Epiphrenic Diverticulum Research Articles

Laparoscopic transhiatal surgery based on high-resolution manometric evaluation of epiphrenic esophageal diverticulum.

Epiphrenic esophageal diverticulum is rare and often associated with abnormalities of esophageal motility. Here, we report a case of a patient diagnosed with high-resolution manometry as having epiphrenic esophageal diverticulum with esophagogastric junction outflow obstruction, which were successfully treated with laparoscopic transhiatal surgery. A 59-year-old woman presented to our hospital for treatment of a symptomatic epiphrenic esophageal diverticulum. An esophagogram revealed a left epiphrenic diverticulum measuring 50mm. High-resolution manometry showed a high integrated relaxation pressure of 35.6mmHg (> 26mmHg) and preserved esophageal peristalsis. A chest computed tomography scan showed no external compression of the distal esophagus. Therefore, we diagnosed an epiphrenic esophageal diverticulum with esophagogastric junction outflow obstruction according to the Chicago Classification v3.0. Laparoscopic transhiatal diverticulectomy, planned and selective myotomy, and Dor fundoplication were performed. We performed myotomy just on the esophageal side and did not perform gastric myotomy. The postoperative course was uneventful, and the postoperative esophagogram showed smooth passage of contrast without leakage or stenosis. High-resolution manometry showed a normal integrated relaxation pressure (11.6mmHg) at three months after surgery. Because an epiphrenic esophageal diverticulum is frequently associated with esophageal motility disorder, not only morphologic but also functional and appropriate treatment must be considered.

341. EXCISION OF EPIPHRENIC DIVERTICULUM WITH CARDIOMYOTOMY AND FUNDOPLICATION

Abstract Background Epiphrenic diverticulum, a type of pulsion diverticulum, is a rare esophageal diverticulum that occurs in up to 2% of the population. It is commonly located in the distal esophagus, 4 to 8 centimeters (cm) above the gastric cardia. Etiology includes raised intraluminal esophageal pressure and is often associated with an underlying esophageal motility disorder. Indications for surgical intervention depends on presence of symptomatic disease including worsening dysphagia, food retention, regurgitation and complications such as aspiration pneumonia. This video illustrates the surgical management of epiphrenic diverticulum and associated surgical outcomes. Methods 60-year-old male initially presented with symptoms of dysphagia, food regurgitation and reflux. Gastroscopy performed identified a large esophageal diverticulum, 3cm from cardioesophageal junction (CEJ) and barium swallow study as well as high resolution manometry verified normal esophageal motility. Biopsies did not show any dysplasia. Patient subsequently underwent laparoscopic excision of epiphrenic diverticulum, cardiomyotomy and anterior 180 degrees fundoplication. Intra-operatively, epiphrenic diverticulum was noted on right lateral aspect of esophagus with a 3cm wide neck, 3cm from CEJ. Diverticulum was resected using a linear stapler and cardiomyotomy was perfomed on the contralateral side along with a partial fundoplication. Results Patient had an uneventful post-operative recovery with no post-operative complications. Histology confirmed esophageal diverticulum with no dysplasia or malignancy seen. Water soluble contrast study performed on post-operative day 1 and 1 year later demonstrated smooth passage of contrast with no hold up. There was also complete resolution of presenting symptoms on follow-up reviews. Conclusion Epiphrenic diverticulum is a rare entity but may present with debilitating symptoms that can affect patient’s quality of life and function. Management of symptomatic patients involves resection of the diverticulum as well as a myotomy and fundoplication to address any underlying motility disorder. This case aims to illustrate the efficacy and positive surgical outcomes that can be achieved with this combined surgical approach. https://www.dropbox.com/scl/fi/v6ow104q16lgfjhdqajix/Diverticulum-excision-v6.mp4?rlkey=nlmta6y835myqzf2rdf9mqocm&dl=0

