S4175 Mastering the Maze: A Technique-Focused Approach to Submucosal Tunneling With Endoscopic Peroral Myotomy for a Case of Achalasia With Multiple Esophageal Diverticula

Introduction: Per-oral endoscopic myotomy (E-POEM) is a safe and effective minimally invasive treatment for achalasia. However, the presence of epiphrenic diverticula—particularly multiple diverticula—significantly increases procedural complexity. Maintaining correct submucosal tunnel orientation in such cases is critical. We report technical considerations and outcomes in a case involving achalasia with 4 distal esophageal diverticula successfully managed using E-POEM with multiple septotomies. Case Description/Methods: A 78-year-old man presented with progressive dysphagia, significant weight loss, and a gastrostomy tube for nutritional support. Esophagram suggested achalasia with multiple large epiphrenic diverticula, but high-resolution manometry was unsuccessful due to inability to pass the catheter into the stomach. Esophagogastroduodenoscopy (EGD) confirmed 4 posterolateral distal esophageal diverticula, the largest being the most distal. FLIP showed a distensibility index of 1.6 mm²/mmHg, EGJ diameter of 8.9 mm, and absent esophageal contractility—consistent with achalasia. The esophagus was irrigated and submucosal injection performed 30 cm from the incisors, 3 cm proximal to the uppermost diverticulum. A tunnel was created to 45 cm, with a 2 cm extension into the gastric cardia. Fluoroscopy confirmed tunnel orientation and gastric access. Complete circular and longitudinal muscle division included all diverticular septa to ensure effective drainage. Hemostasis was achieved, and the mucosotomy closed with 5 endoscopic clips. Intraoperative video guidance aided tunnel navigation and lumen identification. The procedure was completed without complications. The patient had marked symptomatic relief, resumed oral intake, and gained significant weight, allowing gastrostomy tube removal. At 8-month follow-up, he remained asymptomatic. Surveillance EGD showed patent diverticular orifices and a patulous GEJ, indicating durable myotomy. Discussion: Successful tunnel navigation relied on detailed preoperative anatomical assessment, intraoperative spatial awareness, and fluoroscopic guidance. Each diverticular septum was carefully incorporated into the primary myotomy for effective drainage. This approach enabled a complete and durable myotomy, despite significant anatomic distortion. Our case supports the feasibility and safety of E-POEM with targeted septotomy in complex achalasia with multiple diverticula, and underscores the importance of individualized strategy and meticulous technique. Watch the video: https://tinyurl.com/25ACGS4175