Single-session dual peroral endoscopic myotomy: near-complete esophageal myotomy for combined Zenker’s diverticulum and Jackhammer esophagus in a patient with longstanding dysphagia

Dysphagia is a debilitating symptom that affects quality of life and frequently arises from esophageal motility disorders.1 Complex esophageal motility disorders represent a challenging spectrum of conditions characterized by abnormal, often overlapping patterns of esophageal contraction and impaired bolus transit.2 These disorders encompass entities such as achalasia, distal esophageal spasm, and hypercontractile disorders, including jackhammer esophagus, and may coexist with structural abnormalities, such as Zenker’s diverticulum.3 Their multifaceted and sometimes concurrent pathophysiology complicates diagnosis and limits the effectiveness of conventional, single-target therapies. Peroral endoscopic myotomy (POEM) has emerged as a versatile and transformative minimally invasive technique for managing this spectrum of disorders.4 By enabling precise, tailored myotomy of dysfunctional high-pressure zones through a submucosal tunnel, POEM preserves mucosal integrity while offering durable symptom relief with significantly lower morbidity than traditional surgery.5 Its adaptability has expanded its use to patients with complex or overlapping motility abnormalities, allowing treatment of multiple pathological segments in a single session when performed by experienced operators.6 Success rates consistently exceed 90%, with a low incidence of adverse events. We report a unique case of complex esophageal motility disorder successfully treated with near-total esophageal myotomy in a single session, addressing recurrent Zenker’s diverticulum and a coexistent jackhammer esophagus.

A 59-year-old man with no comorbidities presented with progressive dysphagia to solids and liquids for six years. He reported frequent episodes of food impaction, marked regurgitation of undigested food (a few hours after meals), halitosis, and spasmodic retrosternal pain. Symptoms were partially relieved by drinking water immediately after meals, which helped push the food bolus down. He had undergone esophageal surgery six years earlier for Zenker’s diverticulum (operative details are unavailable), with incomplete symptom resolution. A barium swallow performed one year after surgery demonstrated contrast hold-up with a small outpouching in the upper esophagus, suggestive of a recurrent or residual upper esophageal diverticulum.

On evaluation, upper gastrointestinal endoscopy revealed a large hypopharyngeal diverticular pouch measuring approximately 5 cm in axial length, just beyond the cricopharynx, with a prominent ridge (Zenker’s diverticulum) separating it from the true esophageal lumen and containing solid food residue. The remaining esophagus demonstrated multiple concentric rings and strong peristaltic contractions, with notable resistance encountered when advancing the scope across the lower esophageal segment.

Given the possibility of dual pathology, high-resolution manometry (HRM) was performed to assess distal motility disorders. An HRM catheter (Solar GI; Laborie Medical Technologies Corp.) was passed under endoscopic guidance, and the study showed a median integrated relaxation pressure of 5.35 mmHg (upright; normal<12), a distal contractile integral of 9,482 mmHg•s•cm (normal, 450–8,000), and a distal latency of 8.6 seconds (normal>4.5) (Fig. 1). Jackhammer esophagus with a Zenker’s diverticulum was diagnosed. A 24-hour esophageal pH-metry study subsequently performed was normal.

Fig. 1.

High-resolution manometry showing hypercontractile vigor.

The patient underwent combined endoscopic treatment in a single session under general anesthesia in the supine position. Diagnostic endoscopy confirmed the gastroesophageal junction at 38 cm from the incisors and the base of Zenker’s diverticulum at approximately 18 cm. Esophageal POEM was first performed for the hypercontractile esophagus using a gastroscope (GIF-HQ190; Olympus). A submucosal cushion was created 20 cm from the incisors along the posterior esophageal wall (5 o’clock) using a saline–methylene blue solution. A 1.5–2 cm longitudinal mucosotomy was fashioned using a pulsed current delivered through an electrosurgical unit (endoCUT 1 2-3-3, VIO3/300D; ERBE Inc.), followed by precise pre-cutting using a triangle-tip knife (KD‐645L; Olympus) to facilitate submucosal entry. Submucosal tunneling was meticulously advanced using endoCUT and forced coagulation, with proactive hemostasis of larger vessels achieved using Coagrasper hemostatic forceps (FD-410LR; Olympus); the tunnel was extended up to the gastroesophageal junction. A selective circular myotomy was then performed, starting 2 cm distal to the mucosotomy and extending distally to 1 cm into the cardia, resulting in a total myotomy length of 15 cm in the esophagus and 1 cm on the gastric side (endoCUT 1 2-3-3). The mucosal entry was closed with through-the-scope hemoclips (Medorah) (Fig. 2A–F). The mucosa remained intact throughout.

Fig. 2.

(A) Injection of a saline–methylene blue solution into the submucosa. (B) Mucosal incision to expose the submucosal layer for tunnel creation. (C) Targeted pre-coagulation of visible submucosal vessels using a Coagrasper to minimize bleeding. (D) Clear visualization of the submucosal tunnel. (E) Selective myotomy of the circular muscle fibers. (F) Complete closure of the mucosal entry site with hemoclips. (G) Endoscopic view showing the septum separating the esophageal lumen (red arrow) from the diverticular lumen (green arrow). (H) Submucosal injection into the septal mucosa creating a visible bleb to facilitate safe entry and tunneling. (I) Mucosal incision made over the septum to expose the submucosal space. (J) Submucosal tunneling along the esophageal side. (K) Myotomy with mucosectomy bed showing complete division of the septal muscle fibers. (L) Resection base showing the distal extent of Zenker’s myotomy (black arrow) and the proximal mucosal closure site of esophageal POEM secured with hemoclips (blue arrow).

