Epiphrenic Diverticulum Research Articles

Optimal surgical approaches for esophageal epiphrenic diverticulum: literature review and our experience

Esophageal epiphrenic diverticulum is a rare condition usually secondary to a primary esophageal motility disorder. Although epiphrenic diverticulum may be treated by thoracoscopic and laparoscopic management, the optimal surgical approach have not been established. We successfully treated a left epiphrenic diverticulum along with achalasia and paraesophageal hernia by a planned combination of thoracoscopic and laparoscopic procedures aided by preoperative simulation using three-dimensional imaging. We reviewed a series of 17 reports on esophageal epiphrenic diverticulum that required either planned or unplanned unexpected transthoracic surgery. The main reasons for requiring a transthoracic approach were adhesions, site and size of the diverticulum, and length of the diverticulum neck. Unplanned procedure changes were required in 12 of the 114 cases for a conversion rate of 10.5%. Diverticulectomy, myotomy, and fundoplication were the most common surgical treatments administered at 42.6%. Based on literature review and our experience, we have developed a flowchart to identify the characteristics of epiphrenic diverticulum cases that require a transthoracic approach. This flowchart can help to determine therapeutic strategies and the optimal surgical approach to esophageal epiphrenic diverticulum treatment and may reduce unplanned changes in the surgery.

Submucosal endoscopy: the present and future.

Submucosal endoscopy or third-space endoscopy utilizes the potential space between the mucosal and muscularis layers of the gastrointestinal tract to execute therapeutic interventions for various diseases. Over the last decade, endoscopic access to the submucosal space has revolutionized the field of therapeutic endoscopy. Submucosal endoscopy was originally used to perform endoscopic myotomy in patients with achalasia cardia, and its use has grown exponentially since. Currently, submucosal endoscopy is widely used to resect subepithelial tumors and to manage refractory gastroparesis and Zenker's diverticulum. While the utility of submucosal endoscopy has stood the test of time in esophageal motility disorders and subepithelial tumors, its durability remains to be established in conditions such as Zenker's diverticulum and refractory gastroparesis. Other emerging indications for submucosal endoscopy include esophageal epiphrenic diverticulum, Hirschsprung's disease, and esophageal strictures not amenable to conventional endoscopic treatment. The potential of submucosal endoscopy to provide easy and safe access to the mediastinum and peritoneal spaces may open doors to novel indications and rejuvenate the interest of endoscopists in natural orifice transluminal endoscopic surgery in the future. This review focuses on the current spectrum, recent updates, and future direction of submucosal endoscopy in the gastrointestinal tract.

Usefulness of EndoFLIP in Diverticular Peroral Endoscopic Myotomy for Symptomatic Epiphrenic Diverticulum.

Diverticular peroral endoscopic myotomy (D-POEM) is known to be a safe and feasible technique for managing diverticular diseases of the esophagus. In this study, we aim to report our experience with D-POEM and to investigate the usefulness of endoscopic functional luminal imaging probe (EndoFLIP) in determining the need for cardiomyotomy with septotomy for symptomatic epiphrenic diverticulum. Consecutive patients who underwent D-POEM for symptomatic epiphrenic diverticulum between September 2019 and September 2021 were eligible for this study. EndoFLIP and high-resolution manometry results and endoscopic treatment outcomes were retrospectively investigated. A total of 9 patients with symptomatic epiphrenic diverticulum were included. The median size of the diverticulum and septum was 50 (interquartile range [IQR], 48-80) mm and 20 (IQR, 20-30) mm, respectively. The overall technical success rate was 100%, with a median procedure time of 60 (IQR, 46-100) minutes. The 5 patients (high-resolution manometry results; 3 normal, 1 ineffective esophageal motility, and 1 Jackhammer esophagus) who had decreased esophagogastric junction distensibility index on pre-procedure EndoFLIP underwent cardiomyotomy with septotomy regardless of the presence of esophageal motility disorders, and the distensibility index increased and normalized after procedure. The mean dysphagia score decreased from 2.0 ± 1.0 pre-procedure to 0.4 ± 0.7 during a median follow-up of 11 (IQR, 4-21) months post-procedure. No serious adverse events that required surgical intervention or delayed discharge were noted. EndoFLIP may help decide whether to perform combined cardiomyotomy and septotomy for the treatment of an epiphrenic diverticulum. Further large-scale studies are needed to confirm these results.

