A 45-year-old man presented with a history of dysphagia and regurgitation for 8 years. He was diagnosed with type II achalasia cardia and underwent Heller’s myotomy without fundoplication 4 years earlier. The results of the present evaluation, including symptom analysis, EGD, timed barium esophagogram, and esophageal manometry, suggested a relapse. Treatment options were discussed, and peroral endoscopic myotomy (POEM) was performed. The posterior route (5 o’clock) was chosen for POEM to avoid possible submucosal fibrosis along the anterior route.