Peroral Endoscopic Myotomy for Epiphrenic Diverticulum in a High-Risk Patient With Esophagogastric Junction Outlet Obstruction

Abstract

Epiphrenic diverticula are rare and often debilitating, particularly when associated with esophagogastric junction outflow obstruction, and their management is challenging in high-risk surgical candidates. We describe a 77-year-old woman with severe dysphagia, regurgitation, and significant weight loss caused by a large distal epiphrenic diverticulum and esophagogastric junction outflow obstruction. Given her multiple comorbidities, she was not a surgical candidate and underwent peroral endoscopic myotomy with diverticulotomy. The procedure was completed safely, resulting in complete symptom resolution and normalization of her Eckardt score. This case highlights peroral endoscopic myotomy with diverticulotomy as a minimally invasive, anatomy-directed solution for complex esophageal diverticula.

INTRODUCTION

Esophageal diverticula are mucosal outpouchings that can occur in the proximal, middle, or distal third of the esophagus.¹ Distal esophageal pockets are termed as epiphrenic diverticula with a prevalence of 0.015%.¹ They frequently arise as a result of esophageal motility disorders. The standard of care has traditionally involved surgical diverticulectomy, which is associated with complications such as esophageal leak, mediastinitis, infections, and even mortality especially in elderly patients.²

Peroral endoscopic myotomy with diverticulotomy (D-POEM) has emerged as a minimally invasive alternative, allowing for simultaneous treatment of both the diverticulum and the associated motility disorder.³ This case illustrates the successful use of a D-POEM technique in a high-risk elderly patient with epiphrenic diverticulum and esophagogastric junction outflow obstruction (EGJOO).

CASE REPORT

A 77-year-old woman with known EGJOO presented with progressive dysphagia to solids and liquids, daily regurgitation, and unintentional weight loss of 18 pounds over 6 months. She was diagnosed with EGJOO on high-resolution manometry which demonstrated elevated integrated relaxation pressure with preserved peristalsis, consistent with EGJOO and a hypercontractile esophageal pattern. She had previously undergone treatment with serial esophageal dilations and botulinum toxin injection with only transient symptom relief.

A timed barium esophagogram revealed delayed esophageal clearance, a corkscrew appearance suggestive of esophageal spasm, and a large distal epiphrenic diverticulum (Figure 1). A contrast-enhanced computed tomography esophagogram further showed persistent contrast retention at the esophagogastric junction with pooling within the diverticulum, consistent with EGJOO (Figure 2). Upper endoscopy confirmed a wide-necked diverticulum, along with a hypertonic lower esophageal sphincter and impaired esophageal clearance. Her baseline Eckardt score was 10, indicating severe symptom burden.

Figure 1.

Barium esophagogram before peroral endoscopic myotomy with diverticulotomy: (A) lower esophageal sphincter narrowing with delayed clearance (yellow arrow) and (B) cork-screw appearance showing esophageal spasm (blue arrow).

Figure 2.

Computed tomography with esophagogram: (A) delayed contrast passage with narrowing at the esophagogastric junction (yellow arrow) and (B) persistent contrast retention within the distal esophagus and epiphrenic diverticulum (blue arrow).

Given her advanced age and multiple comorbidities including coronary artery disease with prior percutaneous coronary intervention, hypertension, hyperlipidemia, and rheumatoid arthritis, she was deemed a high-risk candidate for surgical diverticulectomy. As a result, she was referred for D-POEM as a minimally invasive alternative.

Procedural details

Upper endoscopy revealed a large epiphrenic diverticulum, arising from the posterior left lateral wall of the distal esophagus (Figure 3). The esophageal lumen was irrigated and cleared of retained debris using sterile water. A submucosal injection of methylene blue mixed with hetastarch was administered to achieve adequate mucosal lift followed by creation of a mucosal incision using a HybridKnife I-type (ERBE, Tubingen, Germany).

Figure 3.

(A) Submucosal injection of methylene blue at the level of lower esophageal sphincter; (B) pink arrow indicates the diverticulum, red dashed line indicates the border of diverticulum, and yellow star reveals esophageal lumen; (C) and (D) submucosal dissection of the lower esophageal sphincter and diverticulotomy; (E) endoscopic view within the submucosal tunnel; and (F) closure of the mucosal incision through the scope clips.

