Enqiang Linghu from the Department of Gastroenterology, Hepatology and Endoscopy at Chinese PLA General Hospital, Beijing, China presents this video case.

The video demonstrated 3 kinds of submucosal tunneling techniques that were simultaneously performed through 1 tunnel in a 53-year-old female patient, namely submucosal tunneling endoscopic resection (STER), submucosal tunneling endoscopic diverticulotomy (STED), and per-oral endoscopic myotomy (POEM). The patient was admitted to our department because of achalasia. The esophageal barium and endoscopic examination both revealed a large diverticulum in the right side. Therefore, we intended to perform POEM and STED. During the operation, an inverted T incision and 5-cm short tunnel were established. Unexpectedly, 1 submucosal tumor originating from muscularis propria was discovered in the tunnel and removed by STER, which was pathologically confirmed as leiomyoma. Myotomy was performed from the lower edge of the diverticulum, namely STED. Thereafter, full-thickness myotomy was performed on the lower esophageal sphincter to finish the POEM. There were no adverse events during or after the procedure. At 3-month follow-up, barium and endoscopic examination confirmed that the ledge of the diverticulum became flattened, which allowed better drainage. The esophageal diameter was reduced from 6.1cm to 3.7cm, and the Eckardt score decreased from 11 to 1.

We would like to mention three points that we found useful for these submucosal tunneling techniques. First, the inverted T incision took advantage of longitudinal and transverse incisions to make entering and closure of the tunnel easier, and then reduce the related complications. Second, for patients with diverticulum, a 5cm short tunnel was established to reduce the operation time and raise the efficacy and safety.  Third, the submucosal dissection was started from both sides to the center during the tunnel establishment to avoid tunnel deflection.

Submucosal tunneling technique has opened a new way for gastrointestinal endoscopic therapeutics. To the best of our knowledge, the tunneling application for diverticulum was first reported and proven to be feasible, safe, and efficient. Further clinical application in the future is anticipated.

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