Abstract
BackgroundAn esophageal diverticulum is rare and is frequently associated with esophageal motility disorders. Jackhammer esophagus is also rare, is characterized by esophageal hypercontraction, and comprises 4.1% of esophageal motility disorders. Here, we report a case of a patient successfully treated by laparoscopic transhiatal surgery for an epiphrenic esophageal diverticulum derived from a jackhammer esophagus diagnosed with high-resolution manometry (HRM).Case presentationThe patient was a 78-year-old man who presented to the hospital with dysphagia. A diverticulum was detected in the lower part of his esophagus by upper gastrointestinal endoscopy. HRM was performed to investigate esophageal motility disorders. His integrated relaxation pressure was normal at 25.9 (< 26) mmHg, but his distal contractile integral (DCI) was very high at 21,464 (1500–13,000) mmHg s cm. Esophageal peristalsis was preserved. Therefore, the patient was diagnosed as having an epiphrenic esophageal diverticulum derived from a jackhammer esophagus for which laparoscopic transhiatal diverticulectomy and Heller-Dor procedure were performed. The postoperative course was uneventful. His symptoms improved, and the level of DCI also returned to a normal level of 3867 mmHg s cm at 2 months after the operation.ConclusionLaparoscopic transhiatal diverticulectomy and esophagomyotomy can be useful procedures for an epiphrenic esophageal diverticulum derived from a jackhammer esophagus due to their lower invasiveness.
Highlights
An esophageal diverticulum is rare and is frequently associated with esophageal motility disorders
We present a patient who successfully underwent laparoscopic transhiatal surgery for an epiphrenic esophageal diverticulum derived from a jackhammer esophagus diagnosed with highresolution manometry (HRM)
In the 2012 Chicago Classification, jackhammer esophagus was identified as a subtype of nutcracker esophagus (NE) and was defined as an esophageal motility disorder characterized by a distal contractile integral (DCI) greater than 8000 mmHg s cm with normal Integrated relaxation pressure (IRP) in at least two of ten swallows on manometry
Summary
Esophageal diverticulum has been reported to occur at a frequency of 1% among all gastrointestinal diverticula [1]. We present a patient who successfully underwent laparoscopic transhiatal surgery for an epiphrenic esophageal diverticulum derived from a jackhammer esophagus diagnosed with HRM. Upper gastrointestinal endoscopy found a 31-mm diverticulum on the left wall in the lower part of the esophagus (Fig. 1a). A barium esophagogram showed a diverticulum in the lower esophagus 50 mm above the esophagogastric junction (EGJ) and no obstruction of contrast at the lower esophageal sphincter (Fig. 1b). Chest computed tomography (CT) revealed a diverticulum on the left wall in the lower esophagus (Fig. 1c). There was no history of esophageal motility disorder in the patient’s family. The patient was diagnosed as having an epiphrenic esophageal diverticulum derived from a jackhammer esophagus. An esophageal diverticulum was observed on the left side of the esophageal wall 5 cm above the EGJ (Fig. 3b). At 2 months after surgery, his symptoms had improved, and his DCI had returned to a normal level of 3867 mmHg s cm (Fig. 2b)
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