Endoscopy 2022; 54(11): E666-E667
DOI: 10.1055/a-1724-6801
E-Videos

Peroral endoscopic myotomy, septotomy, and restoration of esophageal lumen with over-the-scope clips: closing the circle of esophageal diverticula management

1   Endoscopy Unit, Gastroenterology Dept., Hospital Universitario de Navarra (HUN), Navarrabiomed Biomedical Research Center, Universidad Pública de Navarra (UPNA), IdiSNA, Navarra, Spain
,
1   Endoscopy Unit, Gastroenterology Dept., Hospital Universitario de Navarra (HUN), Navarrabiomed Biomedical Research Center, Universidad Pública de Navarra (UPNA), IdiSNA, Navarra, Spain
,
Marta Gómez Alonso
1   Endoscopy Unit, Gastroenterology Dept., Hospital Universitario de Navarra (HUN), Navarrabiomed Biomedical Research Center, Universidad Pública de Navarra (UPNA), IdiSNA, Navarra, Spain
,
Pedro J. Rosón
2   Hospital Quirón Salud Málaga, Gastroenterology Endoscopy Unit, Málaga, Spain
,
Francisco J. Gallego Rojo
3   Hospital de Poniente-El Ejido, Almería, Gastroenterology Department, Almería, Spain
,
1   Endoscopy Unit, Gastroenterology Dept., Hospital Universitario de Navarra (HUN), Navarrabiomed Biomedical Research Center, Universidad Pública de Navarra (UPNA), IdiSNA, Navarra, Spain
,
4   Gastrointestinal Endoscopy Research Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Navarra, Spain
› Author Affiliations
 

Peroral endoscopic myotomy (POEM) is an option for esophageal diverticula treatment based on septum myotomy. However, a significant number of patients continue to be symptomatic owing to the pouch persistence [1] [2] [3] [4].

A 66-year-old man with significant weight loss, dysphagia, and chest pain was referred to our unit. Preoperative workup included: a) endoscopy of large diverticulum above the esophagogastric junction (EGJ); b) barium swallow with dilatation of distal esophagus with two diverticula, contrast hold-up, and tertiary contractions (video image); c) high-resolution impedance manometry indicating type 3 achalasia with a premature contractile segment starting 11 cm above the EGJ; and d) CT scan showing absence of extrinsic lesions.

A POEM was performed. Initial evaluation showed one 2-cm diameter diverticulum without a septum at 29 cm and the 12 o’clock position. Two large diverticula with defined septa were found at 32 cm and 3 o’clock, and 3 cm distally at 9 o’clock ([Fig. 1]). A wide 16-cm long submucosal tunnel exposing 50 % of the esophageal circumference was initiated at 26 cm and extended to 2 cm below the EGJ ([Fig. 2]). An uninterrupted posterior myotomy was started 12 cm above the EGJ to ensure complete dissection of the spastic segment ([Fig. 3]). Then, the myotomy was directed right to dissect the 3 o’clock diverticulum septum; afterwards, it was directed left to the 9 o’clock diverticulum septum and finally to the cardia and fundus, following the direction of the sling fibers. Both diverticulum pouches were everted towards the esophageal lumen and grasped with over-the-scope (OTS) clips ([Fig. 4]). The mucosotomy was closed with through-the-scope (TTS) clips. An early barium swallow demonstrated a restored esophageal anatomy with normal contrast flow ([Fig. 5]). The patient was discharged without complications and remains asymptomatic on a regular diet.

Zoom Image
Fig. 1 Distal diverticulum.
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Fig. 2 Distal diverticulum muscular septum.
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Fig. 3 Septotomy and myotomy.
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Fig. 4 Diverticulum pouch everted towards the esophageal lumen with an over-the-scope clip.
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Fig. 5 Restored esophageal anatomy and normal contrast flow after multimodal treatment.

We conclude that a multimodal one-session endoscopic procedure treating both the underlying motility disorder and the diverticula, with restoration of the lumen mechanically (OTS clips), will lead to better rates of therapeutic success.

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Video 1 Initial barium transit in a patient with type III achalasia and multiple diverticula.


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Competing interests

The authors declare that they have no conflict of interest.

  • References

  • 1 Miutescu BP, Khan S, Mony S. et al. Role of peroral endoscopic myotomy (POEM) in the management of esophageal diverticula. Clin Endosc 2020; 53: 646-651
  • 2 Kamal F, Khan MA, Lee-Smith W. et al. Peroral endoscopic myotomy is a safe and feasible option in management of esophageal diverticula: systematic review and meta-analysis. Dig Dis Sci 2021; 66: 3242-3249
  • 3 Ishaq S, Siau K, Kuwai T. et al. Zenkerʼs peroral endoscopic myotomy (Z-POEM) for recurrent Zenker diverticulum: not so fast!. Endoscopy 2021; 53: 767
  • 4 Nishikawa Y, Inoue H, Abad MRA. et al. Peroral endoscopic myotomy with diverticulum resection. VideoGIE 2020; 5: 534-538

Corresponding author

Eduardo Albéniz, MD
Endoscopy Unit, Gastroenterology Department
Complejo Hospitalario de Navarra
Navarrabiomed Biomedical Research Center
Public University of Navarre (UPNA)
Navarra Health Research Institute (IdiSNA)
Irunlarrea 3
31008, Navarra
Spain   

Publication History

Article published online:
11 February 2022

© 2022. Thieme. All rights reserved.

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  • References

  • 1 Miutescu BP, Khan S, Mony S. et al. Role of peroral endoscopic myotomy (POEM) in the management of esophageal diverticula. Clin Endosc 2020; 53: 646-651
  • 2 Kamal F, Khan MA, Lee-Smith W. et al. Peroral endoscopic myotomy is a safe and feasible option in management of esophageal diverticula: systematic review and meta-analysis. Dig Dis Sci 2021; 66: 3242-3249
  • 3 Ishaq S, Siau K, Kuwai T. et al. Zenkerʼs peroral endoscopic myotomy (Z-POEM) for recurrent Zenker diverticulum: not so fast!. Endoscopy 2021; 53: 767
  • 4 Nishikawa Y, Inoue H, Abad MRA. et al. Peroral endoscopic myotomy with diverticulum resection. VideoGIE 2020; 5: 534-538

Zoom Image
Fig. 1 Distal diverticulum.
Zoom Image
Fig. 2 Distal diverticulum muscular septum.
Zoom Image
Fig. 3 Septotomy and myotomy.
Zoom Image
Fig. 4 Diverticulum pouch everted towards the esophageal lumen with an over-the-scope clip.
Zoom Image
Fig. 5 Restored esophageal anatomy and normal contrast flow after multimodal treatment.