# Thoracoscopic Diverticulectomy for Epiphrenic Esophageal Diverticulum after Peroral Endoscopic Myotomy: A Report of Four Cases

## TL;DR

This paper reports four successful cases of thoracoscopic surgery to treat large esophageal diverticula that did not respond to initial endoscopic treatment.

## Contribution

The study introduces thoracoscopic diverticulectomy as a safe and effective alternative for treating large EED after failed POEM.

## Key findings

- Thoracoscopic surgery was safely performed in four patients with large EED after POEM.
- No postoperative complications occurred, and all patients improved with no relapse.
- Thoracoscopy provided better working space compared to laparoscopic procedures.

## Abstract

An epiphrenic esophageal diverticulum (EED) typically occurs in association with esophageal motility disorders such as esophageal achalasia. Although peroral esophageal myotomy (POEM) is the current standard treatment for esophageal achalasia, laparoscopic diverticulectomy with esophageal myotomy and fundoplication are usually performed for EED. Here, we report four cases of thoracoscopic esophageal diverticulectomy performed for symptomatic EED after POEM for esophageal achalasia.

Between 2022 and March 2024, four patients with EED (average diameter, 68 mm) underwent endoscopic esophageal cleaning prior to surgery. POEM was initially performed in all four cases; however, two patients experienced persistent symptoms, while two experienced progressive EED enlargement over the years, necessitating additional surgery. All operations were performed thoracoscopically with the patient in the left lateral position. After resection of the EED, the mediastinal pleura was sutured. Endoscopy, using an endoscopic balloon, was effective in preventing esophageal strictures. No postoperative complications occurred, and the mean postoperative hospital stay was 5.5 (4–8) days. All patients improved postoperatively and remained relapse-free.

Thoracoscopic esophageal diverticulectomy for large EED can be safely performed with better working space than laparoscopic procedures. Therefore, this technique should be considered a minimally invasive treatment for symptomatic EED cases unresponsive to POEM.