Subsequently, an open Z-POEM was performed for Zenker’s diverticulum. The septal base of the diverticulum was injected with saline–methylene blue to delineate the submucosal plane. A precise mucosal incision with a triangular-tip knife allowed entry into the submucosal space, followed by bilateral submucosal dissection around the septum using a forced coagulation current. The traversing vessels were coagulated using a Coagrasper. After complete exposure, a full-thickness septal myotomy was performed from the apex to the base of the diverticulum and extended 1 cm beyond. Mucosectomy was then performed to convert the diverticular lumen into a wide, unified submucosal tunnel (open septotomy approach), preserving the underlying buccopharyngeal fascia and adventitia (Fig. 2G–L). Both procedures were performed without any immediate complications.

The total procedure duration was 94 min. The patient was kept nil per os and received intravenous fluids to maintain hydration, antibiotics (amoxicillin+clavulanic acid, 500/125 mg), pantoprazole, and paracetamol for analgesia. Oral clear liquids were initiated 24 hours after a gastrografin swallow study confirmed no leakage, which he tolerated well. He was discharged on postoperative day 2 with instructions to gradually progress to a semi-solid diet over one week. At the one-month follow-up, he reported significant symptomatic improvement with full tolerance to a solid diet and no new symptoms.

This case is unique because of the rare coexistence of a recurrent Zenker’s diverticulum and hypercontractile (jackhammer) esophagus in a patient with dysphagia. Longstanding, untreated cases can lead to food stasis, regurgitation, and secondary esophageal body hypercontractility as a compensatory response to proximal obstruction, ultimately evolving into a jackhammer esophagus.7 The severe dysphagia that emerged or worsened after the patient’s failed Zenker’s diverticulum surgical repair raises the question of whether proximal intervention contributed to or unmasked a concurrent jackhammer esophagus. Although postoperative complications, such as recurrent obstruction, pharyngeal dysfunction, or incomplete myotomy, are well recognized and can sustain proximal dysphagia, no established literature directly links Zenker’s repair procedures to jackhammer esophagus. Theoretically, chronic upstream obstruction from incomplete upper esophageal sphincter relaxation or scarring may have led to compensatory distal esophageal hyperperistalsis over time. Alternatively, altered swallowing biomechanics and neural feedback post-surgery could have exacerbated a pre-existing subclinical distal motility disorder in susceptible patients, although this remains speculative. In this patient, longstanding dysphagia was accompanied by new-onset chest pain, a symptom characteristic of distal spastic disorders. Hence, a comprehensive evaluation with HRM, along with endoscopic findings of multiple concentric rings and resistance in the lower esophagus, was pivotal in determining the additional distal motility disorder. Given the narrowing of the esophageal inlet caused by the septum and the presence of a large Zenker’s diverticular pouch, placement of the manometry catheter was technically challenging and was therefore performed under endoscopic guidance.

For Zenker’s diverticulum, we intentionally opted for an open Z-POEM approach, that is, septal myotomy with mucosectomy, given the patient’s history of recurrent symptoms after prior surgical intervention, as this technique has demonstrated better outcomes in such challenging post-surgical cases.8 In contrast, a long-segment esophageal myotomy was performed within a closed submucosal tunnel to preserve mucosal integrity, minimize the risk of contamination, and ensure procedural safety for the hypercontractile esophagus. Because of the fundamentally different nature of the two interventions, one open (with mucosectomy) and one closed (mucosa-preserving), a single continuous tunnel was not feasible; therefore, we deliberately preserved a 2-cm bridge of intact esophageal mucosa between the two sites to allow secure and effective closure of the esophageal POEM entry point.

By addressing the proximal septum (cricopharyngeal muscle) and distal hypercontractile esophageal body during the same anesthesia session, this approach avoids repeated intubation, reduces cumulative procedural risk, and facilitates rapid symptomatic relief. Alternative strategies include staged procedures, such as rigid or flexible endoscopic septotomy first, followed by POEM later, conventional surgical myotomy with diverticulectomy, or transillumination-assisted flexible endoscopic septotomy alone without addressing the esophageal body.9,10 However, these approaches leave the hypercontractile esophageal body untreated, increasing the likelihood of persistent or recurrent dysphagia.

To the best of our knowledge, this is the first reported case of coexistent Zenker’s diverticulum and jackhammer esophagus, wherein the novelty lies in successfully addressing both pathologies in a single session, demonstrating a pioneering minimally invasive approach to multifocal esophageal disease. The excellent short-term outcome in this case, with complete resolution of dysphagia and full tolerance to a solid diet at the one-month follow-up, further supports its clinical utility.

This case has pushed the limits of POEM with single-session pan-esophageal myotomy for complex motility diseases. Nevertheless, further improvements, including standardization of tunnel orientation, septal dissection technique, and objective criteria for myotomy extent in the hypercontractile segment, are needed to enhance reproducibility and broaden the adoption of this combined approach across endoscopy centers.