Clinical outcomes of D-POEM for epiphrenic diverticula: An international multicenter experience of full-thickness septotomy versus submucosal tunneling

Background : Esophageal epiphrenic diverticulum (ED) is a pulsion diverticulum of the distal esophagus that arises from elevated lower esophageal sphincter pressure. Conventional treatment has traditionally involved complex thoracic surgical approaches that are associated with substantial morbidity and mortality. This study aimed to compare outcomes between two minimally invasive variations of diverticular per-oral endoscopic myotomy (D-POEM): full-thickness septotomy with transverse closure (POEM + FTS) and traditional submucosal tunneling followed by septotomy (POEM + S). Methods : This international, multicenter retrospective cohort study included six centers between January 2020 and October 2024. Patients with symptomatic ED who underwent D-POEM were included. The primary outcome was clinical success, defined as an Eckardt score (ES) ≤ 3 or a 1-point reduction in ES for patients with a baseline ES < 3, without the need for repeat intervention during follow-up. Results : A total of 35 patients (mean age, 64.4 years; 51.4% female) underwent D-POEM for ED. POEM + FTS (n = 6) and POEM + S (n = 29) both demonstrated a technical success rate of 100%. An associated esophageal motility disorder was identified in 17 patients (48.6%), including achalasia in 9 patients (52.9%) and esophagogastric junction outflow obstruction in 4 patients (23.5%). Procedural duration was comparable between groups, with a median of 52 minutes in the POEM + FTS group versus 62 minutes in the POEM + S group (P = 0.59). There was no statistically significant difference in adverse event rates between the two groups (0% vs 6.8%; P > 0.999). The median length of hospital stay was significantly longer after POEM + S than after POEM + FTS (4 days [interquartile range (IQR), 2-4 days] vs 1 day [IQR, 1-1 day]; P = 0.01). Clinical success rates were equivalent between groups (100% vs 96.6%, not significant) at a median follow-up of 10 months (IQR, 9-11 months) and 11 months (IQR, 9-12 months), respectively. Conclusion : D-POEM, whether performed as POEM + S or POEM + FTS in expert centers, is feasible, safe, and clinically effective for the treatment of ED. Prospective studies are warranted to further define comparative outcomes.