Reply to Jacobs et al.

We thank Jacobs et al. for their insightful comments on our video entitled “Peroral endoscopic myotomy [POEM] regains anatomical structure and improves emptying for achalasia with multiple esophageal diverticula” [1].

The authors raised concerns about technical difficulty and potential adverse events, and proposed a step-up approach for achalasia with concomitant esophageal diverticula, which starts with standard POEM, reserving diverticulotomy for patients with persistent symptoms. We partially agree with them and suggest achalasia with esophageal diverticula should be managed on a case-by-case basis, depending on the size, depth, number, and location of the diverticula.

For achalasia with small epiphrenic diverticulum without obvious symptoms, or upper esophageal diverticulum that is not in the range of submucosal tunneling, we agree that standard POEM is sufficient and diverticulotomy could be performed in refractory patients. However, for deep or multiple diverticula with obvious remnant contents, which are in the range of submucosal tunneling but are still located some distance from the lower esophageal sphincter, standard POEM with diverticulotomy is more appropriate, and “kills two birds with one scope.” For example, in our video, the patient had four deep diverticula in the lower third of the esophagus. The submucosal tunnel was created from 10 cm above the cardia, will all four diverticula included. A one-step procedure not only provides better symptomatic improvement, but also decreases the technical difficulty and invasiveness, as a second-session myotomy of septa is influenced by the scars from the first tunneling.

We propose several tips in performing the one-step procedure. The plane of dissection should be maintained perpendicular to the circular muscle, and the endoscope should also be repeatedly pulled out of the tunnel to maintain adequate orientation. Large studies with longer follow-up are warranted to provide more data on this question.

• Reference

• 1 Liu XY, Li QL, Jiao TW. et al. Peroral endoscopic myotomy regains anatomical structure and improves emptying for achalasia with multiple esophageal diverticula. Endoscopy 2019; DOI: 10.1055/a-0969-1757.