Two birds, one scope: peroral endoscopic myotomy as a treatment for achalasia and esophageal diverticula

Peroral endoscopic myotomy (POEM) is a potential endoscopic alternative approach for the simultaneous treatment of both achalasia and epiphrenic diverticula.

Liu et al. recently reported a case of POEM in a patient with achalasia and multiple esophageal diverticula [1]. POEM was performed in addition to targeted septotomy of the esophageal diverticula. Post-procedural course was complicated by pain and fever, requiring antibiotics and 8-day hospitalization. At follow-up, Eckardt score decreased from 8 to 2, and contrast study showed partial resolution of diverticula and improved emptying. Based on these findings, the authors concluded that POEM is a safe and effective treatment for patients with achalasia and esophageal diverticula.

POEM for the concomitant treatment of achalasia and esophageal diverticula is novel; hence, data are scarce, heterogeneous, and lacking long-term follow-up [2] [3]. Although the concept of performing endoscopic diverticulotomy during POEM is attractive and elegant, several issues are worth mentioning. POEM with endoscopic diverticulotomy (D-POEM) is technically demanding, as noted by the adverse events reported by Liu et al. Maintaining adequate orientation when dissecting around the septum is crucial in order to avoid inadvertent mucostomy or the creation of a false tunnel towards the luminal side. Importantly, standard POEM for esophageal dysmotility has been shown to achieve good outcomes without the need for diverticulotomy [4]. This has been our experience as well: standard POEM often results in symptomatic improvement and decrease in size of the esophageal diverticula, without the need for routine diverticulotomy. Hence, a reasonable step-up approach would be to start with standard POEM, with D-POEM reserved for patients with refractory symptoms from food stasis in the esophageal diverticula.

In conclusion, POEM may be an effective one-stop procedure for both symptomatic achalasia and esophageal diverticula, with targeted endoscopic diverticulotomy reserved for those with persistent symptoms.

• References

• 1 Liu XY, Li QL, Jiao TW. et al. Peroral endoscopic myotomy regains anatomical structure and improves emptying for achalasia with multiple esophageal diverticula. Endoscopy 2019; DOI: 10.1055/a-0969-1757.
• 2 Yang J, Zeng X, Yuan X. et al. An international study on the use of peroral endoscopic myotomy (POEM) in the management of esophageal diverticula: the first multicenter D-POEM experience. Endoscopy 2019; 51: 346-349
• 3 Sato H, Sato Y, Takeuchi M. et al. Salvage peroral endoscopic myotomy for esophageal diverticulum. Endoscopy 2015; 47: E14-E15
• 4 Orlandini B, Barrett M, Guillaumot MA. et al. Per-oral endoscopic myotomy for esophageal diverticula with or without esophageal motility disorders. Clin Res Hepatol Gastroenterol 2019; DOI: 10.1016/j.clinre.2019.03.013.