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
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