OGBN V09 Laparoscopic Resection of Epiphrenic Diverticulum and Hellers Cardiomyotomy for achalasia

Abstract Background Epiphrenic diverticula are a rare form of diverticulum located in the distal oesophagus. Symptoms are varied as patients may be asymptomatic or present acutely with dysphagia and regurgitation. This video presentation is a case report and discussion of a patient requiring laparoscopic resection of an epiphrenic diverticulum and Hellers cardiomyotomy for concurrent achalasia. Methods The case of a 58 year old man is presented, who attended as an emergency with severe malnutrition and aspiration pneumonia secondary to dysphagia. Initial investigations included an upper GI endoscopy, barium swallow and CT scan which demonstrated a large oesophageal diverticulum and undiagnosed achalasia. Results The video presentation explores the operative technique used during this case in order to resect the epiphrenic diverticulum and perform a subsequent Hellers cardiomyotomy for achalasia. Conclusions Operative intervention was successful and the patient was discharged on day 2 post-operatively with no further complications. This video presentation stimulates further discussion regarding the management and operative technique utilised in epiphrenic diverticulae.

A Giant Esophageal Epiphrenic Diverticulum Causing Dysphagia, Fungal Infection and Aspiration Pneumonia in an Elderly Patient.

Esophageal epiphrenic diverticulum is a rare condition. We present a case of a 70-year male with no known comorbidities who presented with dysphagia, cough, fever, and weight loss for 3 months. CT chest with contrast showed an out-pouching arising from the distal dorsal oesophagus, 15.6 cm long with 0.9 cm neck, containing food particles causing compression and consolidation of adjacent lung segments. His upper gastrointestinal endoscopy showed a large diverticulum arising at 30 cm from incisors with overlying ulcerated and necrotic mucosa. A biopsy of diverticular mucosa showed fungal hyphae and spores and was negative for malignancy. The patient was given antifungals and showed significant improvement of symptoms but considering the huge size of the diverticulum, he was referred to a thoracic surgeon. Key Words: Epiphrenic diverticulum, Dysphagia, Aspiration pneumonia, Fungal infection.

Three-dimensional laparoscopic approach to distal oesophageal diverticula: Single-centre experience.

Epiphrenic oesophageal diverticula are rare and often asymptomatic. When symptoms are present, minimally invasive diverticulectomy is considered the gold standard of treatment. While there is an agreement on the pre-operative assessment, no consensus is achieved when it comes to surgical technique. In the present study, we report our experience and propose a standardised approach to manage this rare oesophageal disorder. We prospectively analysed data of all consecutive patients who underwent three-dimensional (3D) laparoscopic distal oesophageal diverticulum resection during 2015-2020 at Upper gastrointestinal surgical department, St Thomas' Hospital, regarding pre-operative assessment, surgical technique, peri-and post-operative outcomes. Six patients were submitted to 3D laparoscopic diverticulectomy, five of which with additional anterior myotomy and fundoplication and one with additional hiatal hernia repair only. Three patients followed a specific diet in preparation for surgery. Median pre-operative Eckardt symptom score was five. Two patients had normal manometry. Median operative time was 180 min, median estimated blood loss was <100 ml, neither intraoperative complications nor conversions to open approach occurred. All patients reported a complete resolution of symptoms directly after surgery. Median follow-up was 66 months. Five patients have none or minimal residual symptoms. One had recurrence requiring a revision operation for intermittent dysphagia. 3D laparoscopic diverticulectomy offers a reasonable chance of treatment in patients with epiphrenic diverticula. Optimal selection of patients, optimisation for surgery, gaining the surgical experience of carrying out these techniques and impact on short- and long-term results are issues that still remain under debate.

