Recent advances in managing esophageal epiphrenic diverticula: a review of the impact of endoscopy, high-resolution manometry, and POEM.

Epiphrenic diverticula (ED) are pulsion diverticula found in the distal esophagus. They are rare and often associated with esophageal motility disorders. Given technological advances over the past number of years that have impacted the care of patients with ED, it is worthwhile reviewing the recent literature on this entity. As endoscopy is now commonly practiced, there is evidence that ED is mainly being diagnosed endoscopically and that more asymptomatic patients may be diagnosed. The age of patients with ED may also be increasing given increases in life expectancies. Recent studies using high-resolution manometry (HRM), the gold standard for diagnosing motility disorders, have shown that ~ 50-60% of ED patients are diagnosed with a motility disorder according to the Chicago Classification. Studies have also confirmed that the presence of ED is a risk factor for an unsuccessful HRM exam. Finally, with the advent of peroral endoscopic myotomy (POEM), a successful endoscopic treatment is available. While there are several variations to the procedure, such as whether it is performed with septotomy or without, and whether the myotomy is extended through the lower esophageal sphincter and into the stomach or not, POEM has changed the therapeutic algorithm of ED. There is evidence that it has excellent technical and clinical success rates equivalent to that of surgery, but with lower adverse events compared to surgical procedures. In conclusion, recent technological developments have provided a better understanding of ED and offer patients a highly successful, minimally-invasive endoscopic treatment.