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DIVERTICULAR POEM AS AN EFFECTIVE MINIMALLY INVASIVE TREATMENT OPTION FOR EPIPHRENIC DIVERTICULA
Gaston Becherano
*, Anh D. Nguyen, Ashton Ellison, Chanakyaram A. Reddy, Minh-Ly Truong, Roseann Mendoza, Mahalia Sampson-Ansah, Stuart J. Spechler, Vani J. Konda, Eitan Podgaetz
Baylor University Medical Center at Dallas, Dallas, TX
BackgroundEpiphrenic diverticulum is a rare outpouching of the distal esophagus and is associated with esophageal motility disorders, particularly achalasia. Standard treatment involves an esophageal myotomy with diverticulectomy, carries high morbidity with staple line leaks. Peroral endoscopic myotomy with septotomy (D-POEM) is an emerging, safer alternative. This study evaluates D-POEM outcomes in seven patients with epiphrenic diverticula.
MethodsThis retrospective study included all patients who underwent D-POEM for epiphrenic diverticulum between January 2020 and November 2024 at a single institution. Comprehensive workup, including high-resolution manometry (Chicago Classification 4.0), barium imaging, endoscopy, and functional luminal imaging probe (FLIP) panometry was performed. FLIP was also used intraoperatively to assess EGJ metrics and evidence for spastic contractions in the body. Demographics, clinical presentation, outcomes, and follow-up data were collected. Pre- and postoperative Eckardt scores used for symptom assessment.
ResultsSeven patients (mean age 58.2 years, range 31-73, 5 M, 2 F) were included. Symptoms included dysphagia (7), regurgitation (7), chest pain (7), early satiety (1), and weight loss (4). Initial mean Eckardt score was 6 (range 5-8). The mean diverticulum size was 5.1 cm (range 2-8 cm). All patients had a concomitant motility disorder, including Achalasia type 3 (3), EGJOO (3), outflow obstruction (reduced EGJ opening on Endo FLIP but normal IRP on HRM) (1).
The average myotomy length was 9.5 cm (range 6-16 cm). Esophageal spasms were observed above the epiphrenic diverticulum in 5 patients, and these were included in the myotomy.
D-POEM was technically successful in all patients. One had a pinpoint gastric perforation and another a mucosal injury, both managed with endoscopic clips. All patients were discharged on postoperative day 0-2.
At two-week follow-up, all patients tolerated a soft diet without dysphagia or regurgitation. Three-month follow-up EGD was performed on six patients, with all showing sustained symptom improvement and significant reduction in Eckardt scores (mean 1.8 ± 1.06 vs. 6.1 ± 1.16 preoperatively, p < 0.001). The median follow-up was 284 days (range 15–1523 days), with all patients reporting continued symptom relief.
ConclusionsD-POEM is a safe and effective minimally invasive approach for treating epiphrenic diverticula. D-POEM offers lower morbidity compared to traditional surgery and still provides long-term symptom improvement. The POEM approach can target spastic disease above the diverticulum which has the potential to more effectively mitigate an underlying motility disorder.
Figure 1: (A) Epiphrenic diverticulum on esophagram. (B) Lower third of the esophagus. The square box represents the lumen of epiphrenic diverticulum, circle represents the lumen of true esophagus. (C) Intraoperative endo FLIP @ 50 ml. Arrows represent spastic processes in the body, and stars denote the EGJ demonstrating both EGJ obstruction and transient elevation.
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