Minimally Invasive Techniques in the Contemporary Management of Esophageal Diverticula

INTRODUCTION: Management of esophageal diverticulum has shifted from an expansive, open operative approach to a varied open and select endoscopic intervention. This study examines operative outcomes in patients with esophageal diverticula treated with varied approaches at a single academic center. METHODS: A retrospective review of a prospectively maintained database was performed for all patients who underwent operation for esophageal diverticula at a single institution. The patients were grouped by location: Group A (Zenker’s), group B (mid-esophageal), and group C (epiphrenic diverticula). Measured outcomes include postoperative complication, symptoms, and recurrence. RESULTS: A total of 27 patients who underwent operation for symptomatic esophageal diverticula from June 2010 to June 2018 were identified. The mean age was 66.6 years, and 29.6% were women. Mean follow-up was 14 months. Group A consisted of 14 patients, group B 7, and group C 6. Preoperative dysphagia occurred in 81.5% of all patients. Underlying motility disorders were present in 92.3% of group B and C patients. A total of 92% of patients in group A underwent attempted endoscopic resection, with 42.9% converting to open. Robotic-assisted surgery was performed in 100% of group B and 83.3% of group C patients. One esophageal leak occurred in group A; there were no mortalities. Only group A demonstrated radiographic recurrence at 42.8%. Recurrent dysphagia in group A was 50%, group B 28.6% (2/7), and group C 0%. CONCLUSION: Minimally invasive management of esophageal diverticula provides effective symptom resolution. This study verifies the safety of endoscopic, laparoscopic, and robotic approaches with a 0.04% leak rate.

S2434 A Rare Case of Epiphrenic Diverticulum as a Complication of Esophageal Motility Disorders

Introduction: Esophageal diverticula are a rare finding with an estimated incidence of 1:500 000 per year and a prevalence of 0.015–2%. It is usually associated with esophageal motility disorders, particularly Achalasia. The suspected mechanism is secondary to increased intraluminal pressure from the primary esophageal motility disorder, which leads to herniation of the mucosa and submucosa through the muscular layer. It is usually asymptomatic but can present with dysphagia, regurgitation, nausea, vomiting, aspiration, heartburn, weight loss, and retrosternal pain. Here we offer a case of a large esophageal diverticulum in a 52-year-old male who has been having symptoms for years. Given the symptomatic nature of his diverticulum, he underwent surgical repair. Case Description/Methods: A 52-year-old patient with no significant past medical history presented with complaints of dysphagia that was worsening over several years, associated with halitosis and food regurgitation. The patient was having a routine screening colonoscopy when he had an episode of coffee-ground emesis. He subsequently underwent an esophagogastroduodenoscopy which revealed a large epiphrenic esophageal diverticulum. He then had an esophagogram and Computer Tomography (CT) of chest and abdomen, which confirmed the presence of the diverticulum and significant narrowing of the GE junction. Esophageal manometry was not pursued, given the difficulty of placing the probe and the risk of perforation. He subsequently underwent left thoracotomy with resection of the large esophageal diverticulum, long myotomy (11 cm), and Besley fundoplication. Esophagram following surgery was negative for any leak (Figure). He was started on a clear liquid diet that was later advanced to full liquid, with the patient tolerating it well. He was subsequently discharged home. Discussion: Esophageal diverticula are rare findings with an estimated incidence of 1:500 000 per year and a prevalence of 0.015–2%. Most esophageal diverticula are acquired and present in older adults. Surgical repair is associated with mortality of 0 to 9% and morbidity of 20%. This case serves as a reminder to keep a broad differential diagnosis when approaching a patient with symptoms of a motility disorder. Early detection can provide timely management and prevent further complications.Figure 1.: Esophagram after surgical repair of epiphrenic esophageal diverticulum.