325. SURGERY FOR EPIPHRENIC ESOPHAGEAL DIVERTICULUM, SHORT AND LONG TERM RESULTS

Abstract Background and Objectives We present our experience with laparoscopic surgery for epiphrenic oesophageal diverticulum. We wanted to assess our surgical results focusing on the patients’ quality of life. Short- and long-term results of surgical therapy were analysed. Methods 14 patients were examined with a symptomatic causing epiphrenic diverticulum. Patients underwent complex gastroenterological examinations before and after surgery (swallowing x-ray, oesophagogastroscopy, oesophageal manometry/pH monitoring). Surgery: laparoscopic transhiatal epiphrenic diverticulectomy with Heller cardiomyotomy and Dor anterior partial fundoplication were performed in 9 patients; laparoscopic diverticulectomy in 2 patients, laparoscopic Heller-Dor operation without diverticulectomy was 1 case (small (< 3cm) diverticulum) and laparoscopic diverticulectomy + Heller myotomy + Nissen fundoplication in 2 cases. Changes in quality of life with regard to symptoms related to oesophageal function were evaluated in our long-term studies (averaging 60 months, 10–138 months) by Eckardt-Zaninotto score. Results We had no intraoperative complication except one. In one case, a staple line leak developed (1/14 (7%), which was resolved with conservative therapy. Functional check-ups confirmed adequate oesophageal function in majority of the patients. The total symptom score for the patients was 6.3 points before surgery, and it decreased to 1.6 (P .001) after surgery, an average of 74% subjective improvement. During the follow-up period, proton pump inhibitor therapy was started in 4 patients to treat gastroesophageal reflux. In 3 cases, drug therapy was successful; in one case, Nissen antireflux surgery was performed. Conclusion Laparoscopic transhiatal diverticulectomy and Heller–Dor surgery are effective interventions with low morbidity. Patient quality of life significantly improves in the long term, but gastroesophageal reflux disease may occur. Key Words Epiphrenic oesophageal diverticulum, Laparoscopic transhiatal surgery, Long-term results

462. EPIPHRENIC DIVERTICULA. THERAPEUTIC ALTERNATIVES AND OUR EXPERIENCE

Abstract Background Epiphrenic diverticula account for less than 10% of esophageal diverticula and they are located in the last 10cm, in the right posterior quadrant. They are pseudodiverticula, lacking the muscular layer. Recent studies report that over 75% of these occur concomitantly with esophageal motility disorders, making it essential to evaluate them via manometry before deciding on intervention. Asymptomatic patients usually receive non-operative treatment. Indications for surgical treatment include increased diverticulum size, specific symptoms and suspicion of malignancy. Standard surgical treatment consists of laparoscopic approach with diverticulectomy, myotomy and Dor fundoplication. Methods We had 9 cases of esophageal epiphrenic diverticula that required surgical intervention in the last 16 years. In the vast majority of them, laparoscopic diverticulectomy was performed, along with myotomy and Dor fundoplication. Among them, there is a rare case of recurrence of a giant epiphrenic diverticulum in a 55-year-old patient treated with this approach. Due to the complexity of the case, partial esophagectomy and reconstruction with right-sided ascending coloplasty via posterior mediastinal route were decided as definitive treatment. Results The outcome was satisfactory in almost all patients, being the most frequent complications a suture line dehiscence and associated mediastinitis. Conclusion Esophageal diverticular pathology is uncommon, and its treatment is conservative in most cases. Over 75% of epiphrenic diverticula occur in the context of an underlying esophageal motor disorder. Indications for surgical intervention are the presence of symptoms, increased diverticulum size and suspicion of malignancy. The standard treatment consists in diverticulectomy, myotomy and fundoplication, but there are therapeutic alternatives that should be considered and individualized in each case. Symptoms disappearance after surgical treatment is nearly 90%. However, the procedure carries a morbidity and mortality rate of 20%, being the most common complication a suture line dehiscence, occurring in 33% of cases.

640. EPIPHRENIC DIVERTICULECTOMY WITH HELLER MYOTOMY AND DOR FUNDOPLICATION

Abstract The attached video demonstrates epiphrenic diverticulectomy with Heller myotomy and Dor fundoplication, in a symptomatic 62 years old female patient with regurgitation and achalasia. The video offers a unique insight into the complexities of treating this uncommon condition. In this case, a laparoscopic transhiatal approach was used. The video shows the key steps of the surgery, including challenges posed by the diverticulum's unusual location (left side of the esophagus), necessitating the careful opening of the left crura for optimal visualization and safe resection. We believe this teaching case not only sheds light on the intricacies of managing epiphrenic diverticulum but also underscores the importance of tailored approaches in addressing atypical presentations. https://www.dropbox.com/scl/fi/jutvx1akf32nlgf8o57bp/epiphrenic-diverticuluectomy.mp4?rlkey=nmscb8y1k84g9cnfmzohtgjvp&dl=0

Clinical outcomes of peroral endoscopic myotomy with and without septotomy for management of epiphrenic diverticula: an international multicenter experience (with video)

