Diverticular peroral endoscopic myotomy has been described in the management of esophageal diverticuli. This usually entails the creation of a submucosal tunnel that eventually exposes the muscular septum. Further dissection is then performed down on the esophageal side, reaching down to the and on the diverticular side to reach as much as possible down to the base of the diverticulum. This is then followed by cutting the muscular septum. In large diverticuli, however, two problems arise. First, due to the altered anatomy and chronic inflammation, the muscle and the submucosa on the diverticular side become adherent and atrophic, and further dissection is not possible beyond a third or half of the way down to the base of the diverticulum. Secondly, there is usually dense adhesions between the side and the base of the diverticulum with the surrounding structures and the esophageal wall. This in theory will prevent the collapse of the diverticulum and will maintain the shape and depth of the diverticulum even after a septotomy is performed. To solve these issues, we propose this technique. After maximal submucosal dissection is achieved, we pierce through the muscle to reach the space between the side of the diverticulum and the esophageal wall and dissect through this tissue and adhesions. We then proceed with a full thickness myotomy down to 1 cm below the cardia. We then finish off the procedure by cutting any adhesions around the base of the diverticulum, aiming to allow the base of the diverticulum to collapse as much as possible over time. A 50-year-old female presented with symptoms of severe dysphagia and vomiting and weight loss over the last 4 years. A barium esophagogram revealed a large mid-esophageal diverticulum and it was assessed to be about 5-6 cm in depth. Here the diverticulum is seen full of food despite a prolonged fast. You can appreciate the depth of the diverticulum. After cleaning, we find it hard to find the passage to the distal esophagus and it needed some maneuvering to eventually reach it. We then start about 4-5 cm above the septum by injecting saline and methylene blue solution. After a mucosal incision, the submucosal spate is reached. We then proceed with submucosal dissection, aiming to reach and expose the muscular septum. Submucosal dissection then proceeds on the esophageal side of the septum. It is extended distally to reach down to one centimeter below the cardia. We then proceed similarly on the diarticular side. However, after about two centimeters, we reach extensive fibrosis and atrophic submucosa, limiting further submucosal dissection. This is the point where we decide to pierce the muscle on the diarticular side of the septum to reach the peridiarticular space. In this space, the base of the diverticulum is on the right while the esophageal wall is on the left, and we cut through the connective tissue and adhesions in between, aiming to free the base of the diverticulum to aid its eventual collapse. We continue the myotomy down the full length of the esophagus, reaching to about 1 cm below the cardia. Here you can appreciate some residual adhesions fixing the base of the diverticulum to the esophageal wall. They are carefully cut using precise sect mode to avoid thermal injury to the surrounding structures, especially the pleura on the right side of the diverticulum. Inspection now from the lumen reveals that the lumen to the distal oesophagus is now widely open. However, we assess that the mucosal flap is too deep and might cause retention of food. We therefore decided to do a mucosotomy and reconstruction of the flap as demonstrated. The mucosotomy is done horizontally, perpendicular to the axis of the mucosal flap, reaching down to the base as much as possible. The first clip is then placed in the middle of the incision. Aspiration is essential to help approximate the edges. Additional clips are then placed in this manner, to achieve a V-shaped closure of the defect. This is the view 5 weeks later where you can appreciate the collapse of the base of the diverticulum, now almost at the same level of the remnant mucosal flap. Equally importantly, the lumen is widely opened down to the distal esophagus. The patient reported complete resolution of her symptoms and is gaining weight. In conclusion, deep home is an effective minimally invasive procedure for the management of large esophageal diverticulum. Adhesiolysis with freeing the base of the diverticulum, in addition to mucosotomy with flap reconstruction are additional steps that may improve the outcome. Further studies are required to confirm the safety and efficacy of this technique.

diverticular peroral endoscopic myotomy

minimally invasive procedure

large esophageal diverticula

submucosal tunnel

muscular septum