Epiphrenic diverticula are pulsion-type diverticula most commonly located in the distal
esophagus. They are classed as “pseudo-diverticula” and are usually associated with
esophageal motility disorders (EMD) [1].
The main symptoms leading to referral include dysphagia, regurgitation, and chest
pain [2]. In symptomatic patients, laparoscopic or thoracoscopic diverticulotomy combined
with a distal esophagogastric myotomy is considered the “gold standard” treatment.
Peroral endoscopic myotomy (POEM), previously introduced to treat achalasia, is increasingly
used to treat other types of EMD and to perform diverticulotomy (D-POEM) [3].
We describe the case of an 86-year-old man with recurrent symptoms after failure of
laparoscopic diverticulotomy and Heller myotomy. High-resolution manometry and barium
swallow revealed a recurrent epiphrenic diverticulum with primary EMD. Salvage POEM
and D-POEM were performed under general anesthesia ([Fig. 1], [Video 1]).
Fig. 1 Salvage peroral endoscopic myotomy (POEM) associated with diverticulotomy (D-POEM)
for the management of a recurrent epiphrenic diverticulum after surgery. a Submucosal tunneling. b Myotomy. c Septotomy. d Closure of the mucosal incision with endoclips.
Video 1 A combined procedure of peroral endoscopic myotomy (POEM) associated with diverticulotomy
(D-POEM) to treat a recurrent epiphrenic diverticulum with an associated esophageal
motility disorder after surgery. Endoflip was used to evaluate distensibility changes
before and after the procedure. Source for graphical illustration: Catherine Cers,
IRCAD, Strasbourg.
Endoflip (Medtronic, Minneapolis, Minnesota, USA) was used intraoperatively to document
compliance and distensibility changes at the gastroesophageal junction (GEJ) and at
the diverticulum in order to precisely guide myotomy and septotomy. After submucosal
injection and mucosal incision, performed on the opposite wall and 4 cm proximally
to the diverticulum, a longitudinal submucosal tunnel was created using a Triangle
Tip knife (Olympus, Tokyo, Japan) and carried to 2 cm below the GEJ. A proximal-to-distal
myotomy was subsequently performed with preservation of the longitudinal muscles.
Complete septotomy of the diverticulum was then performed. Endoflip measurements were
repeated to ensure the completeness of the myotomy. Finally, the mucosal incision
was closed with endoclips.
The postoperative course was uneventful. Esophageal emptying was satisfactory on barium
swallow performed on postoperative Day 1 and a soft diet was started. At the 2-month
follow-up visit, the patient had regained 5 kg in weight and had complete remission
of symptoms.
POEM combined with a D-POEM procedure may be safe and effective in the treatment of
recurrent epiphrenic diverticula after surgery.
Endoscopy_UCTN_Code_TTT_1AO_2AN
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