Esophageal diverticulum is a rare condition, that is most commonly associated with esophageal motility disorders. The epiphrenic diverticulum typically originates in the distal esophagus, 4-8cm above the cardia and develops in consequence of increased intraluminal pressure. Its estimated yearly incidence is 1:500,000. In the past a surgical treatment was used to remove the diverticulum, but it had 15% morbidity and 3% mortality rates. Nowadays, the endoscopic treatment does not remove the diverticular sac, but it copes with the symptoms and has nominal adverse events.

We present five cases of esophageal diverticula in four patients aged 43 to 71. The procedures were performed from 2020 to 2025. All of the patients had symptoms of dysphagia, vomiting of unprocessed foods, chest pains and reduction in weight, with duration up to 2 years. The diverticula were diagnosed, either with endoscopy, or with upper gastrointestinal series with contrast. One of the patients had two epiphrenic diverticula one above the other. The median size of the diverticula was 5.19 cm (4-7cm range) in height. Three of the four patients had achalasia as a concomitant disease.

            The procedures were performed with the patients placed under general anesthesia in supine position. The endoscopes used had distal attachments placed. After the localization of the diverticula, a solution of Gelofusine and Indigo carmine was introduced in the submucosal space 2 to 3 cm superiorly to the proximal end of the diverticula. Initial mucosal incisions were created. Dissections of both sides of the distal end of the diverticula were performed. From that point to two centimeters distal of the gastroesophageal junction submucosal tunnels were created.  The tunneling was done with utmost care as not to damage the mucosa or the adventitia. Myotomy of the distal septum and myotomy of the muscle layer in the esophagus and up to 2cm below the gastroesophageal junction was performed. The initial incisions were closed using 3 to 5 hemostatic clips. Carbon dioxide insufflation was used during all of the procedures.

The diverticular peroral endoscopic myotomy (D-POEM) significantly relieved the symptoms of the patients and the quantity of the retained food and liquids in the diverticular sacs. The adverse events of the procedures were subcutaneous emphysema and retrosternal pain that faded within three days.

            D-POEM is a safe and effective procedure, that results in symptomatic improvement of the patients with epiphrenic diverticula, especially in those cases, where it is combined with achalasia.