Peroral endoscopic myotomy, septotomy, and restoration of esophageal lumen with over-the-scope clips: closing the circle of esophageal diverticula management

Peroral endoscopic myotomy (POEM) is an option for esophageal diverticula treatment based on septum myotomy. However, a significant number of patients continue to be symptomatic owing to the pouch persistence [1] [2] [3] [4].

A 66-year-old man with significant weight loss, dysphagia, and chest pain was referred to our unit. Preoperative workup included: a) endoscopy of large diverticulum above the esophagogastric junction (EGJ); b) barium swallow with dilatation of distal esophagus with two diverticula, contrast hold-up, and tertiary contractions (video image); c) high-resolution impedance manometry indicating type 3 achalasia with a premature contractile segment starting 11 cm above the EGJ; and d) CT scan showing absence of extrinsic lesions.

A POEM was performed. Initial evaluation showed one 2-cm diameter diverticulum without a septum at 29 cm and the 12 o’clock position. Two large diverticula with defined septa were found at 32 cm and 3 o’clock, and 3 cm distally at 9 o’clock ([Fig. 1]). A wide 16-cm long submucosal tunnel exposing 50 % of the esophageal circumference was initiated at 26 cm and extended to 2 cm below the EGJ ([Fig. 2]). An uninterrupted posterior myotomy was started 12 cm above the EGJ to ensure complete dissection of the spastic segment ([Fig. 3]). Then, the myotomy was directed right to dissect the 3 o’clock diverticulum septum; afterwards, it was directed left to the 9 o’clock diverticulum septum and finally to the cardia and fundus, following the direction of the sling fibers. Both diverticulum pouches were everted towards the esophageal lumen and grasped with over-the-scope (OTS) clips ([Fig. 4]). The mucosotomy was closed with through-the-scope (TTS) clips. An early barium swallow demonstrated a restored esophageal anatomy with normal contrast flow ([Fig. 5]). The patient was discharged without complications and remains asymptomatic on a regular diet.

Fig. 1 Distal diverticulum.

Fig. 2 Distal diverticulum muscular septum.

Fig. 3 Septotomy and myotomy.

Fig. 4 Diverticulum pouch everted towards the esophageal lumen with an over-the-scope clip.

Fig. 5 Restored esophageal anatomy and normal contrast flow after multimodal treatment.

We conclude that a multimodal one-session endoscopic procedure treating both the underlying motility disorder and the diverticula, with restoration of the lumen mechanically (OTS clips), will lead to better rates of therapeutic success.

Endoscopy_UCTN_Code_TTT_1AO_2AN

Video 1 Initial barium transit in a patient with type III achalasia and multiple diverticula.

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Miutescu BP, Khan S, Mony S. et al. Role of peroral endoscopic myotomy (POEM) in the management of esophageal diverticula. Clin Endosc 2020; 53: 646-651
• 2 Kamal F, Khan MA, Lee-Smith W. et al. Peroral endoscopic myotomy is a safe and feasible option in management of esophageal diverticula: systematic review and meta-analysis. Dig Dis Sci 2021; 66: 3242-3249
• 3 Ishaq S, Siau K, Kuwai T. et al. Zenkerʼs peroral endoscopic myotomy (Z-POEM) for recurrent Zenker diverticulum: not so fast!. Endoscopy 2021; 53: 767
• 4 Nishikawa Y, Inoue H, Abad MRA. et al. Peroral endoscopic myotomy with diverticulum resection. VideoGIE 2020; 5: 534-538

Publication History

Article published online:
11 February 2022