Peroral diverticulotomy, a salvage point technique for patients who blow out myotomy. I would like to thank my co-authors, our disclosures. Case history. A 49-year-old man with type 1 akalasia diagnosed by manometry in 22 after symptoms for several months presented for FOAM at an outside hospital with partial initial symptom relief that eroded by 6 months. Two diagnostic endoscopies with endoflip were non-contributory with distensibility in the 4 to 6 range. A barium esophagram, however, demonstrated very slow emptying of liquid barium. He was referred to us for possible salvage redo POAM in 2024. Eckhart's score on presentation on May 10, 2024 was a total score of 4 with dysphagia of 3. On our review of the images from the prior index POAM at the outside hostel we noted this screw-like appearance of the submucosal tunnel in one of the images. We call this the screw sign, which in endoscopic tunnel view would suggest that the tunnel did not successfully cross the LES. Subsequent endoscopy at 1.5 years confirms this with a puckered tight LES and a blowout diverticulum in the area of the prior POAM as shown here. The barium also confirms that with very little emptying, a tight LES and a forming diverticulum in the area of the blowout myotomy as annotated here. So we proceeded with a novel POAM salvage technique for failed myotomy with blowout myotomy that we call peroral direct diverticulotomy, a technique very similar to zPOAM. Here we start our procedure with endoflip measurements, which shows a very tight distensibility of 1.5 and a diameter of 6.1. Here we see the beginning of a diverticulum in the area of the blowout and a residual sphincter is clearly demonstrated at the rim of the diverticulum. So we proceed with direct diverticulotomy of this residual sphincter, we inject saline in the submucosa and using a multifunctional knife that injects through the knife we proceed with dissection of the mucosa in a very similar manner as we do for zPOAM for a Zenker's diverticulum. After incision of the mucosa and continued injection of the submucosa, we proceed with myotomy of the residual lower esophageal sphincter that was left after the prior POAM that did not reach far enough into the stomach. Again, we proceed in a very similar fashion as in zPOAM. We are dissecting carefully the muscle layer, avoiding a full thickness entry into the peritoneal cavity. The intent is to preserve the serosa for increased safety. So this is all performed within a tunnel with a tapered cap at the tip of the endoscope, it is rapidly completed and now we proceed with our standard closure for POAM using endoscopic suturing. A single running suture is placed as usual from left to right with two or three pairs of passes on the distal and proximal lips of the transverse incision. So here the suturing is completed with cinching. You can see that the suturing at the alias successfully closes the tunnel, very nice opening with elimination of the muscle at the rim and the barium on postoperative day 1 even shows much improved emptying compared to the pre-procedural barium. The total poem time was 25 minutes, 2 cm length of myotomy, 24 hour extended observation with no adverse events. We suggested to the patient removal of the suture at 2-4 weeks because its location at the AGJ may result in some narrowing of the AGJ and removal of the suture may further improve emptying of the esophagus. So here the patient returns for the follow-up endoscopy at 1 month, excellent opening in retroflexion, also very good opening with elimination of the leads of the emerging blowout is seen here. Using a double channel scope and an endoscopic scissors and grasper we remove the metallic T-tag and then using a grasper we remove the plastic bumper at the other end of the suture to completely remove all the suture and foreign body material. And you can see here the bumper and the metallic T-tag needle removed. Here we can very clearly see that the distal rim of the blowout myotomy diverticulum has been eliminated, avoiding any retention of food and facilitating food transit through the AGJ. The endoflip confirms a very nice opening with distensibility of 8. And here we can see the nice appearance pre with the residual sphincter and the blowout completely resolved. 6-month follow-up revealed very good results with excellent eating and complete resolution of the patient's symptoms. Blowout diverticula are common findings associated with late presenting POEM or Heller failure. The dPOEM technique often used involves a tunnel parallel to the diverticulum that is cumbersome because it requires oblique cutting at the edge of the diverticulum. Our peroral direct diverticulotomy technique targets the center of the diverticulum rim where it's deepest and where the maximum food retention occurs. Its similarity to zPOEM underlines the same pathophysiology. The blowout myotomy happens through an iatrogenic weakening of the muscle wall upstream of a residual lower sphincter. The Zekers happens due to a tight upper sphincter through a naturally occurring weakness of the muscle. The blowout diverticulum defines very well the residual LES and allows direct cutting without the need for a long tunnel. So in conclusion, as Heller myotomy and now increasingly POEM are performed increasingly in low volume centers in the US, we expect that fail myotomies are expected to rise. Blowout myotomy is a classic and common finding in fail myotomy, particularly in late presentation, which results in food retention at dysphagia. Our peroral direct diverticulotomy technique that we described here is extremely useful and we expect that will be widely applied in the future.

peroral direct diverticulotomy

achalasia

blowout myotomy

dysphagia

POEM