A double tunnel deep home technique, finding your way to a difficult to locate lower esophageal sphincter in spastic achalasia and epiphrenic diverticulum. Esophageal epiphrenic diverticula or ED are rare pulsion type diverticulum in the distal esophagus that can develop in the setting of an underlying esophageal motility disorder. While surgery has been the traditional approach for symptomatic ED, it can be associated with significant morbidity. Recently, POEM with simultaneous diverticulotomy or DPOEM has been suggested in case reports and series as a safe and effective minimally invasive alternative to surgery, yet the optimal approach remains to be determined. In this video we present an unusual case of spastic achalasia with a large symptomatic ED in a difficult to locate lower esophageal sphincter successfully treated with a double tunnel DPOEM technique. An 86 year old woman with a long standing history of achalasia and a large symptomatic ED was admitted to the hospital with progressive dysphagia and failure to thrive. The patient reported daily regurgitation, dysphagia to solids with every meal and a 20 pound weight loss over the course of 12 months. End-embryon mesophagram was obtained which demonstrated diffused esophageal spasms in a large epiphrenic diverticulum with retention of embryon and slow passage across the tight lower esophageal sphincter. Given her age and multiple cardiopulmonary comorbidities, she deferred surgical evaluation and was referred for possible DPOEM. On endoscopy, diffused esophageal spasms could be appreciated upon advancement of the endoscope towards the gastroesophageal junction. A large diverticulum could be appreciated in the distal esophagus with some retained food within the lumen. The lower esophageal sphincter could not be identified on initial evaluation. Upon further examination, a very small orifice was identified at the rim of the epiphrenic diverticulum which measured approximately 2-3 mm in diameter. This could not be traversed. A balloon dilation catheter was advanced across the orifice and this was successfully dilated to 8 mm. Following dilation, the upper endoscope was exchanged for the ultra-slim gastroscope and this was inserted through the orifice confirming this to be indeed the lower esophageal sphincter with passage to the stomach. Once the landmarks were established, we proceeded with the POEM by selecting the cipher mucosal incision at 25 cm from the incisors ensuring that this was above the spastic esophageal segment. After longitudinal submucosal incision, submucosal tunneling towards the distal esophagus was performed by repeated injections and dissection with the needle-type knife. Submucosal tunneling was challenging due to luminal tortuosity and repeated spastic contractions. In spite of identifying the septum of the diverticulum in the distal esophagus, the Further examination within the esophageal lumen revealed that the sphincter was located more towards 11 o'clock in relationship to the tunnel. At this point, the decision was to make a second mucosal incision in the distal esophagus to facilitate tunneling towards the lower esophageal sphincter. Through the second tunnel, careful dissection was performed across the lower esophageal sphincter at the edge of the diverticular septum with widening of the lumen in the tunnel upon extension into the cardia. The myotomy at the lower esophageal sphincter, distal esophagus, and diverticularotomy was performed sequentially using an insulated-tip ESD knife. Once completed, the mucosal incision, the distal esophagus was closed with clips and the initial semicosal tunnel re-entered for completion of the remaining esophageal myotomy. Once the myotomy was completed, the second mucosal incision was adequately closed with clips as well. The patient did well postoperatively, was discharged on day 2. On clinic follow-up 6 weeks after, she denied any delay adverse events. Importantly, she has been able to tolerate regular diet without issues and has not endorsed any reflux symptoms while on proton pump inhibitors. When comparing the time-barren esophagrams before and after POEM, we see a resolution of the spastic esophageal segment, successful diverticulotomy, and adequate emptying of contrast into the stomach through the LES. In conclusion, dPOEM is increasingly recognized as a safe and effective treatment of symptomatic ED and akalasia, yet the optimal technical approach remains to be determined. This video demonstrates the natural evolution of a safe and effective technology in which the combination of conventional dPOEM and a double tunnel approach allowed the successful management of a complicated case of spastic akalasia with EV in an unusually tight LES.

spastic achalasia

epiphrenic diverticulum

dPOEM technique

minimally invasive

double tunneling