Postmyotomy Esophageal Diverticulum-A Unique Entity Mimicking Achalasia Recurrence

Area of Science:

• Gastroenterology
• Surgical Innovation
• Esophageal Motility Disorders

Background:

• Dysphagia recurrence after achalasia myotomy presents diagnostic challenges.
• Postmyotomy esophageal diverticula, often linked to incomplete myotomy, cause dysphagia.
• A novel presentation of esophageal diverticula after successful myotomy mimics achalasia recurrence.

Purpose of the Study:

• To describe a new entity of esophageal diverticula after complete achalasia myotomy.
• To analyze clinical data, diagnosis, treatment, and outcomes of patients with postmyotomy epiphrenic diverticula.
• To propose a diagnostic and treatment algorithm for dysphagia following achalasia myotomy.

Main Methods:

• Review of a prospectively maintained database of achalasia and diverticula patients (January 2012 - June 2024).
• Collection and analysis of demographic, clinical, diagnostic, treatment, and outcome data.
• Focus on patients who underwent esophageal diverticulectomy after prior myotomy.

Main Results:

• Nine patients underwent esophageal diverticulectomy; five had prior achalasia myotomy (per-oral endoscopic myotomy, laparoscopic Heller myotomy, or pneumatic dilation).
• All patients experienced symptom recurrence, with confirmed open lower esophageal sphincter.
• Esophageal diverticulectomy, without additional myotomy, resolved dysphagia (median Eckardt score improved from 5 to 0).

Conclusions:

• Epiphrenic diverticula can occur after adequate achalasia myotomy, causing dysphagia.
• This entity, distinct from insufficient myotomy, is effectively treated by diverticulectomy.
• A diagnostic and treatment algorithm is suggested for postmyotomy dysphagia in achalasia patients.