Epiphrenic Diverticulum Research Articles

V-OG03 Robotic Epiphrenic Diverticulectomy, Myotomy And Hiatus Hernia Repair

Abstract Background Oesophageal epiphrenic diverticulum’s are rare; reported in less than 0.5 per cent of the population. They are noted however in 1–3 per cent of patients complaining of dysphagia. They are almost always associated with a motility disorder of the oesophagus. Surgery is generally the only solution to help with the symptoms of dysphagia and reflux. Methods This video highlights a case of a moderate sized diverticulum causing dysphagia and significant reflux. The procedure was performed on the DaVinci X system; to my knowledge, this is the first time this technique has been performed on the DaVinci X in the UK. A 4 arm technique was used, utilising two right arms and one left. Instruments used were cadiere forceps, hook and sureform stapler. The 12 mm port was docked with arm 3 and sited on the patients left. A stapled diverticulectomy was performed with the Sureform blue cartridge. An endoflex was used to retract the liver. Results The procedure was successfully performed in 150 minutes and involved resection of the diverticulum, hiatal repair and short myotomy up to the neck of the diverticulum. Conclusion The robotic platform allows for better visualisation of the hiatal structures and vagal nerves and the enhanced magnification make for a safer myotomy. The articulating instruments permit safer dissection of the diverticulum. A 4 arm technique makes the myotomy easier and safer to perform.

Peroral Endoscopic Myotomy for the Treatment of Esophageal Diverticula: A Systematic Review and Meta-analysis.

There is limited evidence on the efficacy of peroral endoscopic myotomy (POEM) in patients with esophageal diverticula. This meta-analysis aimed to assess the efficacy and safety profile of POEM in patients with Zenker (ZD) and epiphrenic diverticula. With a literature search through August 2020, we identified 12 studies (300 patients) assessing POEM in patients with esophageal diverticula. The primary outcome was treatment success. Results were expressed as pooled rates and 95% confidence intervals. Pooled rate of technical success was 95.9% (93.4%-98.3%) in ZD patients and 95.1% (88.8%-100%) in patients with epiphrenic diverticula. Pooled rate of treatment success was similar for ZD (90.6%, 87.1%-94.1%) and epiphrenic diverticula (94.2%, 87.3%-100%). Rates of treatment success were maintained at 1 year (90%, 86.4%-97.4%) and 2 years (89.6%, 82.2%-96.9%) in ZD patients. Pooled rate of symptom recurrence was 2.6% (0.9%-4.4%) in ZD patients and 0% in patients with epiphrenic diverticula. Pooled rates of adverse events and severe adverse events were 10.6% (4.6%-16.6%) and 3.5% (0%-7.4%) in ZD and 8.4% (0%-16.8%) and 8.4% (0%-16.8%) in epiphrenic diverticula, respectively. POEM represents an effective and safe therapy for the treatment of esophageal diverticula.

74 LAPAROSCOPIC MANAGEMENT OF A PULSION EPIPHRENIC OESOPHAGEAL DIVERTICULUM SECONDARY TO ACHALASIA.

Abstract This is a video submission of a laparoscopic resection of an epiphrenic oesophageal pulsion diverticulum secondary to achalasia. A Heller’s cardiomyotomy is also performed together with a Toupet fundoplication. Methods The patient is a 40 year old woman with a 12 month history of worsening dysphagia, reflux symptoms, as well as occasional regurgitation of food, worse at night. Barium swallow showed a distal oesophageal diverticulum and oesophageal manometry confirmed type 1 achalasia. Upper GI endoscopy showed no other intra-luminal findings. Results The patient underwent a laparoscopic resection of the diverticulum, together with a Heller’s cardiomyotomy and Toupet fundoplication. There were no post-operative complications. She remains well and asymptomatic at 9 month follow-up. Conclusion Pulsion diverticula secondary to achalasia are a known but rare entity. A few variations exist on how to manage this condition surgically, especially with respect to the type of fundoplication. We present our preferred technique for dealing with this condition. Video https://www.dropbox.com/s/dg4edkamykugupn/Oesophagealdivert.mp4?dl=0

Peroral endoscopic myotomy (POEM) for esophageal diverticula.

