Harsimran Kalsi, MD1, Kobina Essilfie-Quaye, MD2, Carson Creamer, DO2, Mohammad Abu Assi, MD1, Tony Brar, MD1, Yaseen Perbtani, DO2 1University of Central Florida, Gainesville, FL; 2University of Central Florida, HCA Healthcare GME, Gainesville, FL Introduction: Epiphrenic diverticula are rare pulsion-type outpouchings of the distal esophagus, commonly associated with esophageal motility disorders such as esophagogastric junction outflow obstruction (EGJOO). Surgical management can be challenging in elderly patients with multiple comorbidities due to elevated perioperative risk. Double-tunnel peroral endoscopic myotomy with diverticulotomy (D-POEM) has emerged as a minimally invasive alternative that allows for simultaneous treatment of both functional and structural abnormal
Case Description/
Methods:
Case Description A 77-year-old female with known EGJOO presented with progressive dysphagia, regurgitations and weight loss. Previous therapies, including botulinum toxin injection and serial esophageal dilations had minimal symptom relief. Previous high-resolution manometry demonstrated EGJOO with a hypercontractile esophageal pattern while a timed barium esophagogram revealed delayed esophageal clearance. Upper endoscopy identified a large esophageal diverticulum in the distal third of the esophagus, impaired peristalsis, and a hypertonic lower esophageal sphincter, concerning for an esophageal motility disorder characterized by impaired LES relaxation and disordered peristalsis, consistent with EGJOO. Her baseline Eckardt score was 10 (Weight loss 2, Dysphagia 3, Retrosternal pain 2, Regurgitation 3).
Intervention The patient underwent single-session double-tunnel peroral endoscopic myotomy with diverticulotomy.. The procedure involved submucosal tunneling and sequential myotomy of both the distal esophagus and the diverticular septum. Postoperative CT esophagogram did not reveal any evidence of extraluminal contrast extravasation to indicate esophageal or gastric leak. The patient was started on a clear liquid diet and discharged on a proton pump inhibitor and short-course antibiotics.
Follow up
At four-week follow-up, the patient reported marked symptomatic improvement with an Eckardt score of 1. She experienced only a single episode of regurgitation and had successfully progressed from liquids to solid food. Discussion: This case demonstrates the feasibility, safety, and therapeutic efficacy of single-session D-POEM for managing coexisting epiphrenic diverticulum and EGJOO in a high-risk patient. The simultaneous endoscopic approach offers a comprehensive, minimally invasive alternative to traditional surgery, particularly valuable in patients with significant comorbidities.
Figure: Figure 1 (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, yellow star indicates esophageal lumen (c-d) Submucosal dissection of the lower esophageal sphincter and diverticulotomy (e) Endoscopic view within the submucosal tunnel (f) Closure of the mucosal incision with through the scope clips
Disclosures: Harsimran Kalsi indicated no relevant financial relationships. Kobina Essilfie-Quaye indicated no relevant financial relationships. Carson Creamer indicated no relevant financial relationships. Mohammad Abu Assi indicated no relevant financial relationships. Tony Brar indicated no relevant financial relationships. Yaseen Perbtani indicated no relevant financial relationships.
Harsimran Kalsi, MD1, Kobina Essilfie-Quaye, MD2, Carson Creamer, DO2, Mohammad Abu Assi, MD1, Tony Brar, MD1, Yaseen Perbtani, DO2. P1461 - Single-Session Double Tunnel Peroral Endoscopic Myotomy With Diverticulotomy for Epiphrenic Diverticulum With Esophagogastric Junction Outflow Obstruction, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
