Peroral endoscopic tunneling stricturotomy for diverticulum treatment: novel procedure for pediatric esophageal anastomotic diverticula.

BACKGROUND AND AIMS: This case details an 8-year-old female patient with a type C tracheoesophageal fistula and esophageal atresia who developed a symptomatic diverticulum proximal to an anastomotic scar band. This patient underwent diverticular-peroral endoscopic tunneling stricturotomy (D-POETS), a novel procedure for management of symptomatic postoperative diverticula refractory to incisional therapy and balloon dilation.

METHODS

Before the D-POETS procedure, an intraoperative esophagram showed an anastomotic diameter of 18 mm and a proximal diverticulum extending 1 cm below the anastomotic scar band. A mucosal bleb was formed 3 cm proximal to the diverticulum using a methylene blue and saline solution. A mucosotomy was created for submucosal hydrodissection and tunneling using a Hybrid T-type knife (Erbe, Tübingen, Germany). As the endoscope approached the scar band, the easily dissectible submucosal connective tissue transitioned to disorganized scar fibers and a difficult dissection plane.

RESULTS

At its conclusion, the tunnel length measured 3.5 cm and extended 5 mm distal to the scar band. After the stricturotomy, the scar band had an improved diameter (21 mm) with improved esophageal contour. At 8 months postoperatively, the patient's solid food dysphagia remained resolved.

CONCLUSIONS

To our knowledge, the D-POETS technique is the first reported use of endoscopic third-space submucosal tunneling for stricturotomy of an anastomotic diverticulum.