Esophageal diverticula (ED) are uncommon, mostly seen in elderly and can present with a multitude of symptoms. Of the three types of ED, epiphrenic and mid-esophageal diverticulum are still rare. These are often associated with esophageal motility disorder, which contributes to its development. The key step in the management of such symptomatic ED is the division of the septum and tackling the underlying motility dysfunction, if any. Traditional surgical options have high morbidity and mortality while flexible endoscopic septal division cannot adequately manage epiphrenic diverticulum with motility dysfunction. The technique of submucosal space creation and peroral endoscopic myotomy (POEM) has been used to treat a host of esophageal diseases such as achalasia. POEM has been recently described for the management of ED. Two different strategies have been described for tackling using POEM, namely, diverticular POEM (D-POEM) and salvage POEM (S-POEM). While D-POEM entails division of the septum and esophageal myotomy, S-POEM requires only esophageal myotomy without septum division. Multiple retrospective studies in the recent years have described use of POEM for the management of different types of ED with good safety and efficacy with low recurrence rate. This review encompasses a detailed account of the technical steps, pre- and post-procedure evaluation and literature review of safety, efficacy, adverse events, and recurrence rates of the use of POEM for ephiprenic and mid-esophageal diverticulum. We have also proposed a management algorithm based on the type of underlying motility dysfunction and the size of the diverticulum.

ENDOSCOPIC STENTING IN THE TREATMENT OF RECURRENT EPIPHRENIC DIVERTICULUM AFTER LAPAROSCOPIC DIVERTICULECTOMY. CLINICAL CASE REPORT

Epiphrenic diverticulum, also known as a pulsion diverticulum, is a rare type of esophageal diverticulum occurring in the distal 10 centimeters of the esophagus. They are most commonly 4-10 cm above the gastric cardia representing 10% of all esophageal diverticula. Laparoscopic diverticulectomy has become the treatment of choice. This clinical case study is dedicated to minimally invasive treatment of recurrent epiphrenic diverticulum after laparoscopic diverticulectomy. A 74-year-old male patient was admitted to the hospital with complaints of dysphagia, regurgitation and halitosis. The examination revealed a 5 cm epiphrenic diverticulum with sings of inflammation. Laparoscopic transchiatal diverticulectomy, the Dor (anterior) fundoplication, cruroraphia and mediastinal drainage were performed. The patient was discharged on the 11-th postoperative day. The patient exhibited dysphagia relapse during a 3-month follow-up. Taking into account the previous surgical treatment and the habitus endoscopic esophageal stenting was chosen as the technique of choice for management. Under intravenous anesthesia a partially covered metal self-expandable stent 10 cm x 1.8 cm was inserted into the distal esophagus. Next day control fluoroscopy showed stable stent position and no evidence of leakage. The water-soluble contrast agent reached stomach freely. The patient was discharged on the 2nd post-operative day. Within 4 months after having a stent placed, the patient feels well and oral feeding is satisfactory. In terms of literature search we have not come across any reference to the post-epiphrenic diverticulectomy recurrence treatment, so the management was chosen individually based on the comorbid status of the patient. The installation of a partially covered metal self-expandable stent allowed to promptly eliminate dysphagia and design features enabled to achieve stent stable position. A partially covered metal self-expandable stent can be considered effective in the post-epiphrenic diverticulectomy recurrence treatment.

ID: 3526604 FAILED HELLER MYOTOMY WITH DIVERTICULECTOMY? SUCCESS WITH POEM AND DIVERTICULOTOMY: A CASE SERIES

Heller myotomy with esophageal diverticulectomy was standard of care for achalasia concomitant with epiphrenic diverticulum. With increasing frequency, POEM with diverticulotomy has been demonstrated as a feasible method for management of achalasia with a paraesophageal diverticulum. Here, we present two patients with achalasia and paraesophgeal diverticulum that have symptoms refractory to Heller myotomy.

Evaluating esophageal motility beyond primary peristalsis: Assessing esophagogastric junction opening mechanics and secondary peristalsis in patients with normal manometry.

