Work

Rarer than rare: managing an epiphrenic diverticulum in achalasia

Year: 2025

Type: article

Abstract: An epiphrenic diverticulum is an extraordinarily rare condition, occurring in approximately 1 per 500.000 people per year [ 1 ]. It is often associated with esophageal motility disorders (achalasia in 60% of cases) and, when large (i.e. >5 cm), undoubtedly causes symptoms such as dysphagia, regurgitation, weight loss, and aspiration pneumonia [ 1 ] [ 2 ]. Malignant transformation, mostly into squamous cell carcinoma, occurs in about 0.6% of cases [ 3 ]. When a symptomatic diverticulum is associated with a motility disorder, subsequent management must address both conditions: minimally invasive surgery usually includes resection of the diverticulum, myotomy of the lower esophageal sphincter (LES), and an antireflux procedure [ 3 ]. A 77-year-old man presented to the emergency room with progressive dysphagia and food regurgitation. Following two unsuccessful esophagogastroduodenoscopy (EGD) attempts at another hospital, a barium esophagogram showed a dilated esophagus with a prominent diverticulum above the LES ([ Fig. 1 ]). An EGD was eventually completed, revealing a markedly dilated, atonic esophagus filled with partially digested food, and a large epiphrenic diverticulum ([ Video 1 ]). The esophagogastric junction was passed with slight resistance using a 11.6-mm wide, high definition gastroscope (Pentax EG34-i10). A “Contents, Anatomy, Resistance, and Stasis” (CARS) score of 7 was highly suggestive of achalasia [ 4 ]. Type II achalasia was diagnosed via high resolution manometry (HRM), according to Chicago classification 4.0 ([ Fig. 2 ]). Fig. 1 Initial barium esophagogram showing a dilated esophagus with a prominent diverticulum above the lower esophageal sphincter. Fig. 2 High resolution manometry showing the absence of lower esophageal sphincter (LES) relaxation ( a : single swallow, integrated relaxation pressure [IRP] = 32.5 mmHg; b : rapid drink challenge, IRP = 36.5 mmHg), with concomitant esophageal panpressurizations , which is compatible with type II achalasia. Download Type II achalasia and a large epiphrenic diverticulum were diagnosed on barium esophagogram, esophagogastroduodenoscopy, high resolution manometry, and computed tomography before the patient underwent laparoscopic diverticulectomy, Heller myotomy, and Dor fundoplication.Video 1 A preoperative abdominal computed tomography scan confirmed dilatation of the proximal and mid esophagus and a 6 × 5-cm diverticulum ([ Video 1 ]). The patient underwent laparoscopic transhiatal diverticulectomy, Heller myotomy, and Dor fundoplication under intraoperative endoscopic guidance. No perioperative complications occurred. Histology was subsequently negative for malignancy. A postoperative contrast esophagogram showed no leaks and good transit, allowing oral feeding and discharge within a week. At 3-month follow-up, a barium esophagogram confirmed normal passage of barium and resolution of the diverticulum ([ Fig. 3 ]). Fig. 3 Repeat barium esophagogram at 3-month follow-up showing normal passage of barium and resolution of the diverticulum. This case adds to the limited literature documenting epiphrenic diverticula in patients with achalasia, and their management [ 5 ]. A comprehensive diagnostic workup and a tailored surgical approach addressing both the diverticulum and the underlying motility disorder are essential to achieve optimal outcomes. Endoscopy_UCTN_Code_CCL_1AB_2AC_3AF Endoscopy E-Videos https://eref.thieme.de/e-videos E-Videos is an open access online section of the journal Endoscopy , reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/ ). This section has its own submission website at https://mc.manuscriptcentral.com/e-videos . Publication History Article published online: 08 August 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Source: Endoscopy

DOI: 10.1055/a-2653-8710