598. EPIPHRENIC DIVERTICULUM CAUSING GASTROESOPHAGEAL JUNCTION OUTFLOW OBSTRUCTION (EGJOO)

Abstract Oesophageal diverticulum is a rare cause of dysphagia. They are classified based on location- Zenker’s diverticulum distal to the cricopharyngeus; epiphrenic diverticulum above the lower oesophageal sphincter (LES)- or pathophysiology – traction vs pulsion. The prevalence of epiphrenic pulsion diverticulum ranges from 0.2% to 0.8%. We present a case of epiphrenic diverticulum and its management. A 68 year old lady presents with dysphagia to solids and liquids, belching, food regurgitation, and acid brash for 10 years. She had no loss of weight, but experienced daily regurgitation and occasional retrosternal pain. Physical examination was unremarkable. We worked her up with further investigations and scans. A CT abdomen reported a hiatus hernia and mural thickening of distal oesophagus with upstream oesophageal distension. A oesophagogastroduodenoscopy showed residual food in oesophagus. The lower oesophagus was dilated and the LES appeared tight with no masses. There was no hiatus hernia on endoscopy. Barium swallow revealed the lower oesophageal dilatation to be an epiphrenic diverticulum. Manometry studies showed oesophago-gastric junction outflow obstruction. She underwent laparoscopic excision of esophageal diverticulum, cardiomyotomy and anterior partial fundoplication. The video serves to highlight the surgical key steps. She was discharged on post-operative day 3 without complications and barium swallow pre/post op as shown. Oesophageal diverticulum, although rare, remains a differential for dysphagia. For epiphrenic diverticulum, it is important to understand that this is a pulsion diverticulum, with an accompanying gastro-oesophageal outflow obstruction. In addition to surgical management with a laparoscopic diverticulectomy, a cardiomyotomy and partial fundoplication to treat underlying motility disorder is important. This case study and video serves to highlight the condition and present minimally invasive surgical management.

294. AN UNUSUAL CASE OF EPIPHRENIC DIVERTICULUM COEXISTING WITHIN ESOPHAGEAL LEIOMYOMA

Abstract Oesophageal leiomyoma and epiphrenic diverticulum are two rare entities to be simultaneously occurring together. The preoperative diagnosis in such coexisting conditions is often difficult and leiomyoma is mostly an incidental finding. Till date there is no evidence of the pathogenesis that if the diverticulum causes leiomyoma or vice versa?: We report a case of 32-year-old male with no known co-morbids, previous history of accidental kerosine oil intake 7 months ago, with dysphagia and retrosternal burning pain since 4 weeks with no history of documented weight loss. General physical and systemic examinations were unremarkable. Contrast studies showed left sided epiphrenic diverticulum. CECT was suggestive of traction diverticulum. Endoscopy showed a large diverticulum on left side of esophagous 38 cm from incisors. On laparoscopy a mass extending to GEJ was appreciated and patient underwent laparoscopy assisted transhiatal esophagectomy and esophagogastric anastomosis with feeding jejunostomy. Peroperatively a mass of 15 x 8 cm was arising from distal oesophagus histopathology of which came out to be a leiomyoma. On POD ‘0’ patient developed Rt sided pneumothorax for which chest intubation was done. Repeat contrast studies showed a patent anastomosisand patient was discharged home. A careful history, thorough investigations, and surgeon’s awareness of possible synchronous disease processes helps in the management of such patients.

Management of esophageal diverticula through an open surgical approach: A 16 year experience

Introduction: Esophageal diverticula are rare. There are controversies over the indication for surgery and the optimal surgical approach in these patients. In this study, we target to evaluate the complications and outcomes of 34 surgery candidates with esophageal diverticula undergoing an open approach. Method: This is a retrospective review of patients with either cervical or thoracic diverticula who underwent surgery by thoracic surgery teams over a 16-year period. The selected surgical approach was postero-lateral thoracotomy for mid-esophageal and epiphrenic diverticula and left side neck incision for cervical esophageal diverticula. Myotomy was performed only in the case of esophageal motility disorders in patients with thoracic diverticula and in all patients with cervical diverticula. The postoperative intermediate-term outcomes were assessed. Results: Of the 34 patients, 9 patients had cervical diverticula, 13 (38%) had mid-esophageal diverticula and 12 (35%) of those had epiphrenic diverticula. All the patients with epiphrenic and mid-esophageal diverticula underwent postero-lateral thoracotomy, and those with cervical esophageal diverticula underwent cervical approach. 21 patients underwent diverticulectomy and myotomy (61%), and 6 patients underwent diverticulectomy alone (17%). There were a total postoperative (4 patients). None of the patients had in-hospital or 30-day mortality. Conclusion: Although in this era, minimally invasive approach is the first choice for diverticulectomy; however, we observed that in our study the mortality and leak rates were as low as those of the previous studies. Hence, open approach could be safe and effective if it is performed by surgeons with high degree of expertise.