Using an endoscope fitted with a clear distal cap, submucosal dissection was performed to create a tunnel extending distally into cardia. Within the tunnel, the diverticular septum and a tight lower esophageal sphincter were clearly visualized.

Circular myotomy was initiated in the posterior orientation (5 o'clock position) and extended into the cardia. A complete septotomy of the diverticular wall was then performed using the same HybridKnife, extending from the apex to the base of the septum and aligned with the myotomy plane.

Hemostasis was maintained throughout the procedure using coagulation graspers (Olympus, Tokyo, Japan). The mucosal entry site was closed using through-the-scope clips (Boston Scientific, Marlborough, MA).

Outcomes

The patient tolerated the procedure without any immediate or delayed adverse events. A postoperative computed tomography esophagogram on postoperative day 1 showed no evidence of extraluminal contrast or leak. She was started on a clear liquid diet and discharged on postoperative day 2 with a proton pump inhibitor and a 5-day course of oral antibiotics.

Follow-Up

At 8-week follow-up, the patient reported marked improvement in symptoms. She had resumed a soft diet, denied any dysphagia or retrosternal pain, and her post-POEM Eckardt score had improved from 10 to 0. She remained on once-daily proton pump inhibitor therapy and reported no symptoms suggestive of reflux.

DISCUSSION

D-POEM enables concurrent septotomy and esophageal myotomy via a single mucosal entry, offering a minimally invasive solution for patients with symptomatic distal esophageal diverticula and associated motility disorders.^4,5 In this case, we demonstrate the successful use of D-POEM via the posterior approach in a surgically high-risk patient with challenging esophageal anatomy.

Traditionally, epiphrenic diverticula have been managed surgically with laparoscopic diverticulectomy, myotomy, and fundoplication.^1,2 However, these procedures are associated with notable perioperative risks, especially in elderly patients. Furthermore, incomplete septum division has been a limitation of earlier endoscopic techniques.^1,2 D-POEM overcomes this by allowing for complete, targeted septotomy under direct visualization through the submucosal tunnel, potentially reducing the risk of symptom recurrence.^6,7 Sanaei et al also demonstrated POEM's utility in patients with persistent or recurrent symptoms after prior interventions, reinforcing its value as a salvage strategy.⁸

The concept of submucosal tunneling allows precise exposure and division of the diverticular septum. Basile et al first introduced this approach in a case series of elderly patients, reporting high technical success with favorable symptomatic outcomes.³ In a larger series, Yang et al demonstrated a 90.9% technical success rate and 100% clinical response.⁷ More recently, Ren et al⁶ conducted a multicenter study with a minimum follow-up of 3 years, reporting a durable 88.2% clinical success rate with a low incidence of complications.

Surgical treatment of epiphrenic diverticulum carries a high risk of adverse events, with 1 meta-analysis reporting a 21% complication rate, most commonly staple line leaks, which accounted for two-thirds of reinterventions.² By contrast, D-POEM offers a less invasive alternative that addresses both the mechanical outpouching and the underlying motility disorder in a single session.⁴ Its expanding role in this setting underscores the importance of individualized, anatomy-guided therapeutic options especially for patients with elevated surgical risk.

DISCLOSURES

Author contributions: H. Kalsi, KE Quaye: case conception, data acquisition, literature review, and manuscript drafting. C. Creamer, M. Abuassi: clinical data collection and manuscript revision. TS Brar, Y. Perbtani: procedural expertise, critical revision of the manuscript for important intellectual content, and overall supervision. All authors reviewed and approved the final manuscript. H. Kalsi is the article guarantor.

Financial disclosure: None to report.

Previous presentation: This study was presented as a poster (P1461) at the American College of Gastroenterology Annual Meeting; October 26, 2025; Phoenix AZ.

Informed consent was obtained for this case report.

ABBREVIATIONS:

D-POEM

peroral endoscopic myotomy with diverticulotomy

EGJOO

esophagogastric junction outflow obstruction

LES

lower esophageal sphincter

POEM

peroral endoscopic myotomy