There are few data favoring the need for septotomy at the time of peroral endoscopic myotomy (POEM) or if POEM alone is sufficient. Our aim was to compare POEM outcomes with and without septotomy (POEM+S or POEM-S) in patients with symptomatic epiphrenic diverticula (ED) and an underlying motility disorder. This was an international, multicenter retrospective study involving 21 centers between January 2014 and January 2023. Patients with ED and an underlying motility disorder who underwent POEM were included. The primary outcome was clinical success (Eckardt score [ES]≤3 or a 1-point drop in ES for patients with baseline ES<3) without the need for repeat surgical/endoscopic interventions during follow-up. A total of 85 patients (mean age, 64.29 ± 17.1 years; 32 [37.6%] female) with ED and underlying motility disorder underwent POEM+S (n= 47) or POEM-S (n= 38). Patients in the POEM+S group had a significantly higher mean pre-POEM ES (7.3 ± 2.1 vs 5.8 ± 2; P= .002). The most common indication for POEM was achalasia (51% in the POEM+S cohort and 51.8% in the POEM-S cohort; P= .7). A posterior approach was favored in the POEM+S group (76.6% vs 52.6%; P= .02). A similar rate of technical success was seen in both groups (97.9% vs 100%; P= .1). The rate of adverse events was similar between the 2 cohorts (4.2% vs 8.1%; P= .6). The median length of hospital stay after POEM-S was significantly longer compared with POEM+S (2 days [interquartile range (IQR), 1-4 days] vs 1 day [IQR, 1-2 days]; P= .005). Clinical success was equivalent between the 2 groups (83% vs 86.8%; P= .6) at a median follow-up duration of 8 months (IQR, 3-19 months). In patients with ED and an underlying motility disorder, both POEM+S and POEM-S are equally safe and effective, with similar procedure duration and a low recurrence rate at short-term follow-up. Future comparative prospective studies with long-term follow-up are required to validate these findings.

Peroral endoscopic myotomy with diverticulotomy using a double tunnel technique: finding your way to an elusive lower esophageal sphincter in spastic achalasia and epiphrenic diverticulum

Peroral endoscopic myotomy with diverticulotomy using a double tunnel technique: finding your way to an elusive lower esophageal sphincter in spastic achalasia and epiphrenic diverticulum

A Multidisciplinary Minimally Invasive Approach Is Necessary for the Contemporary Management of Esophageal Diverticula.

Background: Esophageal diverticula were traditionally treated with open surgery, which is associated with significant morbidity and mortality rates. Management has shifted to minimally invasive approaches with several advantages. We examine outcomes in patients with esophageal diverticula treated with minimally invasive techniques by a multidisciplinary surgical team at a single center. Materials and Methods: A retrospective review of a prospectively maintained database was performed for patients who underwent minimally invasive surgery for esophageal diverticula at our institution from June 2010 to December 2022. Primary outcomes were 30-day morbidity and mortality rates. Secondary outcomes were symptom resolution, length of stay (LOS), readmission, and need for reintervention. Results: A total of 28 patients were identified. Twelve patients had pharyngeal diverticula, 7 patients had midesophageal diverticula, and 9 patients had epiphrenic diverticula. Thirty-day morbidity and readmission rates were 10.7% (3 patients), 1 pharyngeal (sepsis), 1 midesophageal (refractory nausea), and 1 epiphrenic (poor oral intake). There were no esophageal leaks. Average LOS was 2.3 days, with the pharyngeal group experiencing a significantly shorter LOS (1.3 days versus 3.4 days for midesophageal, P < .01 versus 2.8 days for epiphrenic, P < .05). Symptom resolution after initial operation was 78.6%. Reintervention rate was 17.9%, and symptom resolution after reintervention was 100%. There were no mortalities. Conclusion: This study demonstrates that esophageal diverticula can be repaired safely and efficiently when performed by a multidisciplinary team utilizing advanced minimally invasive endoscopic and robotic surgical techniques. We advocate for the management of this rare condition at a high-volume center with extensive experience in foregut surgery.

Clinical presentation and therapy for Epiphrenic diverticulum - Case report

Clinical presentation and therapy for Epiphrenic diverticulum - Case report

Combined thoracoscopic and laparoscopic surgery for epiphrenic diverticulum with associated gastroesophageal reflux disease: a case report

