Chisthi MM, Kuttanchettiyar KG, Viswanath S. One tunnel, two pathologies: Tailoring submucosal tunnelling per-oral endoscopic myotomy in achalasia with epiphrenic diverticulum by septum morphology. World J Gastroenterol 2026; 32(35): 118916 [DOI: 10.3748/wjg.118916]
Corresponding Author of This Article
Sindhu Viswanath, MS, Assistant Professor, Department of Otorhinolaryngology, Government Medical College Trivandrum, Ulloor, Thiruvananthapuram 695011, Kerala, India. sindhuvn@gmail.com
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Gastroenterology & Hepatology
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editorial
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Chisthi MM, Kuttanchettiyar KG, Viswanath S. One tunnel, two pathologies: Tailoring submucosal tunnelling per-oral endoscopic myotomy in achalasia with epiphrenic diverticulum by septum morphology. World J Gastroenterol 2026; 32(35): 118916 [DOI: 10.3748/wjg.118916]
World J Gastroenterol. Sep 21, 2026; 32(35): 118916 Published online Sep 21, 2026. doi: 10.3748/wjg.118916
One tunnel, two pathologies: Tailoring submucosal tunnelling per-oral endoscopic myotomy in achalasia with epiphrenic diverticulum by septum morphology
Meer M Chisthi, Krishnakumar G Kuttanchettiyar, Sindhu Viswanath
Meer M Chisthi, Krishnakumar G Kuttanchettiyar, Department of General Surgery, Government Medical College Kollam, Parippally 691574, Kerala, India
Sindhu Viswanath, Department of Otorhinolaryngology, Government Medical College Trivandrum, Thiruvananthapuram 695011, Kerala, India
Co-first authors: Meer M Chisthi and Krishnakumar G Kuttanchettiyar.
Author contributions: Chisthi MM and Kuttanchettiyar KG drafted the manuscript and they contribute equally to this study as co-first authors; Viswanath S and Chisthi MM acquired and analyzed the data; Viswanath S and Kuttanchettiyar KG vetted the manuscript; all authors approved the final version to be published and agreed to be accountable for all aspects of the work.
AI contribution statement: The only AI tool used was DeepSeek (version from March 2025). We used it selectively on paragraphs that felt awkward or unclear - primarily in the Introduction and Discussion sections. After editing, we compared the AI-polished version against our original draft line by line to ensure no factual or logical changes were introduced. We take full responsibility for every claim, citation, and conclusion in this manuscript.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest regarding the publication of this paper.
Corresponding author: Sindhu Viswanath, MS, Assistant Professor, Department of Otorhinolaryngology, Government Medical College Trivandrum, Ulloor, Thiruvananthapuram 695011, Kerala, India. sindhuvn@gmail.com
Received: January 14, 2026 Revised: February 16, 2026 Accepted: March 10, 2026 Published online: September 21, 2026 Processing time: 217 Days and 12.8 Hours
Abstract
Achalasia complicated by epiphrenic diverticulum presents a significant therapeutic dilemma. While per-oral endoscopic myotomy (POEM) has transformed achalasia management, the optimal handling of the concomitant diverticulum remains contentious. Hao et al[1] describe the simultaneous treatment of concomitant achalasia with epiphrenic diverticulum using a submucosal tunneling technique. This editorial synthesizes recent evidence to advocate for a decisive paradigm shift from universal protocols to a precise, morphology-guided strategy. Key data from meta-analyses indicate that POEM achieves success rates of 88%-95% in this group of patients. Crucially, outcomes are equivalent whether a selective septotomy is performed for obstructing septa or standard myotomy alone is used for non-septated diverticula. This tailored approach minimizes unnecessary intervention, reduces procedural risks, and maintains excellent efficacy. We propose a pragmatic clinical framework centered on real-time endoscopic phenotyping, positioning it as the evolving standard of care that embodies the principles of personalized, precision endoscopy for complex esophageal disorders.
Core Tip: Management of achalasia with epiphrenic diverticulum is evolving. A one-size-fits-all septotomy is no longer justified. Intra-procedural endoscopic phenotyping allows for a selective approach: Division of a functionally obstructive muscular septum when present and standard myotomy alone when absent. This precision strategy, supported by recent meta-analytic data showing high treatment success for per-oral endoscopic myotomy in epiphrenic diverticula, achieves comparable outcomes to universal septotomy while minimizing overtreatment and its associated risks.
