The patient is a 77-year-old male with history of type 2 achalasia status post laparoscopic Heller myotomy with Toupet fundoplication four months prior to presenting to our facility. Following surgery, his symptoms of dysphagia and regurgitation remained unchanged from what he was experiencing prior to surgery. He underwent upper endoscopy and manometry which were consistent with ongoing type 2 achalasia. He was discussed at this institution's multispecialty motility conference and a per oral endoscopic myotomy (POEM) was recommended. During the procedure, he was noted to have a tight band of esophageal mucosa two centimeters proximal to the esophagogastric (EG) junction which was suspected to be caused by incomplete myotomy with uncut fibers at that level of the esophagus. A posterior approach was selected for the POEM to utilize a fresh surgical plane and complete the endoscopic myotomy. At the conclusion of the procedure, the tight esophageal outflow obstruction was no longer present. Postoperatively the patient experienced immediate relief of the dysphagia and regurgitation.