LAUSR

Epiphrenic diverticulum is a rare disorder, with an incidence of 1/500000, and is more usually related to esophageal motility disorders including achalasia [1]. A 76-year-old woman was referred to our service for dysphagia, blockages, and retrosternal pain. She experienced several episodes of aspiration pneumonia. The esophagogram showed a large diverticulum, 10 cm above the diaphragm, with an important contrast reflux. A manometry was performed and showed no aperistalsis but the esophagogastric junction could not be passed. We performed a computed tomography (CT) scan with oral contrast, which showed a 3.5 ×5.7 cm epiphrenic diverticulum (▶Fig. 1). Thoracic surgery was contraindicated for this elderly woman and peroral endoscopic myotomy (POEM) [2–4] was proposed to cut the septum. We performed a submucosal tunneling dissection 7 cm above the diverticulum using a 1.5mm Dual Knife (Olympus, Tokyo, Japan). Once we reached the septum, we dissected the submucosa until we reached the periesophageal space in the mediastinum. Then, the tunnel was continued 5 cm under the diverticulum in the esophageal axis to expose the septum. Myotomy was performed selectively on the circular fibers (▶Fig. 2, ▶Video1). The tunnel entrance was then closed using five hemostatic clips (Boston Scientific, Marlborough, Massachusetts, USA). The procedure was performed without any complications with the patient under general anesthesia. Postoperative contrast swallow showed no difference from the preoperative test (▶Fig. 1b). The patient resumed feeding at postoperative Day 1 and was discharged at Day 3. At follow-up 2 months later, she was asymptomatic without any aspiration or dysphagia. ▶ Fig. 1 The epiphrenic diverticulum. a Contrast swallow showed a large epiphrenic diverticulum in the lower esophagus with no clear stenosis. b Contrast swallow after peroral endoscopic myotomy (POEM). c Computed tomography scan before POEM (AL, anterior left; PR, posterior right). d Endoscopic aspect of the septum before POEM. Video 1 Procedure of peroral endoscopic myotomy to cut the diverticulum septum. E-Videos