Post written by Zaheer Nabi, MD, DNB, from the Asian Institute of Gastroenterology, Hyderabad, India.

In this video case, we describe per oral endoscopic myotomy (POEM) in a case of achalasia with large diverticulum at the lower end of esophagus. POEM was performed in the standard fashion. In addition, the septum between diverticulum and submucosal tunnel was also divided. The technical steps of endoscopic septum division have been demonstrated in the video. After the mucosal incision, submucosal tunnel was extended towards the gastric side as well as the diverticulum. In this way, the diverticulum was adequately exposed for subsequent division of the muscle fibers constituting the septum.

This video highlights the feasibility of POEM in a case with large esophageal diverticulum. It is important to dissect the septum in these cases to avoid incomplete relief of symptoms due to persistent diverticulum. Submucosal tunneling may be challenging in the presence of a diverticulum due to risk of mucosal injury and fear of losing the direction of tunneling.

POEM with division of diverticular septum is a novel way of treating large epiphrenic diverticulum. Division of septum alone is sufficient in cases without co-existent achalasia. Whereas, myotomy should be extended into the stomach in cases with co-existent achalasia. This technique can serve as a safe, effective, and less-invasive alternative to laparoscopic diverticulectomy.

Submucosal tunneling endoscopic septum division (STESD) has been reported for the treatment of Zenker’s diverticulum. The proposed advantages of this technique include complete division of the septum without increased risk of perforation. The same principles of submucosal endoscopy can be applied in cases with esophageal epiphrenic diverticulum.

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