Post written by Ryan Law, DO, from the Department of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA.

We present a 93-year-old man with classic symptoms and manometric findings consistent with type III achalasia with an associated large epiphrenic esophageal diverticulum. He underwent an anterior POEM at an outside institution. He presented to our institution with persistent symptoms and lack of improvement following his POEM. Barium esophagram revealed severe esophageal dysmotility, esophageal obstruction, and a persistent, large esophageal diverticulum with intermittent contrast passage through the gastroesophageal junction. We subsequently performed a repeat POEM with diverticuloseptotomy using a greater curvature approach. Prior to endoscopic intervention we performed EndoFLIP. At a 40mL fill the distensibility was 2.5mm²/mm HG, and the diameter at the lower esophageal sphincter (LES) was 10.7mm. We initially created a submucosal tunnel between the diverticular mucosa and the diverticular septum. A parallel tunnel was then created within the submucosa of the true esophageal lumen with extension through the LES and into the gastric cardia. Following creation of the parallel tunnels and isolation of the septum, repeat POEM was performed by dividing the circular muscle fibers of the distal esophagus and proximal stomach. The muscle fibers of the diverticular septum were then divided. Repeat EndoFLIP demonstrated a distensibility of 5.8mm²/mm HG and the diameter at the lower esophageal sphincter (LES) of 14.9mm using a 40mL fill volume. No intraprocedural adverse events occurred. Post-operative day 1 CT esophagram showed no leak, and the patient was discharged home in good condition. At 3-week follow-up, the patient reported complete resolution of his dysphagia and regurgitation symptoms and is tolerating a near normal diet.

This video demonstrates a less-invasive therapeutic option for patients with achalasia and a epiphrenic diverticulum, which could obviate the need for a larger scale surgical operation. This endoscopic approach does require additional technical skill; however, endoscopists comfortable with submucosal endoscopy are capable of successfully managing these nuances.

I think that this case validates that epiphrenic diverticula may not be a contraindication to POEM as was once thought. While this finding certainly adds case complexity and requires additional pre- and peri-procedure planning, patients with such anatomy can be effectively treated in a minimally invasive manner.

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