Postmyotomy Esophageal Diverticulum—A Unique Entity Mimicking Achalasia Recurrence

<b><i>Background:</i></b> Recurrence of dysphagia following myotomy for achalasia poses clinical and diagnostic challenges. Postmyotomy esophageal diverticula is a rare disorder, usually developing due to inadequate myotomy, resulting in dysphagia. We herein present a new entity of esophageal diverticula developing after successful complete myotomy, which causes dysphagia and mimics recurrence of achalasia. <b><i>Methods:</i></b> A review of the prospectively maintained database of all patients with achalasia and diverticula between January 2012 and June 2024 was performed. Demographic, clinical data, diagnosis, treatment, and outcomes were collected and analyzed. <b><i>Results:</i></b> A total of 9 patients underwent esophageal diverticulectomy in our institution. Five patients had achalasia and myotomy either by per-oral endoscopic myotomy, laparoscopic Heller myotomy, or pneumatic dilation. All patients suffered from a recurrence of symptoms, with an open lower esophageal sphincter confirmed by manometry or EndoFLIP™. The time from myotomy to diagnosis was 31-117 months. Four were males and 1 was female between the ages of 33 and 58 years, with an average body mass index of 22.4 kg/m². All patients underwent esophageal diverticulectomy with no additional myotomy. Median preoperative and postoperative Eckardt scores were 5 and 0 respectively, with complete resolution of symptoms. <b><i>Conclusions:</i></b> Epiphrenic diverticula is a rare cause of postmyotomy dysphagia in achalasia patients. Previously, this entity was described in the context of insufficient myotomy; however, we present here a case series of patients with epiphrenic diverticula following adequate myotomy with no distal obstruction. Following diverticulectomy, their dysphagia was resolved. We suggest an algorithm for the diagnosis and treatment of dysphagia following myotomy for achalasia.