Post written by Fatih Aslan, MD, from the Department of Gastroenterology and Advanced Endoscopy, Koc University Hospital, Istanbul, Turkey.

This case involved a 53-year-old woman who presented with dysphagia, chest pain, cough, and vomiting. Diagnostic evaluation revealed a 9-cm epiphrenic diverticulum along with an underlying esophageal motility disorder. We successfully treated this rare and complex condition through a completely endoscopic and minimally invasive approach without the need for surgery.

Epiphrenic diverticula are rare, distal esophageal outpouchings traditionally treated with surgery. However, high morbidity and recurrence rates have led to growing interest in less-invasive alternatives.

With the evolution of third-space endoscopy, peroral endoscopic myotomy (POEM) has been introduced as a treatment modality for such disorders. Yet in large diverticula, POEM alone may be insufficient, as the diverticulum can remain as a food reservoir and continue to cause symptoms, limiting overall clinical success.

In this case, we combined POEM, endoscopic submucosal dissection, submucosal tunneling endoscopic resection, and traction-assisted dissection with the incorporation of absorbable barbed sutures, commonly used in surgery, into the endoscopic field. This allowed us to achieve complete anatomical and functional restoration without surgery.

This video highlights a novel, scar-free, organ-preserving approach to a complex and rare esophageal disease that has traditionally been managed surgically. By featuring this case, we show how third-space endoscopy techniques, when paired with advanced suturing strategies, can expand the scope of therapeutic endoscopy and reduce the need for invasive surgery.

It also presents a clear visual demonstration of how surgical materials such as barbed sutures can be safely and effectively adapted to endoscopic use, contributing to a secure closure, reduced recurrence risk, and optimal healing.

Other endoscopists can learn from this experience that:

• Complex esophageal conditions such as large epiphrenic diverticula, once considered surgical cases, can now be effectively and safely managed with third-space endoscopic techniques.
• POEM and endoscopic submucosal dissection principles can be adapted to address uncommon but challenging clinical scenarios.
• Traction-assisted dissection improves precision and safety in difficult areas.
• The use of barbed sutures for closure after endoscopic resection may reduce recurrence and ensure a watertight seal, contributing to successful reconstruction.

This case illustrates how far the boundaries of endoscopic therapy can be extended. By successfully integrating a surgical suturing technique into endoscopic practice, we were able to not only resect the diverticulum but also close both the diverticular base and tunnel entrance securely, preventing recurrence and achieving complete healing. No morbidity or organ loss occurred. All the patient’s symptoms resolved completely.

This experience may serve as a foundation for future innovative endoscopic interventions, especially for patients in whom traditional surgery carries high risk or morbidity. It opens the door for minimally invasive yet curative solutions in complex esophageal pathology.

Schematic view of the epiphrenic diverticulum.

Read the full article online.

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