A robotic-assisted approach is safe and effective for repairing giant epiphrenic diverticulum

Epiphrenic esophageal diverticulum is a rare disorder accounting for <10% of all esophageal diverticula. Surgical treatment may be necessary for larger diverticula causing significant symptoms. In this technical note, we describe a robotic-assisted approach to repair of a giant epiphrenic diverticulum. A 53-year-old female presented to the Department of Surgery, University of Colorado in January 2020 with a long-standing history of dysphagia and regurgitation associated with halitosis. Following a thorough preoperative workup, the patient underwent a robotic-assisted transhiatal approach with resection of the diverticulum followed by complete myotomy and Dor fundoplication. The patient had no perioperative complications and demonstrated complete relief of symptoms at the 6-month follow-up. A robotic-assisted transhiatal approach is a safe and effective technique for the resection of large epiphrenic diverticula. Complete myotomy followed by an antireflux procedure is critical to reducing perioperative complications and maintaining long-term symptom relief. Further prospective studies are needed to evaluate the specific morbidity risks associated with this approach.

Minimally invasive surgery for motility disorders of the oesophagus

Introduction and aims. We present our experience with minimally invasive surgery for pharyngoesophageal (Zenker) diverticulums, epiphrenic diverticulums and achalasia cardiae focusing on the perioperative features and patients’ quality of life. Patients and methods. Between 1 January 2003 and 31 December 2020, patients were selected with a symptom-causing Zenker diverticulum, epiphrenic diverticulum and achalasia cardiae. In 17 cases, transoral stapler diverticulostomy, in 23 cases transcervical diverticulectomy and cricomyotomy were done because of Zenker diverticulum, in 14 cases, laparoscopic transhiatal surgery was performed because of epiphrenic diverticula, while in 63 cases, laparoscopic Heller–Dor operation were carried out because of achalasia cardiae. Perioperative results, the quality of life outcomes of various surgeries were evaluated in mid- and long-term. Results/conclusions. The surgeries were performed with minimal blood loss, zero mortality and low morbidity. According to our result, the two different surgical approaches in the therapy of Zenker’s diverticulum, the laparoscopic Heller–Dor procedure applied in the management of epiphrenic diverticulas and achalasia cardiae are safe and effective operations. In the long term, the symptom control in patients after minimally invasive surgeries is sufficient and only a small percentage of the patients may require additional medication therapy and/or reintervention due to persistent complaints.

Esophageal Cancer in Epiphrenic Diverticulum With Fistulization to the Lung.

CASE REPORT A 56-year-old man with a history of smoking and alcohol dependence presented to the emergency department with a 3-day history of epigastric pain and fever. The laboratory results were consistent with infection (white blood cell count: 27.8 × 103/mm3; C-reactive protein: 287 mg/L). Computed tomography showed an esophageal perforation in continuity with a right lower lobe abscess (Figure 1). Esophagogastroduodenoscopy demonstrated an ulcerative mass originating from a large epiphrenic diverticulum concealing a fistula at the inferior aspect (Figure 2).Figure 1.: Axial section of computed tomography showing the epiphrenic diverticulum with perforation (*) and pulmonary abscessation of the right lower lobe (arrow).Figure 2.: (A) Endoscopic view on the epiphrenic diverticulum (*) with an ulcerative wall and (B) endoscopic view inside the diverticulum showing the fistula (arrow) on an ulcerative base.Pathological examination confirmed the presence of a squamous cell carcinoma (Figure 3). After a 10-day antibiotic treatment (penicillin 4 × 1 g), an esophagectomy and segment-6-sparing lower lobectomy through right thoracotomy were performed. Owing to inflammation, the reconstruction was postponed, and a cervical esophagostomy was created. Twelve days later, a retrosternal laparoscopic-assisted esophagogastric reconstruction was performed.Figure 3.: Histopathological image (H&E coloring, ×25) on the edge of the diverticulum showing the origin of the squamous cell carcinoma (arrow).Pathological examination demonstrated transmural invasion into the right lower lobe and 3 positive lymph nodes (pT4b N2). The patient was discharged after 10 days after an uneventful postoperative course. Adjuvant chemotherapy (6 courses of a combination of Oxaliplatin, 5- Fluorouracil and Leucovorin (FOLFOX)) was administered for 3 months, followed by paclitaxel for local lymph node recurrence. A follow-up positron emission tomography with computed tomography, 9 months after surgery, revealed disease progression in mediastinal lymph nodes and metastases in the kidney and liver. Despite salvage immunotherapy with nivolumab, the patient died 3 months later. Epiphrenic diverticula are very rare and account for only 10% of all esophageal diverticula.1 The incidence of the latter is estimated between 0.06% and 3.6% and is the result of the herniation of mucosa and submucosa through the muscular wall of the esophagus.2,3 The development of cancer in an esophageal diverticulum is seen in only 0.3%–3% and believed to be the consequence of chronic irritation of retained food and its subsequent inflammation.4 Most tumors are detected in an advanced stage given the absence of the muscularis propria. In a literature overview of Yoshida et al, 1 in 3 patients (7/19) was diagnosed with invasion in the surrounding organs and had a 1-year mortality rate of 66% (4/6).5 Therefore, early detection is paramount and could be realized with regular endoscopic and radiologic follow-up and subsequent treatment. DISCLOSURES Author contributions: LJ Ceulemans, MD, PhD is the article guarantor. All authors of this article have substantially contributed to the conception and design, drafting and revision of its content, and approval of the final version. All authors agree to the correctness and are accountable for all the content of this article. Financial disclosure: None to report. Informed consent was obtained for this case report.

