Peroral direct diverticulotomy: una técnica de miotomía endoscópica peroral de rescate para pacientes con divertículo...

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.