Endoscopy 2022; 54(11): E666-E667
DOI: 10.1055/a-1724-6801
E-Videos

Peroral endoscopic myotomy, septotomy, and restoration of esophageal lumen with over-the-scope clips: closing the circle of esophageal diverticula management

1   Endoscopy Unit, Gastroenterology Dept., Hospital Universitario de Navarra (HUN), Navarrabiomed Biomedical Research Center, Universidad Pública de Navarra (UPNA), IdiSNA, Navarra, Spain
,
1   Endoscopy Unit, Gastroenterology Dept., Hospital Universitario de Navarra (HUN), Navarrabiomed Biomedical Research Center, Universidad Pública de Navarra (UPNA), IdiSNA, Navarra, Spain
,
Marta Gómez Alonso
1   Endoscopy Unit, Gastroenterology Dept., Hospital Universitario de Navarra (HUN), Navarrabiomed Biomedical Research Center, Universidad Pública de Navarra (UPNA), IdiSNA, Navarra, Spain
,
Pedro J. Rosón
2   Hospital Quirón Salud Málaga, Gastroenterology Endoscopy Unit, Málaga, Spain
,
Francisco J. Gallego Rojo
3   Hospital de Poniente-El Ejido, Almería, Gastroenterology Department, Almería, Spain
,
1   Endoscopy Unit, Gastroenterology Dept., Hospital Universitario de Navarra (HUN), Navarrabiomed Biomedical Research Center, Universidad Pública de Navarra (UPNA), IdiSNA, Navarra, Spain
,
4   Gastrointestinal Endoscopy Research Unit, Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Navarra, Spain
› Author Affiliations
 

Peroral endoscopic myotomy (POEM) is an option for esophageal diverticula treatment based on septum myotomy. However, a significant number of patients continue to be symptomatic owing to the pouch persistence [1] [2] [3] [4].

A 66-year-old man with significant weight loss, dysphagia, and chest pain was referred to our unit. Preoperative workup included: a) endoscopy of large diverticulum above the esophagogastric junction (EGJ); b) barium swallow with dilatation of distal esophagus with two diverticula, contrast hold-up, and tertiary contractions (video image); c) high-resolution impedance manometry indicating type 3 achalasia with a premature contractile segment starting 11 cm above the EGJ; and d) CT scan showing absence of extrinsic lesions.

A POEM was performed. Initial evaluation showed one 2-cm diameter diverticulum without a septum at 29 cm and the 12 o’clock position. Two large diverticula with defined septa were found at 32 cm and 3 o’clock, and 3 cm distally at 9 o’clock ([Fig. 1]). A wide 16-cm long submucosal tunnel exposing 50 % of the esophageal circumference was initiated at 26 cm and extended to 2 cm below the EGJ ([Fig. 2]). An uninterrupted posterior myotomy was started 12 cm above the EGJ to ensure complete dissection of the spastic segment ([Fig. 3]). Then, the myotomy was directed right to dissect the 3 o’clock diverticulum septum; afterwards, it was directed left to the 9 o’clock diverticulum septum and finally to the cardia and fundus, following the direction of the sling fibers. Both diverticulum pouches were everted towards the esophageal lumen and grasped with over-the-scope (OTS) clips ([Fig. 4]). The mucosotomy was closed with through-the-scope (TTS) clips. An early barium swallow demonstrated a restored esophageal anatomy with normal contrast flow ([Fig. 5]). The patient was discharged without complications and remains asymptomatic on a regular diet.

Zoom Image
Fig. 1 Distal diverticulum.
Zoom Image
Fig. 2 Distal diverticulum muscular septum.
Zoom Image
Fig. 3 Septotomy and myotomy.
Zoom Image
Fig. 4 Diverticulum pouch everted towards the esophageal lumen with an over-the-scope clip.
Zoom Image
Fig. 5 Restored esophageal anatomy and normal contrast flow after multimodal treatment.

We conclude that a multimodal one-session endoscopic procedure treating both the underlying motility disorder and the diverticula, with restoration of the lumen mechanically (OTS clips), will lead to better rates of therapeutic success.

Endoscopy_UCTN_Code_TTT_1AO_2AN

Video 1 Initial barium transit in a patient with type III achalasia and multiple diverticula.


Quality:
Endoscopy E-Videos
https://eref.thieme.de/e-videos

Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online. Processing charges apply (currently EUR 375), discounts and wavers acc. to HINARI are available.

This section has its own submission website at https://mc.manuscriptcentral.com/e-videos


#

Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Eduardo Albéniz, MD
Endoscopy Unit, Gastroenterology Department
Complejo Hospitalario de Navarra
Navarrabiomed Biomedical Research Center
Public University of Navarre (UPNA)
Navarra Health Research Institute (IdiSNA)
Irunlarrea 3
31008, Navarra
Spain   

Publication History

Article published online:
11 February 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Distal diverticulum.
Zoom Image
Fig. 2 Distal diverticulum muscular septum.
Zoom Image
Fig. 3 Septotomy and myotomy.
Zoom Image
Fig. 4 Diverticulum pouch everted towards the esophageal lumen with an over-the-scope clip.
Zoom Image
Fig. 5 Restored esophageal anatomy and normal contrast flow after multimodal treatment.