Overcoming the challenge of peroral endoscopic myotomy in a type 3 achalasia corkscrew esophagus

Performing peroral endoscopic myotomy (POEM) for corkscrew esophagus and advanced achalasia is challenging because of the spiral nature of the esophagus. During submucosal tunneling in a posterior POEM, it is important to have a straight endoscope with the mucosa superiorly (12 o’clock position) and the muscle layer inferiorly, and to maintain this orientation at all times. We describe a technical challenge during POEM and a safe approach to tunneling.