Functional luminal imaging probe (FLIP) Panometry assesses the esophageal response to distention and may complement the assessment of primary peristalsis on high-resolution manometry (HRM). We aimed to investigate whether FLIP Panometry provides complementary information in patients with normal esophageal motility on HRM. Adult patients that completed FLIP and had an HRM classification of normal motility were retrospectively identified for inclusion. 16-cm FLIP studies performed during endoscopy were evaluated to assess EGJ distensibility, secondary peristalsis, and identify an abnormal response to distention involving sustained LES contraction (sLESC). Clinical characteristics and esophagram were assessed when available. Of 164 patients included (mean(SD) age 48(16) years, 75% female), 111 (68%) had normal Panometry with EGJ-distensibility index (DI) ≥2.0 mm2 /mmHg, maximum EGJ diameter ≥16mm and antegrade contractions. Abnormal EGJ distensibility was observed in 44/164 (27%), and 38/164 (23%) had an abnormal contractile response to distension. sLESC was observed in 11/164 (7%). Among 68 patients that completed esophagram, abnormal EGJ distensibility was more frequently observed with an abnormal esophagram than normal EGJ opening: 14/23 (61%) vs 10/45 (22%); P=0.003. Epiphrenic diverticula were present in 3/164 patients: 2/3 had sLESC. Symptomatic patients with normal esophageal motility on HRM predominantly have normal FLIP Panometry; however, abnormal FLIP findings can be observed. While abnormal Panometry findings appear clinically relevant via an association with abnormal bolus retention, complementary tests, such as provocative maneuvers with HRM and timed barium esophagram, are useful to determine clinical context.

Diverticula in the gastrointestinal tract

The prevalence of diverticula varies depending on the location within the gastrointestinal tract. Diverticula of the esophagus, stomach and small intestine are rare, more frequent are peripapillary diverticula and colonic diverticula. Meckel diverticula can also be of relevance in adults. Diverticula have to be differentiated from intramural pseudodiverticulosis of the esophagus and bile duct cysts. An endoscopic and radiological diagnostic work-up is only necessary for symptomatic diverticula or complications. In some cases additional functional diagnostic tests, such as high-resolution esophageal manometry to detect underlying motility disorders (Zenker's diverticulum, epiphrenic diverticulum) or the hydrogen breath test to detect bacterial overgrowth in the small intestine (diverticula of the small intestine) are mandatory. Effective treatment requires the close interdisciplinary cooperation between different specialist disciplines. Therapeutic modalities include pharmacotherapy, endoscopy and surgical methods.

Per Oral Endoscopic Myotomy for the Management of Large Esophageal Diverticula (D-POEM): Safe and Effective Modality for Complete Septotomy.

With the advent of the technique of sub-mucosal tunnelling, peroral endoscopic myotomy (POEM) has been used for the treatment of esophageal diverticulum, which otherwise is a recurring problem with conventional flexible endoscopic treatment due to incompleteness of septotomy. This study reports our experience of the use of diverticular POEM (D-POEM) technique in the management of large esophageal diverticulum. This is a retrospective study of prospectively maintained database including all consecutive patients with symptomatic esophageal diverticulum presenting at a tertiary care academic center. D-POEM was performed using the technique of submucosal tunnelling and septotomy. Besides baseline parameters, technical success, clinical success, size of diverticula, procedure time, complications and symptom recurrence on follow up were noted. A total of five patients (4 males; median age 72) were included with an average Charlson comorbidity index of 3.2 ± 0.8. Of them, three had Zenker's while two had epiphrenic diverticulum. The median symptom duration was 12months with a mean diverticulum size of 68.8 ± 1.9mm. The mean procedure time was 64.80 ± 12.6min. with a mean septotomy/myotomy length of 79.44 ± 12.2mm. Minor adverse events were noted intra-procedure in two cases. Clinical success achieved in all cases with a significant mean dysphagia score reduction from 2.20 to 0.20 post procedure (p = 0.011). On a median follow up of 280days (range 98-330), none had recurrence of symptoms. Our data highlighted that complete septotomy by D-POEM technique can be achieved for the management of large esophageal diverticulum and is safe and effective.

