Peroral endoscopic myotomy and simultaneous endoscopic diverticuloseptotomy in a case of achalasia with diverticula

A 58-year-old man with symptoms of dysphagia and regurgitation was admitted for treatment. Evaluation with endoscopy and contrast esophagogram revealed achalasia cardia with a small mid-esophageal diverticulum and a large epiphrenic diverticulum ([Fig. 1], [Fig. 2]). Peroral endoscopic myotomy (POEM) and a simultaneous endoscopic diverticuloseptotomy were performed in this case ([Video 1]). Firstly, submucosal injection and mucosal incision were made at about 5 cm above the epiphrenic diverticulum. Secondly, a submucosal tunnel was created pointing toward the diverticular septum and extended on both sides of the septum, i. e., the diverticular and esophageal lumen side ([Fig. 3]). Thirdly, complete myotomies of the muscle layer of the diverticular septum and the esophagus were performed separately. Due to technical difficulty, a small mucosal perforation occurred at the most narrow, twisted, and spasmodic part of the distal esophagus ([Fig. 4]). In the final step, the small mucosal injury and the entry of the tunnel were closed with endoclips. An X-ray contrast study 5 days after POEM revealed a free flow of contrast medium across the gastroesophageal junction and a collapsed epiphrenic diverticulum ([Fig. 5]). There was substantial improvement in the patient’s clinical symptoms as well. At the 3-month follow-up, the patient reported complete resolution of dysphagia.

Fig. 1 Contrast esophagogram before peroral endoscopic myotomy shows a large epiphrenic diverticulum (black triangle) on the right anterolateral esophageal wall. A thin streak of contrast medium is visible across the lower esophageal sphincter (black star).

Fig. 2 Endoscopic images show a small mid-esophageal diverticulum (black arrow) and a large epiphrenic diverticulum (black triangle). White arrows show the entrance of the narrow lumen of distal esophagus.

Video 1 Peroral endoscopic myotomy and simultaneous endoscopic diverticuloseptotomy in a case of achalasia with diverticula.

Fig. 3 A submucosal tunnel was created pointing toward the diverticular septum and extended on both sides of the septum.

Fig. 4 A small mucosal injury occurred at the most narrow, twisted, and spasmodic part of the distal esophagus during peroral endoscopic myotomy (black arrow).

Fig. 5 Contrast esophagogram 5 days after peroral endoscopic myotomy shows quick passage of contrast medium across the gastroesophageal junction into the stomach; the previously large diverticulum has collapsed.

POEM has been introduced for achalasia treatment as a less invasive alternative to laparoscopic Heller myotomy [1]. However, a few patients with achalasia have a co-existing large epiphrenic diverticulum, which may cause technical difficulties and increase the rates of procedure-related adverse events [2] [3]. In our case, a small esophageal mucosal injury occurred during POEM, which was completely sealed by an endoclip without any postoperative complications. Classically, a diverticulum of the middle esophagus is classified as a Rokitansky diverticulum, and it rarely attains an appreciable size or produces any symptoms [4]. We did not treat the small mid-esophageal diverticulum in this case.

Endoscopy_UCTN_Code_TTT_1AO_2AM

Competing interests

None

• References

• 1 Zaninotto G, Leusink A, Markar SR. Management of achalasia in 2019. Curr Opin Gastroenterol 2019; DOI: 10.1097/MOG.0000000000000544.
• 2 Bechara R, Woo M, Hookey L. et al. Peroral endoscopic myotomy (POEM) for complex achalasia and the POEM difficulty score. Dig Endosc 2019; 31: 148-155
• 3 Li HK, Linghu EQ. New endoscopic classification of achalasia for selection of candidates for peroral endoscopic myotomy. World J Gastroenterol 2013; 19: 556-560
• 4 Sato H, Takeuchi M, Hashimoto S. et al. Esophageal diverticulum: New perspectives in the era of minimally invasive endoscopic treatment. World J Gastroenterol 2019; 25: 1457-1464