Failed Heller myotomy with diverticulectomy, success with POEM and diverticulotomy, a case series by Dr. Andrew Leopold. Principal investigator is Dr. Raymond Kim. These are our disclosures. Heller myotomy with esophageal diverticulectomy was standard of care for achalasia concomitant with epiphrenic diverticulum. With increasing frequency, POEM with diverticulotomy has been demonstrated as a feasible method for management of achalasia with paraesophageal diverticulum. Here we present two patients with achalasia and paraesophageal diverticulum that have symptoms refractory to Heller myotomy and esophageal diverticulectomy. The first case is a 60-year-old female with a history of type 2 achalasia with an esophageal diverticulum and a failed Heller myotomy with diverticulectomy 10 months prior, which was complicated by esophageal pulmonary fistula and recurrent aspiration pneumonia, necessitating G-tube replacement. She was still NPO due to recurrent aspiration. Lastly, she also has a history of metastatic breast cancer. She was again admitted to the hospital for pneumonia. Here is an image of a barium esophagram which occurred before POEM. It demonstrates a leak from the esophagus that was characterized as an esophageal pulmonary fistula. The leak is between the two red dotted lines and the blue circle shows the esophageal diverticulum. On endoscopy we can visualize the esophageal fistula. As we move distally into the esophagus, we can see the suture from attempted diverticulectomy. Here we can see the large esophageal diverticulum adjacent to the lower esophageal sphincter, and due to achalasia, the high tone of the LES resists advancement of the endoscope. Pre-POEM endoflip showed distensibility index of 1.3 at 60 cc. The anterior location of the Heller myotomy as well as the location of the esophageal diverticulum necessitates mucosotomy on the left wall of the esophagus. First, submucosal injection of methylene blue was at 35 cm from the incisors. Initial mucosal incision occurred at this location on the left wall of the esophagus. The submucosal tunnel was extended with dissection to 43 cm. Diverticular septum could not be identified. Location of the diverticular septum was attempted to be found with a subsequent methylene blue dye injection, but this was also not successful, as the septum still could not be identified. At this time, the patient had decreased tidal volume and an increase in end tidal CO2. A decision was therefore made to close the esophageal to pleural fistula. The fistula was treated with argon plasma coagulation. Then, one endoscopic suture was placed at the fistula site. A new submucosal injection with methylene blue was made at the 3 o'clock position at 39 cm, followed by subsequent mucosal incision. This location was chosen more distally, so there would be more ease in location of the septum. The submucosal tunnel was extended to 45 cm and 1 cm into the gastrocardia, where myotomy began. Myotomy was then extended approximately to 40 cm, where it involved the diverticular septum, shown here. After complete myotomy and diverticulotomy, mucosotomy site was closed using two endoscopic sutures. This is the second suture. Endoflip topography was then performed with a 16 cm probe, and distensibility index improved from 1.3 to 5.25 at 60 cc. Then, the initial mucosotomy at 35 cm was closed with an endoscopic suture. A second endoscopic suture was placed at the fistula site for reinforcement. This is a post-operative barium esophagram three weeks post-procedure. As we move from left to right, we can see no endoleak, demonstrating interval resolution of the esophageal pulmonary fistula. Contrast also shows flow through the esophagus and into the stomach. The esophageal fistula was successfully closed, and the patient was cleared to have a gradually advanced diet. One month later, she did have pneumonia recurrence, but this was due to incomplete treatment of her prior pneumonia. She was eventually transitioned to home hospice care for her metastatic breast cancer, where she remained on a full diet. The next case is a 67 year old male with a history of type 2 achalasia and esophageal diverticulum, as well as failed hellermyotomy and diverticulectomy four months prior. He presented as an inpatient for weight loss and electrolyte abnormalities, and could only tolerate a liquid restrictive diet. His predominant symptoms were dysphagia and esophageal fullness, which required self-induced vomiting for relief. This pre-pulmonary barium esophagram demonstrates a 3-4 cm diverticulum, which actually causes impaction of the barium tablet at the site of the diverticulum. There is also a remarkable distal esophageal narrowing after the diverticulum. On endoscopy, we can see the esophageal diverticulum. Because prior hellermyotomy was approached anteriorly, our approach during POEM is from the posterior side. First, methylene blue dye was injected into the submucosa of the esophagus posteriorly. The initial mucosal incision occurred at this location, 37 cm from the incisors. A submucosal tunnel was extended distally towards the diverticular septum, and here we can see the septum coming into view. The septum is now dissected free from the submucosa, and the submucosal tunnel is extended into the diverticulum shown here. Tunneling also is continued toward the gastriccardia, extending into it by 1 cm, 44 cm from the incisors. Myotomy begins at the diverticular septum and extends towards the gastriccardia. Here, the myotomy now extends 1 cm into the gastriccardia. Diverticulotomy is then performed. This is demonstrated here. It is extended completely through the muscular layer. Now we can see the full length of the myotomy. Endoflip was performed after myotomy was completed and demonstrated a successful POEM. It was performed using stepwise distensions and demonstrated response to treatment. The mucosotomy was closed with an endoscopic suture. In the postoperative barium esophagram, there is a smooth transition of the bolus from the esophagus into the stomach. Flow and the narrowing in the distal esophagus are greatly improved. There is no leak. By discharge, he was tolerating a full diet. At 6-month follow-up, he had no symptoms of dysphagia. He has experienced almost no reflux since POEM with an ECART score of 1. His only symptom is nighttime regurgitation when lying down within 3 hours of eating. He returned to a healthy weight and continues to take twice daily PPI. In patients with achalasia and concomitant esophageal diverticulum that failed heller myotomy and esophageal diverticulectomy, we favor a posterior approach to mucosal tunneling and myotomy during subsequent POEM. Endoscopic suturing of the mucosotomy site may provide an additional layer of safety in prevention of esophageal leak. We favor pre- and post-endoflip measuring distensibility index to confirm adequate myotomy. In conclusion, POEM for patients with achalasia and parasophageal diverticulum is challenging but feasible. Patients with achalasia and esophageal diverticulum that fail heller myotomy and diverticulectomy should be considered for POEM.

achalasia

esophageal diverticulum

Heller myotomy

peroral endoscopic myotomy

diverticulotomy