Esophageal Diverticulum - Indications and Efficacy of Therapeutic Endoscopy.

Objective Esophageal diverticulum is rare, and the concomitance of esophageal motility disorders (EMDs) and the efficacy of novel endoscopic treatment have not been investigated in Japan. Methods An examination including high-resolution manometry (HRM) was performed for patients with both EMDs and epiphrenic diverticulum. EMD-related epiphrenic diverticulum and Zenker's diverticulum were treated using salvage peroral endoscopic myotomy (s-POEM) and endoscopic diverticulotomy, respectively. Results Six cases of epiphrenic diverticulum were diagnosed in this study. Among 125 patients with achalasia and spastic disorders, concomitant epiphrenic diverticulum was observed in 4 (3.2%). Of these, three showed a normal lower esophageal sphincter pressure on HRM, although gastroscopy and esophagography revealed typical findings of an impaired lower esophageal sphincter relaxation. These four patients were successfully treated with s-POEM, and the Eckardt score improved from 6.3 to 0.25 at 32.5 (range: 13-56) months of follow-up, with equivalent treatment efficacy to that observed for achalasia and spastic disorders without epiphrenic diverticulum. In contrast, the two remaining cases of epiphrenic diverticulum had normal esophageal motility. Six cases of Zenker's diverticulum were diagnosed, and endoscopic diverticulotomy was successfully performed in all. The dysphagia score decreased from 2.8 to 0.17 at 14.8 (range: 2-36) months of follow-up. Overall, 12 endoscopic treatments were performed for esophageal diverticulum; no adverse events were observed. Conclusion In epiphrenic diverticulum patients, concomitant EMDs are not rare and should be carefully diagnosed. A normal lower esophageal sphincter pressure on HRM does not always mean a normal lower esophageal sphincter relaxation. S-POEM and endoscopic diverticulotomy are effective minimally invasive treatment options for EMD-related epiphrenic diverticulum and Zenker's diverticulum.

Successful D-POEM after failed surgical myotomy and diverticulectomy.

Video 1Case series showing 2 patients with prior failed Heller myotomy and diverticulectomy, with subsequent success with POEM, diverticulotomy, and closure with endoscopic suturing. Case 1 also depicts closure of an esophagopleural fistula.

Giant Epiphrenic Diverticulum: A Challenging Case

A diverticulum is a limited saccular protrusion of the esophageal wall, communicating with its lumen. Anatomically, esophageal diverticula are classified into pharyngoesophageal, median, and epiphrenic. Treatment of esophageal diverticula is based on several basic pathophysiological principles. Small and asymptomatic diverticula do not require specific treatment. Large and symptomatic diverticula require surgical intervention, consisting of diverticulectomy combined with myotomy. Operations for symptomatic epiphrenic diverticula make up no more than 2% of all operations on the esophagus. We describe a case of an epiphrenic diverticulum with the dimensions 88x60x90 mm in a 54-year-old patient. Surgical treatment of this disease was performed according to the Lewis method. The article also describes methods of dealing with concomitant postoperative complications and a brief review of the literature on epiphrenic diverticula.

