HRM) provide complementary assessments of esophageal and esophagogastric junction dynamics, while timed barium esophagram (TBE) and endoscopy detect structural issues. Redo myotomy (POEM or LHM), pneumatic dilation (PD), and emerging techniques, such as per-oral plication of the esophagus (POPE), offer targeted therapy with favorable safety and symptom improvement. Recurrent dysphagia is multifactorial, requiring comprehensive esophageal evaluation. Advanced diagnostics and minimally invasive interventions expand therapeutic options, particularly in end-stage disease.