Salvage peroral endoscopic myotomy for esophageal diverticulum.

Esophageal diverticulum often causes secondary dysmotility. If a diverticulum associated with a functional disorder is growing and exacerbating symptoms, surgical treatment is usually indicated [1,2]. Peroral endoscopic myotomy (POEM) was introduced by Inoue et al. in 2010 as a novel treatment technique for achalasia [3]. Here, we report our clinical experience of salvage POEM for esophageal diverticulum. An 84-year-old woman was referred to our hospital with a 30-year history of dysphagia. Endoscopy and esophagography revealed a giant diverticulum in the mid esophagus, into which most of the barium flowed (●" Fig.1,●" Fig.2a). The diverticulum compressed the true esophageal lumen, although high resolution manometry (Star Medical Co., Tokyo, Japan) showed no findings of a primary motility disorder (●" Fig.3). The patient was not suitable for curative surgery, and salvage POEM was undertaken as a less invasive treatment. A posterior wall myotomy (side opposite the diverticulum) was performed longitudinally, from the oral side of the diverticulum to the gastric side, and a pathologic thick layer of muscle was completely resected (●" Fig.4a,b). The patient’s subjective dysphagia was markedly decreased, and the smooth passage of barium flow was observed during esophagography (●" Fig.2b). The most common treatment for esophageal diverticulum is surgical resection. However, the surgical procedure is invasive and often difficult because of factors Fig.3 There are no findings of a primary motility disorder by high resolution manometry. Fig.2 a Preoperative esophagography showing barium inflow into the diverticulum and an empty true lumen. b After the peroral endoscopic myotomy procedure, barium flow through the true lumen is significantly improved, and pathologic muscle contraction is relieved. Fig.1 A diverticulum is seen in the mid esophagus. Cases and Techniques Library (CTL) E14