Treatment of multiple esophageal diverticula by peroral endoscopic myotomy

A 55-year-old man with persistent dysphagia and chest pain for 5 years was referred to our medical team. Gastroscopy (Olympus, Tokyo, Japan) revealed two distinct diverticula: one mid-esophageal diverticulum located 33 cm from the incisors and another “kissing” epiphrenic diverticula 43 cm from the incisors ([Fig. 1], preoperation). Barium swallow showed the size of the esophageal diverticula to be 4 mm, 19 mm and 22 mm, respectively ([Fig. 2], preoperation). Esophageal manometry showed no findings of a primary motility disorder ([Fig. 3]).

Fig. 1 Pre- (a) and postoperative (b) (1-month follow-up) gastroendoscopic images of two distinct esophageal diverticula: single esophageal diverticulum at 33 cm from the incisors (A); “kissing” esophageal diverticula at 43 cm from the incisors (B).

Fig. 2 Pre- and postoperative (1-week follow-up) barium swallow results. The sizes of the three esophageal diverticula were 4 mm (A), 19 mm (B), and 22 mm (C), respectively.

Fig. 3 Esophageal manometry results showed no findings of a primary motility disorder.

The patient asked for minimally invasive therapy, so we used peroral endoscopic myotomy (POEM) ([Video 1]). A 2-cm oblique mucosal incision was made between the “kissing” diverticula, at 3 – 5 cm above the diverticula, using a triangle-tip knife positioned at the tunnel entry. Another incision was made on the same side 3 – 5 cm above the single diverticulum, which was 33 cm from the incisors. For both diverticula, a submucosal longitudinal tunnel was made on each side of the septum and ended 1 – 2 cm distal to the bottom of the diverticulum. Circular muscle, longitudinal muscle, and base muscle between the esophageal lumen and diverticulum were dissected using the triangle-tip knife ([Fig. 4], [Fig. 5]). Finally, the mucosal incisions were closed with hemostatic clips.

Video 1 Gastroscopy showed multiple esophageal diverticula, which were treated successfully by peroral endoscopic myotomy.

Fig. 4 Peroral endoscopic myotomy of the single diverticulum. a A submucosal tunnel was made in the single esophageal diverticulum at 33 cm from the incisors. b The base muscle between the esophageal lumen and the diverticulum was dissected.

Fig. 5 Peroral endoscopic myotomy of the “Kissing” esophageal diverticula. a A submucosal tunnel was made at 43 cm from the incisors. b The base muscle between the esophageal lumen and diverticula was dissected.

The patient took semifluid food the following day, and was discharged from hospital on postoperative day 7 with symptoms completely resolved. A barium swallow test 1 week later showed a dramatically flatter diverticula bottom ([Fig. 2], postoperation). The 1-month follow-up gastroscopy showed increased esophageal lumen ([Fig. 1], postoperation), and the patient had gained 3 kg in weight.

The first application of POEM was reported in 2010 [1]. Since then, POEM has been applied to gastroparesis and esophageal diverticulum [2] [3]. In the present case, we successfully treated multiple esophageal diverticula by POEM, which expanded its application. Further studies on the long-term efficacy and follow-up after POEM are required.

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• References

• 1 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
• 2 Li QL, Chen WF, Zhang XC. et al. Submucosal tunneling endoscopic septum division: a novel technique for treating Zenker’s diverticulum. Gastroenterology 2016; 151: 1071-1074
• 3 Wu C, Zhang Q, Liu W. et al. Successful treatment of giant esophageal diverticulum by per-oral endoscopic myotomy. Endoscopy 2018; 50: E107-E108