Two male patients, aged 83 and 74, both taking antithrombotic drugs (one under anticoagulation with edoxaban and the other patient under dual antiplatelet therapy with acetylsalicylic acid and ticlopidine) were referred to our department due to a large epiphrenic esophageal diverticulum (mean size of 45.±7.1mm) on outpatient upper gastrointestinal endoscopy, associated with achalasia-like symptoms (dysphagia, regurgitation and nonintentional weight loss) with a mean Eckardt score of 6.5±2.1. High-resolution esophageal manometry revealed distal esophageal spasm in one of the cases. Esophageal motility disorders are often associated with esophageal diverticula, indicating the need for intervention to address not only the structural esophageal problem but also the associated motility disorder. Left-side esophageal diverticula (6–12 o’clock position), especially epiphrenic diverticula pose an additional major bleeding risk for Peroral Endoscopic Myotomy (POEM) due to the potential injury of the aorta and other major vessels.

For this specific subtype of left-side esophageal diverticula, we propose a double tunneling approach in a single procedure: the left tunnel limited to septotomy (D-POEM) and the right tunnel for E-POEM from the diverticulum to the cardia, reducing the risk of major bleeding. For both cases, left tunnel in a posterior approach (7 o’ clock position) for D-POEM was performed using a triangle-tip (TT) Knife J (Olympus, Japan) with Spray Coag 2.5 mode (VIO3 ERBE, Germany), starting 3cm proximal to the diverticular septum and extending 3cm distal to the septum. After isolating the septum, a complete septotomy was performed with TT-knife J with Endocut Q 2.0/Forced Coag 3.0 mode. Then, right tunnel in a posterior approach (5 o’ clock position) and subsequently complete myotomy were performed for E-POEM, from the level of the diverticular septum to the cardia, using the same knife and electrosurgical parameters described for D-POEM. Both mucosotomies were closed with TTS clips. Mean procedure time was 97.5±31.8min. One patient presented subcutaneous emphysema and capnoperitoneum requiring intraprocedural percutaneous drainage. No other complications were reported. 

At a mean follow-up of 5.0±4.2months, both patients remain completely asymptomatic (Eckardt score of 0), with no complications.

We present a variant double tunneling technique combining D-POEM with a complete septotomy and limited esophageal myotomy at the left side of the esophagus and E-POEM with a complete myotomy up to the cardia at the right side of the esophagus, that has proven to be effective and safe for the treatment of symptomatic left-side epiphrenic esophageal diverticula, addressing both structural and motility abnormalities in a single procedure. This minimally invasive endoscopic approach highlights the effective treatment of symptoms associated with the diverticulum, the prevention of its recurrence, treating underling motility disorders, which are often associated with it, and avoiding potential injury of large vessels and major bleeding complication, given the diverticulum proximity to the aorta and other major vessels, even in patients under antithrombotic drugs.