BackgroundSurgery is indicated for symptomatic epiphrenic esophageal diverticula. Based on the features of a case, thoracoscopic or laparoscopic approaches may be used. Epiphrenic diverticula are often associated with esophageal motility disorders, but cases of reflux esophagitis have rarely been reported. In this report, we describe a case of an epiphrenic esophageal diverticulum with reflux esophagitis, which was successfully treated by thoracoscopic diverticulectomy and laparoscopic fundoplication.Case presentationA 69-year-old man visited the hospital with a chief complaint of eructation and hiccup. Upper gastrointestinal endoscopy revealed a diverticulum in the left wall of the esophagus, which was 37–45 cm distal to the incisors. High-resolution manometry (HRM) showed no esophageal motility disorders. Due to the large size of the diverticulum, a thoracoscopic resection of the esophageal diverticulum was performed. Additionally, the patient had reflux esophagitis due to a hiatal hernia. The anti-reflux mechanism would be more impaired during the diverticulectomy; therefore, we decided that anti-reflux surgery should be performed simultaneously. Thoracoscopic esophageal diverticulectomy and laparoscopic Dor fundoplication were performed. The patient had an uncomplicated postoperative course and was discharged on the tenth operative day. He has been symptom-free without acid secretion inhibitors for 21 months after the surgery.ConclusionsWe described a rare case of a large epiphrenic diverticulum with reflux esophagitis. A good surgical outcome was achieved by thoracoscopic resection of the diverticulum and laparoscopic Dor fundoplication.

Epiphrenic diverticulum: is diverticular peroral endoscopic myotomy (D-POEM) enough or do we need to go one step forward?

Epiphrenic diverticulum: is diverticular peroral endoscopic myotomy (D-POEM) enough or do we need to go one step forward?

Peroral endoscopic myotomy for the treatment of epiphrenic diverticulum.(Case series)

Peroral endoscopic myotomy for the treatment of epiphrenic diverticulum.(Case series)

S2881 Interesting Cause of Food Impaction–A Large Epiphrenic Diverticulum

S2881 Interesting Cause of Food Impaction–A Large Epiphrenic Diverticulum

Transabdominal Management of Epiphrenic Diverticula in the Setting of Achalasia: A Single-center Review.

The perioperative and functional outcomes of patients with epiphrenic diverticula (ED) on a background of achalasia managed via a minimally invasive transabdominal approach are under-reported. We describe our center's experience over 10 years of treating such patients. A single-center, retrospective chart of a prospectively maintained hospital database was performed. All patients with a diagnosis of ED and manometrically proven achalasia were identified. Demographic, clinical, and surgical data were extracted from the institution's medical records. Patients were stratified by whether they underwent myotomy only or myotomy plus diverticulectomy and compared in a univariate manner. There were 18 patients who met the inclusion criteria. The median age of the cohort was 67.1 years (range 53.1 to 77.8), the maximal size of the diverticula was 3.5cm (range 2.0 to 7.0), and the distance of the proximal lip of the diverticulum to the incisors was 33.5cm (range 28.0 to 38.0). In terms of surgical intervention, 14 patients (77.8%) underwent myotomy plus diverticulectomy, and 4 (22.2%) underwent myotomy alone. The duration of surgery was significantly longer in the former (177.5 vs. 75.0min, P =0.031). In total, 9/18 (50.0%) of patients were discharged on the day of surgery. There was a trend to more major postoperative complications following diverticulectomy plus myotomy, with 2/13 (15.4%) patients suffering staple line leaks. Excellent long-term functional outcomes were achieved, with 81.3% of patients having sustained resolution of their symptoms. Laparoscopic transabdominal approach for the treatment of ED offers an acceptable risk profile and favorable functional outcomes in patients with underlying achalasia.

Kill two birds with one stone: one submucosal tunnel for achalasia combined with large epiphrenic diverticulum.

Kill two birds with one stone: one submucosal tunnel for achalasia combined with large epiphrenic diverticulum.

478. ROBOTIC REPAIR OF EPIPHRENIC DIVERTICULUM

Abstract We show a robotic repair of a epiphrenic diverticulum in a patient with a previous treatment 10 years ago by laparoscopic with diverticulectomy with a heller miotomy. This time we performed a complete ressection with a new miotomy in a thoracic aproach https://drive.google.com/file/d/1ancYQoy9csA1NjXhswGuDtkd1EjR0M7B/view?usp = sharing.

Technical Success in Performing Esophageal High-Resolution Manometry in Patients with an Epiphrenic Diverticulum.

