
==== Front
VideoGIE
VideoGIE
VideoGIE
2468-4481
Elsevier

S2468-4481(24)00075-4
10.1016/j.vgie.2024.05.003
Original Article
Peroral endoscopic myotomy with diverticulotomy using a double tunnel technique: finding your way to an elusive lower esophageal sphincter in spastic achalasia and epiphrenic diverticulum
Hayat Maham MD 1
Draganov Peter V. MD 2
Hasan Muhammad K. MD 1
Xiao Yasi MD 1
Arain Mustafa A. MD 1
Kadkhodayan Kambiz K. MD 1
Cosgrove Natalie MD 1
Yang Dennis MD 1
1 Center for Interventional Endoscopy, AdventHealth, Orlando, Florida
2 Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
09 5 2024
8 2024
09 5 2024
9 8 356358
© 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.
2024
American Society for Gastrointestinal Endoscopy
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Video

Abbreviations

D-POEM double tunnel peroral endoscopic myotomy with diverticulotomy

ED epiphrenic diverticula

LES lower esophageal sphincter

TBE timed barium esophagram
==== Body
pmcIntroduction

Esophageal epiphrenic diverticula (ED) are rare pulsion-type diverticulum in the distal esophagus that can develop in the setting of an underlying esophageal motility disorder as a result of the contractile dyscoordination between the distal esophagus and lower esophageal sphincter (LES). Although surgery has been the traditional approach for symptomatic ED, it can be associated with significant morbidity.1 Case reports and small case series have suggested peroral endoscopic myotomy with simultaneous diverticulotomy (D-POEM) as a potential minimally invasive alternative to surgery.2,3 In this Video 1, available online at www.videogie.org, we present an unusual case of spastic achalasia with a large ED and a difficult-to-locate LES successfully treated with a “double tunnel” D-POEM technique.

Case

An 86-year-old woman with history of achalasia and symptomatic ED presented with progressive dysphagia and failure to thrive. The patient reported daily regurgitation, dysphagia to solids with every meal, and a 20-pound weight loss over the past 12 months. Timed barium esophagram (TBE) demonstrated diffuse esophageal spasms, with retention of contrast in a large ED with slow passage across a tight LES (Fig. 1). Given her age and comorbidities, the patient deferred surgery and was referred for D-POEM.Figure 1 Timed barium esophagram showing spastic esophageal contractions with “corkscrew” appearance, retention of contrast with within large epiphrenic diverticulum, and slow passage across the tight lower esophageal sphincter.

On endoscopy (GIF-HQ190; Olympus America, Center Valley, Pa, USA), diffuse esophageal spasms were identified in addition to a large ED at the level of the gastroesophageal junction. The LES was difficult to localize. After careful inspection, we identified a small orifice measuring 3 mm in diameter at the rim of the ED (Fig. 2A). After dilation to 8 mm (CRE Wire-guided Balloon Dilatation Catheter; Boston Scientific, Marlborough, Mass, USA), we were able to traverse it with an ultraslim endoscope (GIF-XP190N), confirming that this was indeed the tight LES. A mucosal incision (Hybrid I-type knife; ERBE, Marietta, Ga, USA) was made at 25 cm to initiate the submucosal tunneling. Despite identifying the diverticular septum, the LES could not be localized within the tunnel. At this point, a second mucosal incision was made in the distal esophagus immediately proximal to the LES for a second submucosal tunnel. The shorter tunnel facilitated identification of the tight LES and successful dissection into the cardia (Fig. 2B). We then performed simultaneous diverticulotomy and myotomy of the LES using an insulated tip knife (IT-nano; Olympus America) (Fig. 2C). Once completed, we then re-entered the first tunnel to complete the remainder of the esophageal myotomy (Fig. 2D). Both mucosal incisions were successfully closed with through-the-scope clips (SureClip; Microtech, Ann Arbor, Mich, USA) (Fig. 2E).Figure 2 A, Endoscopic view of small opening of the lower esophageal sphincter (LES) (red circle) at the edge of the diverticular septum (yellow dotted lines). B, Endoscopic view within the submucosal tunnel of the LES opening (red circle) adjacent to the diverticular septum (yellow dotted lines). C, Endoscopic myotomy and septotomy using an insulated tip knife. D, Endoscopic myotomy of the spastic esophageal segment proximal to the epiphrenic diverticulum. E, Closure of the mucosal incision with through-the-scope clips.

The patient was discharged on postoperative day 2. On clinic follow-up 6 weeks after the D-POEM, the patient denied any delayed adverse events. She had been able to tolerate a regular diet and did not endorse any reflux symptoms while on proton-pump inhibitor therapy once daily. When compared with her preprocedure TBE, a repeat TBE 8 weeks after the D-POEM demonstrated resolution of esophageal spasms, successful diverticulotomy, and adequate emptying of contrast into the stomach (Fig. 3).Figure 3 Comparison of the timed barium esophagram before and after the procedure. Red arrows demonstrate resolution of the esophageal spastic contraction, epiphrenic diverticulum, and improved emptying of contrast through the lower esophageal sphincter into the stomach. POEM, peroral endoscopic myotomy with diverticulotomy.

Conclusion

This video demonstrates the natural evolution of a safe and effective technology in which the combination of conventional D-POEM and a double tunnel technique allowed the successful management of a complicated case of spastic achalasia with ED with an unusually tight LES.

Disclosure

Dr Yang is a consultant for Boston Scientific, Fujifilm, Olympus, Medtronic, Microtech, 3D-Matrix, and Neptune Medical. Dr Yang has received research grant support from 3D-Matrix and Microtech. Dr Draganov is a consultant for Boston Scientific, Fujifilm, Olympus, Medtronic, Microtech, and Cook Medical. Dr Hasan is a consultant for Boston Scientific, Olympus, Microtech, and Neptune Medical. Dr Arain is a consultant for Boston Scientific, Cook Medical, and Medtronic. Dr Cosgrove is a consultant for Boston Scientific and Cook Medical. All other authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Double tunnel per-oral endoscopic myotomy with diverticulotomy for the management of spastic achalasia and symptomatic epiphrenic diverticulum.
==== Refs
References

1 Basile P. Gonzalez J.M. Le Mouel J.P. Per-oral endoscopic myotomy with septotomy for the treatment of distal esophageal diverticula (D-POEM) Surg Endosc 34 2020 2321 2325 32144556
2 Kamal F. Khan M. Lee-Smith W. Peroral endoscopic myotomy is a safe and feasible option in management of esophageal diverticula: systematic review and meta-analysis Dig Dis Sci 66 2021 3242 4249 33123940
3 Ren L. Ye H. Xie W. Diverticular peroral endoscopic myotomy (D-POEM) for symptomatic oesophageal diverticulum: a multicentre cohort study with a minimum follow-up of 3 years Surg Endosc 38 2024 253 259 37985492
