Peroral direct diverticulotomy: a salvage peroral endoscopic myotomy technique for patients with "blown-out myotomy"

In patients with achalasia treated via Heller myotomy (HM) or peroral endoscopic myotomy (POEM), incomplete myotomy can lead to a "blown-out myotomy" (BOM) diverticulum, worsening obstruction, and dysphagia. We present peroral direct diverticulotomy (PODD), a salvage technique, similar to the "ultrashort tunnel" Zenker's peroral endoscopic myotomy technique, targeting the residual sphincter at the diverticular septum.

We performed PODD in a 49-year-old man with type I achalasia who underwent POEM with minimal relief (Eckardt score 4). At 18 months, the esophagram showed delayed emptying, incomplete myotomy, and BOM diverticulum, and endoscopy revealed a "puckered," tight lower esophageal sphincter (LES) and a BOM diverticulum. PODD achieved a 2-cm myotomy at the diverticular septum, completing the initial myotomy.

The 25-minute procedure was uneventful, and the patient was discharged after 23 hours. Four-week follow-up endoscopy showed patulous LES, resolution of the septum, and no reflux esophagitis. Endoluminal functional lumen imaging probe and esophagram were consistent with resolution of obstruction. At 6 months, swallowing was improved (Eckardt score 1) with no gastroesophageal reflux disease symptoms.

As POEM spreads to low-volume centers, BOM diverticula-once mainly seen after failed HM-are increasingly seen after POEM. PODD offers a technically simple, effective salvage technique with potential broad applicability in managing POEM and HM failure due to BOM.