Today, I'd like to present a rare case of POM on a patient with achalacea and esophageal diverticulum. Here's our disclosure. This patient is a 55-year-old female who came to our hospital with a chief complaint of dysphagia for almost 10 years. She had feeling of obstruction after swallowing both soy or liquid food, and sometimes she also suffered from vomiting after eating. Previous gastroscope found food retention in esophagus, but no lesion or malignancy was detected. After she admitted, we had a gastroscope and here's what we found. The esophagus was dilated with fluid retention. There's a narrow ring about 35 centimeters from the incisor. The cardio could barely be passed with tension at 37 centimeters. And there's a diverticulum about 1.5 centimeters in diameter above the edge of the dented line. We also performed endoscopic ultrasonography, and we found the muscularis propria layer of the lower esophagus was significantly thickened with a maximum thickness of 6.3 millimeter and the ciliary methyl about 4.4 millimeter in thickness. Upper gastrointestinal contrast was also performed, and we found a big-like stenosis of the lower esophagus, the slow passage of contrast agent, dilation of the upper esophagus, and retention of contrast agent. Also there was a pocket shadow at the right edge of the stenosis segment with a smooth inner wall of approximately 6 centimeter, and the contrast agent was filled and air liquid level was observed. So this is the diverticulum. We also had high-resolution esophageal manometry, and we found increased ALES pressure and ineffective esophageal motility in esophagus body. And the diagnosis of the manometry was gastroesophageal junction outflow obstruction, EGGLO in abbreviation. After the evaluation, the patient was diagnosed with achalacea and esophageal diverticulum, and POM was conducted on this patient. We can see the cardia wrapping the endoscope tightly. The cardia was narrow. A diverticulum approximately 1.5 centimeter in diameter was seen in the right anterior wall of the esophagus, approximately 1.5 centimeter above the dented lie. A mixture of normal saline and indigo carmine was injected into the right posterior wall about 7 centimeter above the dented lie. A submucosa bleb is raised and the mucosa incision is performed. The incision is done longitudinally with careful decision of the submucosa fibers around the incision to allow the gastroscope to be introduced into the submucosa space. Then the endoscope was within the submucosa while preserving the integrity of the mucosa. A submucosa tuner was established to 3 centimeter beyond the gastroesophageal junction. And the reach of the vertical line was shown. Then selective myotomy of the inner circular muscle bottle is performed, starting 6cm above AGJ. The longitudinal muscle beneath could be seen. and full-thickness myotomy was conducted two centimeter near the cardiac And then the muscle layer of the ridge was cut off to the base of the diverticulum. Make sure the ridge was cut off completely to prevent further foot retention after surgery. And after the operation, we can see the cardio was open, and the ridge between the ventriculum collapsed, and the stenosis was relieved. There was no resistance to endoscopic passage, and all visible vascular stump was treated, and the tunal entrance was closed with endoscopic clips. About one week after therapy, we had the upper gastrointestinal contrast examination again, and this time, we found no dilation or contrast agent retention in esophagus, and also the diverticulum has shrunk compared with before. Most importantly, the patient's symptom has relived. So what can we learn from this patient? What can we learn from this patient? It is a rare case of a carassia with esophageal diverticulum, and the patient of this condition can benefit from POM, and when we conduct POM in this situation, we should cut the ridge to prevent foot retention in diverticulum after POM. Thank you.

achalasia

esophageal diverticulum

peroral endoscopic myotomy

dysphagia

esophageal manometry