Simultaneous treatment of concomitant achalasia coexisting with epiphrenic diverticulum: The practice of submucosal tunneling technique

doi:10.3748/wjg.v32.i9.114758

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World Journal of Gastroenterology

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1007-9327

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Cohort Study

©Author(s) (or their employer(s)) 2026. No commercial re-use. See Permissions. Published by Baishideng Publishing Group Inc.

World J Gastroenterol. Mar 7, 2026; 32(9): 114758
Published online Mar 7, 2026. doi: 10.3748/wjg.v32.i9.114758

Simultaneous treatment of concomitant achalasia coexisting with epiphrenic diverticulum: The practice of submucosal tunneling technique

Ning-Li Chai, En-Qiang Linghu, Long-Song Li, Song Su, Jing-Yuan Xiang, Xiao-Tong Niu, Zi-Meng Wang, Ya-Wei Bi, Xin-Wei Hao

Xin-Wei Hao, Ya-Wei Bi, Zi-Meng Wang, Xiao-Tong Niu, Jing-Yuan Xiang, Song Su, Long-Song Li, En-Qiang Linghu, Ning-Li Chai, Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China

Co-first authors: Xin-Wei Hao and Ya-Wei Bi.

Co-corresponding authors: En-Qiang Linghu and Ning-Li Chai.

Author contributions: Hao XW and Bi YW contribute equally to this study as co-first authors; Linghu EQ and Chai NL contribute equally to this study as co-corresponding authors; Chai NL was the first to propose performing both myotomy and septotomy within the same tunnel; all procedures were performed by Linghu EQ, Chai NL, and Bi YW; Chai NL and Hao XW designed the research study; Hao XW, Bi YW, Wang ZM, Niu XT and Xiang JY performed the research; Hao XW, Su S and Li LS analyzed the data; Hao XW and Bi YW wrote the manuscript; Chai NL and Linghu EQ jointly reviewed the paper; all authors have read and approved the final manuscript.

Institutional review board statement: This retrospective study was approved by the Medical Ethics Committee of Chinese PLA General Hospital (Approval No. S2024-710-01).

Informed consent statement: All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrollment.

Conflict-of-interest statement: The authors report no relevant conflicts of interest for this article.

STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.

Data sharing statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Corresponding author: Ning-Li Chai, MD, Chief Physician, Professor, Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, No. 28 Fuxing Road, Haidian District, Beijing 100853, China. chainingli@vip.163.com

Received: September 28, 2025
Revised: December 7, 2025
Accepted: January 4, 2026
Published online: March 7, 2026
Processing time: 153 Days and 2.3 Hours

Abstract

BACKGROUND

Esophageal epiphrenic diverticulum (ED) often occurs in patients with esophageal motility disorders, and its incidence rate is approximately 3%-7% in achalasia (AC). A distinct septum has been observed in some patients with AC coexisting with ED during gastroscopy. Digestive endoscopic tunnel technique has emerged as a promising therapeutic approach for these patients.

AIM

To evaluate the therapeutic effectiveness of specific treatment methods for ED with septum (ED + S) or ED without septum (ED - S) in AC patients.

METHODS

This retrospective cohort study included 31 patients with AC and esophageal diverticula (21 patients with septum and 10 patients without septum) between January 2016 and January 2025. In ED + S group, submucosal tunneling myotomy combined with diverticular septotomy was performed, while patients in the ED - S group underwent submucosal myotomy alone. The Eckardt scores before and after surgery were compared to evaluate symptom relief and clinical success. The Gastroesophageal Reflux Disease Questionnaire (GERD-Q) score and gastroscopy findings were used to evaluate postoperative gastroesophageal reflux.

RESULTS

The corresponding operation steps were completed in both groups, with a technical success rate of 100%. We successfully followed up with 18 and 10 patients in the ED + S and ED - S group, with a median follow-up period of 2.5 years and 3.0 years, respectively. The postoperative Eckardt scores [median (interquartile range)] were significantly lower in both groups compared with preoperative scores [ED + S group: 6.0 (4.0-8.0) vs 0 (0-2.0), P < 0.05; ED - S group: 6.0 (3.75-8.25) vs 1.0 (0-3.0), P < 0.05]. The clinical success rates (Eckardt score ≤ 3) were 88.9% and 90.0%, respectively. The GERD-Q score was used to evaluate postoperative gastroesophageal reflux, and 3 patients (3/18, 16.7%) in ED + S group and 2 patients (2/10, 20%) in ED - S group experienced symptomatic reflux (GERD-Q score ≥ 8).

CONCLUSION

In AC patients with ED + S, submucosal tunneling myotomy with diverticular septotomy can achieve good therapeutic effects. When there is no obvious septum, submucosal tunneling myotomy is an effective method.

Keywords: Achalasia; Esophageal diverticulum; Per-oral endoscopic myotomy; Blown-out myotomy; Digestive endoscopic tunnel technique

Core Tip: Epiphrenic diverticulum (ED) often occurs in patients with esophageal motility disorders, with achalasia (AC) being the most common. During gastroscopy in patients with AC coexisting with ED, a distinct septum is sometimes observed, while it is absent in others. In response to this clinical situation, we conducted a retrospective study to evaluate the safety and effectiveness of specific treatment methods in different clinical scenarios. The study demonstrated that submucosal myotomy combined with diverticular septotomy offers good clinical outcomes for AC patients with ED and obvious septum, and peroral endoscopic myotomy is effective for AC patients without septum.