BACKGROUND: 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). While surgery has been the traditional approach for symptomatic ED, it can be associated with significant morbidity. Case reports and small case series have suggested POEM with simultaneous diverticulotomy (D-POEM) as a potential minimally invasive alternative to surgery. In this video, 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 DESCRIPTION: An 86-year-old woman with history of achalasia and symptomatic ED presents with progressive dysphagia and failure to thrive. The patient reports daily regurgitation, dysphagia to solids with every meal and a 20-lb weight loss over the past 12 months. Timed barium esophagram demonstrated diffuse esophageal spasms, with retention of contrast in a large ED with slow passage across a tight LES. Given her age and comorbidities, the patient deferred surgery and was referred for D-POEM. She recovered well from the procedure without adverse events and had near complete resolution of symptoms at 2-month follow-up.

ENDOSCOPIC METHODS: On endoscopy, 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. After dilation to 6 mm, we were able to traverse it with an ultra-slim endoscope, confirming that this was indeed the tight LES. A mucosal incision was made at 25 cm to initiate the submucosal tunneling. In spite of 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 facilitate identification of the very tight LES and successful submucosal dissection into the cardia. We then performed simultaneous diverticulotomy and myotomy of the LES. Once completed, we then re-entered the first tunnel to complete the remainder of the esophageal myotomy. Both mucosal incisions were successfully closed with clips.

CONCLUSION: This video represents the natural evolution of a safe and effective technique in which the combinations of innovations in the field (D-POEM with double-tunnel access) allowed the successful management of a complicated case of spastic achalasia with ED and an unusually tight LES.

Waleed Aljohani

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