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Combined per oral endoscopic myotomy and septotomy for type 2 achalasia with mid-esophageal diverticulum

P Riva, MD1, L Swanstrom, MD1, D Mutter, MD2, J Marescaux, MD2, S Perretta, MD2. 1Institute of Image Guided Surgery, Strasbourg, France, 2IRCAD-Department of Digestive and Endocrine Surgery, Strasbourg, France

Introduction: Esophageal diverticula are often associated with a concomitant esophageal motor disorder, which is thought to be the cause of the diverticulum and some of the patient's symptoms. This is the case of a 67XX year old patient with a type 2 achalasia and a diverticulum in the middle third of the esophagus. The patient c/o dysphagia and regurgitation at every meal, and a 10 kg weight loss. Eckardt score was 9. Decision was made to perform a combined per oral endoscopic myotomy and septotomy.

Methods: The patient is positioned supine under general anesthesia. Carbon dioxide is used for insufflation during the procedure. After the insertion of an overtube, exploratory endoscopy is carried out to rule out any esophageal or gastric disease and to indentifyidentify the landmarks which will guide the procedure including the measure of the distensibility at the esophago-gastric jJunction (EGJ) using the endoflip ipedanceimpedance planimetry catheter (Crospon LTD, Galway). An injection of approximately 0.5 mL dye into the lesser curvature of the gastric cardia is performed to facilitate the localization of EGJ during the procedure. The diverticulum is identified and measured and food remnants carefully removed to garanteeguarantee a clean entry into the submucosal space. An initial longitudinal 15–20-mm mucosal incision is made at the neck of the divertiuculum and a septomtomy carried out through the muscular layer. A submucosal injection is then performed at the distal margin of the initial incision to gain access to the submucosal space. This is followed by submucosal tunneling extended to the gastric cardia, 2 cm beyond the EGJ, reaching the dark blue tattoo of the gastric injection point. A 14 cm myotomy is carried out first distally at the EGJ then proximally on the inner circular muscle to meet the initial dissection at the diverticular neck. At the end of the procedure, the endoscope is passed down to the stomach to confirm smooth passage through the EGJ and sufficient release of the outflow obstruction at the GEJ is confirmed with the endoflip catheter. The mucosal entry site is closed using multiple clips.

Results: The combined POEM and endoscopic septotomy approach proved to be safe and effective in treating this complex case. The UGI series on post-operative day one showed smooth passage of contrast media through EGJ with no leakage and stasis, and improved empyting of the residual esophageal mucosal outpouching. The post-operative course was uneventufuluneventful and the Eckardt score 0.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 80102

Program Number: V045

Presentation Session: Flexible / Therapeutic Endoscopy and NOTES

Presentation Type: Video

52

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