The experience of tunnel method using in treatment of patient with epiphrenic diverticulum

<h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Оценка результатов лечения пациентки с эпифренальным дивертикулом. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> Представлен опыт эндоскопического лечения пациентки 65 лет с эпифренальным дивертикулом, которая поступила в клинику с жалобами на затруднения прохождения любой пищи, гнилостный запах изо рта, боли в грудной клетке. По данным эндоскопического и рентгенологического исследования обнаружен дивертикул в нижней трети пищевода с задержкой содержимого в нем. Для лечения пациентки использован эндоскопический тоннельный метод миотомии. <h3>РЕЗУЛЬТАТЫ</h3> Длительность операции составила 120 мин. Для выполнения вмешательства использовали инструментарий для пероральной миотомии. Осложнений в ходе операции и послеоперационном периоде не выявлено. При рентгеноскопии в 1-е сутки после операции нарушений прохождения контрастного вещества не выявлено. При обследовании через 6 мес после операции жалоб нет. Питание через рот свободное. <h3>ЗАКЛЮЧЕНИЕ</h3> Эндоскопическая тоннельная дивертикулотомия в лечении пациентов с эпифренальным дивертикулом является малоинвазивным вмешательством и может быть альтернативой стандартным операциям благодаря своей высокой эффективности, безопасности и малой травматичности. Для определения показаний и противопоказаний, оценке отдаленных результатов, необходимо дальнейшее накопление опыта подобных операций с их анализом.

S1886 Massive Gastrointestinal Bleeding From a Epiphrenic Diverticulum: A Case Report and Brief Review of the Literature

INTRODUCTION: Esophageal diverticulum is a rare condition that results from outpouching of the esophageal wall. It can be divided, based on location, into three types. Zenker's diverticula are found in the upper third of the esophagus and account for 70% of cases. Epiphrenic diverticula arise in the lower third of the esophagus and account for 20% of the cases. Mid-esophageal diverticula are the least common and account for 10% of the cases. When symptomatic, the main symptoms are dysphagia, regurgitation, halitosis and chronic cough. In this case, we present a rare case of gastrointestinal bleeding from epiphrenic diverticulum. CASE DESCRIPTION/METHODS: A 77-year-old male with a past medical history significant for atrial fibrillation on Rivaroxaban who presented with complaints of hematemesis and melena of one day duration. Vital signs were stable and physical examination was unremarkable. Lab work showed hemoglobin of 6.6 mg/dl, INR of 2.4, and an aPTT of 42 seconds. He underwent EGD which showed a large mid-esophageal diverticulum with blood clots and ulcerated mucosa (Figure 1). Chest CT scan with oral contrast 9 cm esophageal diverticulum along the right side of the distal esophagus (Figures 2a and b). Surgery was felt to be technically difficult and the patient was managed conservatively. The patient's hematemesis resolved gradually and his hemoglobin stabilized. DISCUSSION: Epinephric diverticulum is a rare medical entity. It's a false, pulsion diverticulum that result from outpouching of the submucosal and mucosal layers of the esophageal wall due to increased intraluminal pressure. Usually epiphrenic diverticula are asymptomatic. When symptomatic, presentations include epigastric pain, regurgitation, dysphagia and weight loss. Epiphrenic diverticulum presenting with upper GI bleeding is very rare with only 9 case reports identified in our literature review. It’s postulated that diverticular mucosal ulceration results from incomplete emptying of food from the diverticula. This causes irritation of the diverticular mucosa with subsequent GI bleeding.Figure 1.: endoscopic images of distal esophagus showing huge epiphrenic esophageal diverticulum with blood clots and ulcerated mucosa.Figure 2a.: Cross sectional view of chest CT scan with oral contrast showing 9 cm epiphrenic diverticulum.Figure 2b.: chest CT scan with oral contrast showing 9 cm epiphrenic diverticulum.

