endoscopic diverticulectomy and myotomy for epiphrenic diverticulum. Epiphrenic diverticulum is typically located four to eight centimeters above the gastric cardia and involves herniation of the mucosal and submucosal layers through the weak muscle segments. It is primarily caused by increased distal oesophageal pressure due to hypertensive motility disorders. Traditional treatment with the thoracotomy carries significant risks of adverse events and morbidity. In a 65-year-old male patient presented with the difficulty swallowing and chest pain, radiological imaging revealed a four-centimeter epiphrenic diverticulum in the distal oesophagus. Monometry showed findings consistent with the spastic echolasia. During endoscopy, diverticulum and spastic segments were observed. Paroral endoscopic myotomy, endoscopic diverticulectomy, and hand suturing closure were planned to address the issue. Our objective is to relieve symptoms, remove the diverticulum, ensure proper oesophageal reconstruction, prevent adverse events, and promote rapid healing. During endoscopy, an epiphrenic diverticulum was identified at the three o'clock position with spastic contractions observed distal to it. A submucosal injection of saline and endocarmine was performed at the five o'clock position, five centimeter proximal to segment where the contraction began. A linear mucosal incision was then made using an endoscopic knife to create posterior tunnel extending to gastroesophageal junction. The posterior aspects of the diverticulum was successfully freed during submucosal dissection performed in separate coagulation mode. Subsequently, an anterior tunnel was created, extending from a tunnel entrance to a point distal to the diverticulum, and two tunnels were merged. Following this, the anterior aspect of the diverticulum entrance was dissected. And circumferential dissection was performed toward the base of the diverticulum to achieve complete release. As the standard scope could not reach the base of the diverticulum, a nasal endoscope was utilized. Dissection at the diverticulum base was completed using a needle knife. Subsequently, the standard scope was reintroduced, and the diverticulum was fully released. Finally, the diverticulum was fully released, and it could be easily inverted into the lumen through the tunnel. During dissection, the remaining submucosa proximal to the diverticulum, which supported controlled scope movements and separated the tunnels, was cut to merge the tunnels. An over-the-scope snare was inserted and opened inside the luminal side of the diverticulum. The base was grasped with the forceps and pulled into the snare. The snare was closed and pulled, inverting the diverticulum into the lumen, to prevent its return to original position and to facilitate view of diverticulum entrance. Using a needle holder, a barbed suture was placed into the cap and introduced into the tunnel. It was then passed continuously three times, starting distally and moving proximally along the diverticulum entrance within the tunnel. Finally, the suture was locked by passing it proximally to distally across the entrance. The excess suture was cut with endoscopic scissors and removed, effectively sealing the mouth of the diverticulum. As the diverticulum mouth was sealed, the inverted diverticulum was released from snare and the snare was removed. Afterwards, to reduce the pressure causing the diverticulum and to prevent the formation of a new diverticulum, a posterior selective circular myotomy using the intramuscular tunnel technique was performed between the proximal part of the diverticulum and the gastroesophageal junction. In this technique, injections were made between the two muscle layers to create an intramuscular tunnel followed by circular myotomy. Finally, a full thickness myotomy was performed between the gastroesophageal junction and the end of the tunnel. The myotomy was completed without touching the sealed diverticulum entrance. Following the myotomy, the inverted diverticulum was resected using a standard polypectomy technique. After the resection, the mucosal defect was closed with a barbed suture. The both sides of the defect, right and left, were sutured five times from distal to proximal. A cross suture was then passed between the last two sutures to lock the suture. The excess suture was cut with the endoscopic scissors and removed. The procedure was completed by closing the tunnel entrance with hemoclips. You can now see the reconstructed esophagus and the sutured area. After the procedure, parenteral antibiotics, fluid, and PPI were initiated. On postoperative day 2, no contrast leakage or retention was observed. Oral intake was started with a liquid diet on day 2, and the patient was discharged on day 4. Both clinical and laboratory parameters remained stable during the follow-up period. Myotomy effectively reduced the pressure causing the diverticulum. A posterior myotomy not only prevents the formation of a new diverticulum, but also minimizes the risk of recurrence. The use of the tunneling and traction techniques facilitates the inversion and resection of the diverticulum. Suturing prevents recurrence and the formation of reservoir. Peroral endoscopic myotomy is an effective and safe treatment for esophageal motility disorders. For epiphrenic diverticulum, peroral endoscopic myotomy plus endoscopic diverticulectomy can be minimal invasive endoscopic treatment option. Hand suturing closure is an effective and safe method for endoscopic closure.

epiphrenic diverticulum

spastic achalasia

peroral endoscopic myotomy

endoscopic diverticulectomy

esophageal motility disorders