Treatment of Achalasia and Epiphrenic Diverticulum.

Epiphrenic diverticulum (ED) is a pulsion pseudodiverticulum found in the distal 10 cm of the esophagus. Motility disorders are present in the majority of patients with ED explaining the pathophysiology of this rare disease. Achalasia is the most common underlying disorder. We present a review on the diagnosis and management of ED in the setting of achalasia. Literature review. Symptoms are most related to the underlying motility disorder. The diagnostic workup should always include an upper digestive endoscopy and a barium esophagogram. Esophageal manometry identifies the motility disorder in most patients. Therapeutic options include laparoscopic, thoracoscopic and endoscopic procedures. While a myotomy must always be performed, diverticulectomy is not always necessary. Epiphrenic diverticulum is a rare condition whose pathophysiology involves an underlying motility disorder-achalasia in most cases. Symptoms usually include dysphagia, regurgitation, heartburn, and respiratory complaints and correlate with the motility disorder rather than the diverticulum per se. Upper digestive endoscopy and barium esophagogram are needed for the diagnosis-manometry may add useful information but is not imperative for the treatment. Laparoscopic Heller myotomy with a partial fundoplication is the procedure of choice, with satisfactory symptom relief and several advantages over the thoracic approach. Diverticulectomy may be performed in selected patients. Peroral endoscopic myotomy (POEM) are novel techniques, effective and minimally invasive that can be an option for patients unfit for surgery.

Esophageal motility disorders missed during endoscopy.

Esophageal motility disorders are sometimes misdiagnosed on endoscopic examination. We aimed to identify the proportion of patients with esophageal motility disorders missed during endoscopy and their clinical characteristics. Patients diagnosed with either disorder with esophagogastric junction outflow obstruction or major disorders of peristalsis using high-resolution manometry in our hospital from April 2015 to March 2021 were included in this study. Missed esophageal motility disorders were defined as patients with any endoscopic misdiagnosis such as normal esophagus or esophagitis within 1year before the manometric diagnosis. We determined the proportion of missed esophageal motility disorders and identified independent predictors of missed esophageal motility disorders using multivariate analysis. A total of 41/273 esophageal motility disorders (15.0%; 95% confidence interval 11.3-19.7%) were missed during endoscopy within 1year before manometric diagnosis. In the stepwise logistic regression analysis, the following variables were selected as independent variables for patients with missed esophageal motility disorders during endoscopy: non-dilated esophagus (odds ratio = 4.87, 95% confidence interval: 1.81-13.12, p = 0.002), the presence of epiphrenic diverticulum (odds ratio = 8.95, 95% confidence interval: 1.88-42.65, p = 0.006), the use of transnasal endoscopy (odds ratio = 4.71, 95% confidence interval: 1.59-13.92, p = 0.005), and the combined use of esophagram (odds ratio = 0.023, 95% confidence interval: 0.0025-0.20, p = 0.0008). Based on retrospective analysis, 15% of esophageal motility disorders were missed during endoscopy. Understanding the clinical characteristics of missed esophageal motility disorders could help improve endoscopic diagnoses.

A Case of Acute Mediastinitis due to Perforation of an Esophageal Epiphrenic Diverticulum during Follow-up of the Diverticulum

横隔膜上食道憩室は稀な疾患であり，食道運動障害や逆流症状を伴う場合は手術適応となる，今回，われわれは食道憩室穿孔・急性縦隔炎を発症し，ドレナージ術後に二期的な切除再建手術で良好な経過を得た症例を経験した．症例は68歳，男性．つかえ感を主訴に受診し，横隔膜上食道憩室を認め手術を予定していたが，自覚症状が消失したため本人の希望で経過観察としていた．経過中に食道憩室穿孔，急性縦隔炎を発症したため，緊急で腹腔鏡下経裂孔的縦隔ドレナージ術を施行した．縦隔炎改善後に胸腔鏡下食道亜全摘術を施行し，術後縫合不全をきたしたものの保存的に軽快し，術後35日目に退院とした．横隔膜上食道憩室は逆流などの症状を認めるが，憩室の拡大に伴い症状が自然軽快することがあり，穿孔の高リスクとなる可能性がある．憩室穿孔による急性縦隔炎を伴う食道憩室穿孔例には二期的手術が有効であった．