Simultaneous peroral endoscopic myotomy and submucosal tunneling endoscopic septum division in one tunnel for diffuse esophageal spasm combined with epiphrenic diverticulum

Abstract

Figures

a Tightly closed gastroesophageal junction. b Narrow rings of diffuse esophageal spasm. c An epiphrenic diverticulum. d, e Creation of a submucosal tunnel. f, g Completion of the full-thickness myotomy. h–j The muscle of the diverticulum septum was completely cut off. k The tunnel entrance was closed by metal clips. l One year after operation, the disappearance of the large diverticulum and narrow rings, with a smooth passage of the EGJ.

Full text

A 78-year-old female patient was admitted with dysphagia for 2 years. High-resolution esophageal manometry confirmed diffuse esophageal spasm (DES). Endoscopy showed multiple narrow rings in the middle and lower esophagus lumen, tight stenosis at the esophagogastric junction (EGJ), and a epiphrenic diverticulum (ED) located above the narrowed EGJ ( Fig. 1 a–c ). Given the DES accompanied by ED, peroral endoscopic myotomy (POEM) combined with submucosal tunneling endoscopic septum division (STESD) was performed ( Video 1 ). After establishing the submucosal tunnel, the annular muscle bundle and diverticular ridge were completely transected ( Fig. 1 d–g ), and the whole layer of esophageal muscle bundle was completely severed 2 cm above and below the EGJ ( Fig. 1 h–k ). Substantial reduction of lower esophageal sphincter tonus was confirmed by easy passage of the EGJ through the endoscope. The length of the tunnel and muscle incision is 18 and 15 cm, respectively. The patient was discharged on postoperative day 3 without complication. One year after the operation, a follow-up endoscopy confirmed the disappearance of the diverticulum and narrow rings, with a smooth passage of the EGJ ( Fig. 1 l ).

a Tightly closed gastroesophageal junction. b Narrow rings of diffuse esophageal spasm. c An epiphrenic diverticulum. d, e Creation of a submucosal tunnel. f, g Completion of the full-thickness myotomy. h–j The muscle of the diverticulum septum was completely cut off. k The tunnel entrance was closed by metal clips. l One year after operation, the disappearance of the large diverticulum and narrow rings, with a smooth passage of the EGJ.

Simultaneous POEM and STESD in one tunnel for diffuse esophageal spasm combined with epiphrenic diverticulum.Video 1

This case is the first report about simultaneous POEM and STESD in one tunnel for DES with ED. In this case, POEM may not be enough to resolve the symptoms of dysphagia, necessitating combined STESD for ED. Moreover, incision of diverticular ridge and spastic muscle layer in the same tunnel should avoid mucosal injury and esophageal perforation, which greatly increases the difficulty of operation. ED is currently thought to be secondary to an underlying esophageal motility disorder (EMD), such as DES or achalasia 1 . The traditional treatment for EMD combined with ED is laparoscopic epiphrenic diverticulectomy, myotomy, and fundoplication, with high postoperative morbidity and mortality 2 . This implies that the application of simultaneous POEM and STESD in one tunnel may be a safe and effective technique for DES combined with ED.

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