P4521 - Novel Non-Injection Non-Tunnel Technique for Peroral Endoscopic Myotomy (Ni-POEM) for the Treatment of a Refractory Killian-Jamieson Diverticulum (KJD)

Carter E. Edmunds, MD¹, Eleazar Enrique. Montalvan-Sanchez, MD², Dalton A.. Norwood, MD³, Sergio A. Sánchez-Luna, MD^4
1University of Alabama at Birmingham Hospital, Birmingham, AL; ²Yale Digestive Diseases, New Haven, CT; ³UAB Minority Health & Health Equity Research Center, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL; ⁴Basil I. Hirschowitz Endoscopic Center of Excellence, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL

Introduction: A Killian-Jamieson diverticulum (KJD) appears as a mucosal outpouching through a muscular defect inferior to the cricopharyngeus muscle and lateral to the longitudinal muscle. Transcervical and endoscopic stapler-assisted diverticulotomies have been the preferred approaches, but peroral endoscopic myotomy (POEM) has emerged as a treatment modality for cricopharyngeal diverticula.

Case Description/Methods: A 63-year-old female presented with a 2-year history of recurrent dysphagia and regurgitation after undergoing open diverticulectomy (OD) nine years ago for a KJD. She had six endoscopic dilations, which were unsuccessful. An esophagogram revealed a persistent diverticulum (Fig. 1A). She opted for a novel, non-injection, non-tunnel technique for the peroral endoscopic myotomy (Ni-POEM) approach due to failed OD and dilations. On esophagogastroduodenoscopy, a 2 cm diverticulum was identified (Fig. 1B), and a scissors-type knife and an electrosurgical generator (Dry Cut settings) were used to make a mucosal incision to expose the underlying muscular septum. This was followed by complete septomyotomy without requiring submucosal injection, tunneling, or dissection (Ni-POEM, Fig. 1C). The myotomy was extended 1 cm below the base of the diverticulum. The edges of the flap were trimmed, and three endoscopic clips were placed in the base of the defect. No complications occurred, and an esophagogram 1-day post-op revealed no leak and resolution of the diverticulum (Fig. 1D). At three months of follow-up, the patient endorses complete resolution of her dysphagia and regurgitation.

Discussion: While open surgical diverticulectomies and stapling techniques have been the most common interventions utilized for pharyngoesophageal diverticulum in the past, POEM has become a promising alternative in recent years. This novel technique has the benefit of being less invasive -especially with the risk of laryngeal recurrent nerve injury in open cervical interventions for KJD- yet still being highly effective. Previous endoscopic techniques, such as the traditional endoscopic septotomy, have a higher risk of recurrence due to the inability to perform a complete septal myotomy. However, the Ni-POEM technique reduces this risk while maintaining the previously stated benefits, especially obviating the need for submucosal injection and dissection, thus decreasing operative time and achieving the same efficacy as the traditional POEM technique.



Disclosures:


Carter E. Edmunds, MD¹, Eleazar Enrique. Montalvan-Sanchez, MD², Dalton A.. Norwood, MD³, Sergio A. Sánchez-Luna, MD⁴. P4521 - Novel Non-Injection Non-Tunnel Technique for Peroral Endoscopic Myotomy (Ni-POEM) for the Treatment of a Refractory Killian-Jamieson Diverticulum (KJD), ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.