340 EXPANDING THE ROLE OF POEM TO ESOPHAGEAL EPIPHRENIC DIVERTICULA—FEASIBLE, SAFE AND EFFECTIVE.

Abstract Epiphrenic diverticula (ED) is a rare disorder which can be associated with significant surgical morbidity. Presence of an esophageal motility disorder, often achalasia, is classically associated with ED with some arguing that symptoms are primarily attributed to the motility disorder rather than the diverticula itself. The role of peroral endoscopic myotomy (POEM) is expanding for palliation of achalasia. The objective of our study is to investigate the outcomes of POEM in patients with epiphrenic diverticula. Methods A retrospective analysis of a prospectively maintained database was conducted in a tertiary care institution between April 2014 and July 2019. A total of 217 patients receiving a POEM during the study time period were identified with 13 patients having ED. Video recordings of POEM with and without ED were compared for technical differences. Patient demographics, prior esophageal procedures and epiphrenic diverticula characteristics were collected. Primary outcome was post-operative Eckardt scores. We also explored integrated resting pressure (IRP) on manometry, barium column height and width, complications and patient reported outcomes. Standard statistical methods were applied using R. Results Among 13 patients with ED (median age 74.2, 69% male), 7 small and 6 large diverticula were identified. No post-operative complications were noted. The median Eckardt score significantly decreased from 8 [IQR 5–9] pre POEM to 0 [IQR 0–2] post POEM, with similar improvements in median IRPs (24.5 mmHg [IQR 16.9–31.3] vs. 4.3 mmHg [IQR 2.4–7.6], 1 min barium column height (9.2 cm [IQR 6.3–17.9] vs. 3.2 cm [IQR 0–7.1] and 1 min barium column width (3.3 cm [IQR 2.7–3.5] vs. 0.75 cm [IQR 0–3.7]. Post-operative pH studies were conducted in 7 (53.8%) patients demonstrating a DeMeester score of more than 14.72 in 5 (71.4%) patients. Conclusion We demonstrate that POEM is technically feasible, safe and associated with excellent outcomes in patients with small and large diverticula. In our study cohort no further surgical therapy was required to address the diverticula. Reflux was managed medically. Considering its low morbidity profile POEM should be considered for therapy in selected patients with epiphrenic diverticula.

453 LAPAROSCOPIC RESECTION OF A GIANT EPIPHRENIC DIVERTICULUM

Abstract Epiphrenic diverticula are acquired mucosal out-pouchings of the distal third of the oesophagus; vastly undiagnosed due to their usual asymptomatic status, with limited number in all published series, and a still ongoing debate both in their surgical indication and technique. This video shows all steps we think that are necessary when operating an epiphrenic diverticulum, in order to illustrate them all and to show the feasibility of performing such operation with minimally invasive procedures. Methods A 52-year-old male was diagnosed of a symptomatic giant epiphrenic diverticulum after previous complaints of dysphagia and regurgitation of undigested food. Preoperative barium-swallow and upper endoscopy confirmed the diagnosis, excluding any other secondary aetiology, and conventional oesophageal manometry did not show any relevant findings. Results Surgery was indicated for symptomatic disease, and a laparoscopic procedure was performed, with pneumoperitoneum created through a Veress needle and trocars placed similar to those used for a hiatal hernia repair. After opening the hiatus, access was granted to the mediastinum and the diverticulum was identified and dissected, and when its neck was completely exposed, diverticulectomy was performed using endostapler loads reinforced with Peri-strips Dry®. Aferwards, both an oesphageal myotomy (from the oesophago-gastric junction to the distal point of the diveticulum’s neck) and a partial Dor fundoplication (despite the absence of relevant findings in the conventional manometry) were performed. Conclusion Surgical management of epiphrenic diverticula should entail both resection of the pouch (diverticulectomy, to avoid postoperative persistent symptoms) and treatment of the underlying motility disorder that has been demonstrated in other studies in nearly 100% of the patients using high-resolution manometry (myotomy and fundoplication, both to avoid recurrences and leakages of the staple line). The laparoscopic approach is feasible without video-assisted thoracoscopy in diverticula with their neck up to 10 cm from the oesophagogastric junction. Video https://www.dropbox.com/s/hugbemgi6wl55kp/EpiphrenicDiverticulumx2.mp4?dl=0

Management of Epiphrenic Diverticula and Short-term Outcomes

Epiphrenic diverticulum is a rare and benign condition with significant surgical morbidity and evolving surgical management. The objective of this study was to analyze short-term clinical outcomes after surgery for epiphrenic diverticula. We conducted a retrospective cohort study in a single tertiary care center of all patients who underwent treatment for epiphrenic esophageal diverticula from June 1990 to December 2016. Data collection included demographics, operative details and short-term outcomes (esophageal leak, other complications, 30-day mortality). In addition, all preoperative imaging was reviewed by an esophageal radiologist in order to describe epiphrenic diverticula characteristics in a uniform and blinded manner. Of the 94 patients in the study, 84 patients were managed with an open surgical approach and 10 with minimally invasive techniques. Median size of diverticula was 5.5 cm and mean height above gastroesophageal junction was 4 cm. A myotomy was completed in 95% of patients and a fundoplication in 58%. The MIS group had a shorter length of stay (4 vs 6 days). Overall complication rate was 27% with an esophageal leak rate of 7% with 60% grade I leaks that sealed with conservative management. Complete resection of the diverticulum, closure of the muscle over the resection, contralateral myotomy, and consideration for partial fundoplication are common strategies utilized to surgically treat patients with epiphrenic diverticulum. Minimally invasive approaches are increasingly utilized.