High-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders, yet it can be poorly tolerated and technically challenging. Epiphrenic diverticula (ED) are located in the distal esophagus and are associated with underlying motility disorders. ED patients (2008-2022) were retrospectively compared to achalasia patients (2008-2022) and all other patients (2021-2022) who underwent HRM at a single center. Complete success was defined as at least 7 interpretable swallows including measurements throughout the esophagus into the stomach. HRM studies involving children, previously treated achalasia, and sedation or endoscopic-assistance were excluded. 20 ED patients (mean age 66; 60% female) were compared to 76 achalasia patients and 199 controls. HRM was completely successful in 70.0% of ED patients, 85.5% of achalasia (p = 0.106 vs ED), and 91.0% of controls (p = 0.004 vs ED). Most failures in the ED and achalasia groups were due to inability to traverse the esophagogastric junction (EGJ), while patient intolerance was the main reason in controls. Half of the ED group had motility disorders (25% achalasia, 15% hypercontractile esophagus, 10% absent contractility). Large diverticulum size was inversely associated with technical success compared to small diverticulum size (40% vs 100%, p = 0.013), while the presence of a motility disorder did not significantly affect success (60% vs 88.9%, p = 0.303). In conclusion,ED is a predictor of unsuccessful HRM. This appears to be mainly related to an inability to traverse the EGJ due to the size of the diverticulum. Consideration should be given to alternative means of evaluating motility, such as endoscopy-assisted HRM, given the high likelihood of failure with traditional HRM.

Thoracoscopic approach as surgical management of esophageal epiphrenic diverticulum.

Management of diverticulum of the lower esophagus or epiphrenic diverticulum can be performed using the abdominal or thoracic approach. In some cases, the thoracic approach is preferred, but few studies have described thoracoscopic resection. The objective of the present study was to investigate the thoracoscopic approach for management of epiphrenic esophageal diverticulum. From 2008 to 2018, all patients undergoing surgery for epiphrenic esophageal diverticulum by the thoracoscopic approach were included in this single-center, retrospective, observational study. Data on diverticulum, surgery and follow-up were assessed. During the study period, 14 patients underwent surgery. Two patients had two diverticula. The mean location of the superior edge of the diverticulum was 7cm (2-14cm) above the gastro-esophageal junction. The mean size of the diverticulum was 39 millimeters (20-60). Thoracoscopic approach was used in all patients. No conversion to thoracotomy was required. Mean operative time was 168min (120-240). No postoperative mortality occurred. The overall complication rate was 40% (6 complications out of 15 resections), with three major complications including leaks (n=2) and a case of bronchoesophageal fistula (n=1). Median length of hospital stay was 12 days (8-40). At a mean postoperative follow-up of 20.7 months (5-71), 85% of patients had complete disappearance of preoperative symptoms without recurrence of the diverticulum on the barium swallow study test. Thoracoscopic approach as management of epiphrenic diverticulum is feasible, with acceptable short-term morbidity. The thoracoscopic approach is also effective in resolving preoperative symptoms.

A case report of achalasia and large epiphrenic diverticulum treated by peroral endoscopic myotomy combined with diverticuloseptotomy

The combination of esophageal achalasia with epiphrenic diverticulum is extremely rare and mostly treated surgically. Several cases of successful endoscopic treatment were presented in the literature, but treatment strategy has not yet been defined. Aim. To present a case of the rare combination as achalasia and giant esophageal epiphrenic diverticulum successfully treated endoscopically. Case report. We present to your attention a case report of a 75-year-old woman with complete dysphagia, significant weight loss, who was diagnosed with symptomatic epiphrenic diverticulum secondary to achalasia. Upper gastrointestinal endoscopy showed signs of severe fibrosis in the submucosal layer of the diverticulum. She received peroral endoscopic myotomy combined with diverticuloseptotomy made from the same submucosal tunnel. The regression of symptoms from 10 to 2 points according to the Eckardt symptom score clinically showed the treatment success. Conclusions. The presented endoscopic one-tunnel technique could be an effective miniinvasive option for large symptomatic epiphrenic diverticula associated with achalasia.

Near-infrared fluorescence-assisted thoracoscopic diverticulectomy of esophageal diverticulum: a case report

BackgroundEsophageal diverticulum is a rare condition that requires treatment only when symptoms are present. Surgery has been considered to be the only curative option for symptomatic cases. The most popular procedure is diverticulectomy. Clear and intact exposure of the diverticulum’s neck is the basis for safe and effective diverticulectomy.Case presentationWe herein report a case of a 57 year-old woman with an epiphrenic diverticulum. VATS diverticulectomy was scheduled. To better identify the diverticulum neck, we injected indocyanine green (ICG) into the diverticulum through the endoscopic channel, and the diverticulum wall and neck were clearly visible under near-infrared (NIR) fluorescence. With the help of this method, diverticulectomy was successfully performed.ConclusionThis case shows that NIR fluorescence with ICG is safe, simple and reliable and can be used for diverticulectomy.