Our video case presentation shows endoscopic myotomy or POEM alone as treatment for esophageal epiphrenic diverticulum. We have no disclosures. Esophageal epiphrenic diverticulum is usually associated with esophageal motility disorders and can occur in elderly patients. Paraoral endoscopic myotomy or POEM has been shown to achieve favorable outcomes and can provide a safer alternative to surgical myotomy and diverticulectomy in patients. Our patient was an 87-year-old male with a history of coronary artery disease who presented with a two-year history of dysphagia and regurgitation, as well as a 45-pound weight loss in nine months. He underwent a barium esophagram shown here that demonstrated a large epiphrenic diverticulum and a narrowed esophagogastric junction outlet. Diverticulum entrance is highlighted here. A flexible endoscope was inserted through the mouth into the esophagus and stomach. Here you can see at the beginning of the endoscopy the esophageal diverticulum, which still contained food particles. Adjacent, the esophagogastric junction is notably tight when passed with the scope. Functional luminal imaging probe was delivered across the EGJ to determine if myotomy was indicated. Saline-filled impedance balloon was assessed at 30 and 40 milliliters, with observed sensibility of 0.4, diameter 4.8, and a balloon pressure of 50. DI at 40 milliliters was similarly reduced at 0.3, all reflecting an EGJ outflow obstruction as the root cause of the diverticulum. Here you can see the submucosal injection of methylene blue. We performed the poem in the standard fashion, starting with the submucosal injection of methylene blue with saline solution, followed by mucosotomy, followed by smooth muscle dissection, then followed by myotomy. Following mucosotomy to create entry into the submucosal space, the submucosal vessels were divided with low forced coagulation as they were encountered here. The endoscope with a clear dissecting cap was used to enter the submucosal tunnel, which was extended further by continued dissection shown here. We continued with the submucosal dissection. The submucosal tunnel was extended onto the cardia by three centimeters. Following mucosotomy, the esophageal epiphrenic diverticulum can be seen on the right side. The tunnel is now directed away from the diverticulum and back towards the true lumen as shown here. The myotomy was started at just above the visual line the myotomy was started at just above the visualized esophageal diverticulum, opening at 30 centimeters from the incisors, and it was extended to 43 centimeters. You can see here the longitudinal muscle fibers of the esophagus as we divided the circular muscles, which are notably thickened. The myotomy, like the tunnel, is also directed away from the diverticulum seen on the right side. Following completion of myotomy, the scope was removed from the tunnel and passed into the stomach through the now low-pressure esophagogastric junction. Following intervention, repeat assessment using a functional luminal probe was performed with visualization to ensure no passage into the tunnel. Here, the flexible luminal imaging probe can be seen adjacent to the mucosotomy site. Here you can see the post-poem balloon distensibility measurements side-by-side at 30 and 40 milliliter fills. There was a marked increase in distensibility and diameter from prior now with DIs of 3.1 and 3.2, and a Dmin of 10.7 and 13.2. Mucosal entrance to the submucosal tunnel was closed using four endoscopic clips seen here. Following poem, our patient was extubated without any issues and reported improvement in his dysphagia and regurgitation one month post-operatively. His ECARD score improved from six pre-operatively to zero. At the patient's one-month visit, his barium swallow showed significant improvement. Our case demonstrates that poem is an effective intervention in treating symptomatic esophageal diverticulum. It should be considered as a first-line treatment, especially in older patients with multiple medical comorbidities. It provides a less invasive alternative for patients compared to the standard surgical treatment. Our case also demonstrates that poem can be used as primary treatment for symptomatic esophageal diverticulum. It's an effective intervention in treating dysphagia and should be considered first-line in older patients with comorbidities.

esophageal diverticulum

per-oral endoscopic myotomy

dysphagia

minimally invasive

elderly patients