Introduction

Blown-out myotomy (BOM) is a rare complication following Heller myotomy or Peroral Endoscopic Myotomy (POEM), characterized by pseudodiverticular dilation at the site of the  previous myotomy [1,2]. It results from mucosal herniation through the muscular defect and can lead to food stasis and symptom recurrence. Risk factors include type III achalasia, elevated integrated relaxation pressure (IRP), and inadequate myotomy extension [3–5]. Diverticular-Peroral Endoscopic Myotomy (D-POEM) has emerged as a promising minimally invasive treatment [6,7].

Case Presentation

A 68-year-old man with type III achalasia, who had previously undergone an anterior POEM in 2017, presented with recurrent dysphagia, retrosternal pain, and mild weight loss (Eckardt score 7). Upper GI endoscopy revealed two pseudodiverticular ectasias—BOMs—in the middle and distal esophagus. Barium swallow confirmed esophageal dilation. The patient underwent endoscopic treatment utilizing a D-POEM approach involving double septotomy.

Procedure

Under general anesthesia, endoscopy revealed food debris inside the BOMs, which was removed using a Roth-Net. A mucosal incision was performed 8 cm above the squamocolumnar junction. Submucosal tunneling and full-thickness myotomy were extended 8 cm (with 3 cm on gastric side), including the distal diverticular septum. Mucosal closure was achieved with four endoclips.To address the middle BOM, a second mucosal entry was created. A 7 cm tunnel and septotomy were performed in a similar manner, followed by clip closure.

Outcome

Postoperative endoscopy after 24 hours confirmed proper clip placement and mild mucosal trauma. The patient resumed oral intake within 24 hours and was discharged on postoperative day 2. At three-month follow-up, symptoms had resolved (Eckardt score 2).

Conclusion

This is the first reported case of simultaneous double D-POEM for BOM in two esophageal segments. D-POEM is safe, effective, and should be considered for symptomatic BOM.