S5233 Single-Session Double Tunnel Peroral Endoscopic Myotomy With Diverticulotomy for Epiphrenic Diverticulum With Esophagogastric Junction Outflow Obstruction

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 abnormalities. Case Description: A 77-year-old woman 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 lower esophageal sphincter relaxation and disordered peristalsis, consistent with EGJOO. Her baseline Eckardt score was 10 (weight loss 2, dysphagia 3, retrosternal pain 2, regurgitation 3). The patient underwent single-session D-POEM. The procedure involved submucosal tunneling and sequential myotomy of both the distal esophagus and the diverticular septum. Postoperative computed tomography 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. At 4-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.