POEM is the endoscopic equivalent of surgical myotomy and a newer technique for the management of achalasia.1 POEM utilizes the principles of submucosal endoscopy to transform the submucosal layer in the esophagus and proximal stomach into a tunnel through which esophageal and gastric myotomy are carried out using a flexible endoscope.1 Given previous TBE studies, post-POEM TBE could provide benefits for identifying those who are more likely to fail therapy and require additional intervention. However, DeWitt et al.6 reported that post-POEM TBE has limited utility in predicting a patient’s clinical response. In the study, they performed TBE using 100 mL of water-soluble contrast (gastrografin), not barium. TBE was performed within 24 hours of POEM. They compared the number of patients with an Eckardt score >3 at 24 months after POEM between those with good esophageal emptying (<10% retention) and those with poor esophageal emptying (>10% retention). No significant difference in recurrence was observed between those with good and poor emptying (6% vs. 13%, p=0.37).6 The limited utility of the TBE reported in the study would not surprise me. The timing of performing the post-POEM TBE was too early compared to that in other studies. Mucosal edema associated with both mechanical and thermal injury during POEM might be more prominent immediately after POEM and thus lead to more esophageal stasis during TBE. The different types of contrast and fixed dosage might mislead the results. These are probable causes of the observation suggesting failure to identify its utility. Fortunately, the study by Suwatthanarak et al.7 that was published in this issue of Clinical Endoscopy was a well-designed post-POEM TBE study in which the role of TBE amongst patients with improved symptoms following POEM in the prediction of recurrence was evaluated.7 In this study, TBE was performed at 1 month after POEM, and the recurrence was defined as an Eckardt score >3. They demonstrated that the recurrence rate was higher in the discordant group (Eckardt score improved >50%, TBE decreased <50%) compared to that in the concordant group (both the Eckardt score and TBE improved >50%). The discordant group had a 6.8-fold higher recurrence rate than the concordant group (52.9% vs. 7.7%, p=0.017). Therefore, this study concluded that TBE led to benefits for predicting recurrent achalasia after POEM. More favorable outcomes for POEM have been reported in patients who do not respond well to conventional therapies and who have failed prior endoscopic and surgical myotomy. However, POEM is unable to correct the underlying pathophysiology and thus, does not normalize swallowing but merely improves it. Moreover, the efficacy of POEM tends to decrease with time. Thus, long-term follow-up and frequent repeated or alternative treatments will be required.8 Therefore, TBE after POEM should be utilized to detect patients who have a high risk of recurrence even in those who initially reported symptom relief.