Post written by Maham Hayat, MD, and Dennis Yang, MD, from the Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA.

Our case is that of an 86-year-old woman with a history of achalasia and symptomatic epiphrenic diverticulum (ED) who was referred for peroral endoscopic myotomy (POEM) with simultaneous diverticulotomy. Endoscopy revealed a large ED and an extremely tight lower esophageal sphincter (LES).

An initial submucosal tunnel was made through which the diverticular septum was identified, but the LES could not be localized. As such, a second mucosal incision was performed, and a shorter submucosal tunnel was created immediately proximal to the LES that facilitated identification of the LES in the tunnel and successful dissection into the cardia, allowing for subsequent simultaneous diverticulotomy and extended myotomy through both tunnels.

The video highlights some of the technical challenges that can be encountered in patients with achalasia and concomitant large ED. In this particular patient, the combination of conventional POEM with simultaneous diverticulotomy and a double tunnel technique facilitated completion of both the diverticulotomy and myotomy.

More than a decade since its introduction into clinical practice, the POEM technique continues to evolve. In this video, we demonstrate modifications to the procedure with a double tunnel technique to complete simultaneous endoscopic diverticulotomy and myotomy in a challenging patient.

Comparison of the timed barium esophagram before and after the procedure. Red arrows demonstrate resolution of the esophageal spastic contraction, epiphrenic diverticulum, and improved emptying of contrast through the lower esophageal sphincter into the stomach. POEM, peroral endoscopic myotomy with diverticulotomy.

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