Laparoscopic transhiatal surgery for an epiphrenic esophageal diverticulum derived from a jackhammer esophagus: a case report

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.

Esophageal Disorders

Typically, symptoms that may indicate the presence of an esophageal disorder include heartburn, dysphagia, odynophagia, and regurgitation. Endoscopy is the technique of choice to evaluate the mucosa of the esophagus and to detect structural abnormalities, whereas esophageal manometry is the standard test to diagnose motor disorders of the esophageal body and the lower esophageal sphincter. This review examines normal esophageal anatomy and physiology, the diagnosis of esophageal disorders, disease states causing dysphagia, and gastroesophageal reflux disease. Figures show the cross-sectional anatomy of the esophagus; an algorithm for the evaluation of dysphagia; the anatomy of the gastroesophageal junction; esophagograms of patients with achalasia, late-stage achalasia, and diffuse esophageal spasm; endoscopic views of esophageal strictures; a proximal esophageal web on barium swallow in a patient with Plummer-Vinson syndrome; an endoscopic view of the esophagus of a 25-year-old man with a 3-year history of severe dysphagia; photographs of midesophageal traction diverticulum, multiple epiphrenic diverticula, long-segment Barrett esophagus, and severe Candida esophagitis; and a treatment algorithm for extraesophageal manifestations of gastroesophageal reflux disease. Tables list the high-resolution manometry classification of esophageal motility disorders, causes of esophageal strictures, classic endoscopic findings in patients with eosinophilic esophagitis, the Los Angeles classification of erosive esophagitis, categories of dysplasia, surveillance of Barrett metaplasia, medications implicated in pill-induced esophagitis, and classification of caustic esophageal injury. This review contains 13 figures, 40 tables, and 82 references. Keywords: achalasia, dysphagia, esophagus, reflux, strictures, diverticula, endoscopy, larynx

Treatment of Epiphrenic Diverticulum: How I Do It.

Epiphrenic diverticulum is a rare esophageal disorder occurring as an outpouching of mucosa and submucosa through the muscular layers, within 10 cm above the cardia. As the majority of epiphrenic diverticula are asymptomatic, the real incidence varies because of a considerable number of cases detected incidentally during radiographic or endoscopic evaluation. Traditionally, the operation was performed through a left thoracotomy approach and the diverticulectomy was completed with esophago-cardial myotomy and a Belsey Mark IV fundoplication. Laparoscopy offers many advantages in the treatment such as the possibility of extension of the myotomy from the lower esophagus through the stomach and the concomitant antireflux procedure to avoid postoperative reflux. The abdominal approach is also more comfortable for the patients and, as there is no need for transthoracic drains, is more tolerated in terms of postoperative pain. In this article, we do review our technique with all the steps of the operation illustrated by intraoperative pictures.

Peroral endoscopic myotomy alone is effective for esophageal motility disorders and esophageal epiphrenic diverticulum: a retrospective single-center study.

Esophageal epiphrenic diverticulum (ED) is associated with esophageal motility disorder (EMD). If a diverticulum associated with EMD is enlarging with worsening symptoms, surgical intervention, including laparoscopic epiphrenic diverticulectomy with myotomy and fundoplication, is indicated. However, some studies suggest that myotomy alone, with less adverse events, is sufficient to improve symptoms. Additionally, peroral endoscopic myotomy (POEM) is considered effective and safe for EMD. Since theoretically, POEM is endoscopic Heller myotomy, POEM without diverticulectomy is considered a less invasive, promising treatment option for EMD and ED. We aimed to determine the efficacy and safety of POEM alone for ED with EMD. This single-center study was retrospective. A total of 298 patients underwent POEM in Kobe University Hospital from April 2015 to October 2018. Of them, 14 patients had ED. Procedure-related outcomes and treatment outcomes 3months post POEM were evaluated in these patients. The median maximum ED diameter was 29 (range 9-90) mm; and the median POEM procedure time, 77.5 (range 41-123) min. Pneumoperitoneum, which required needle decompression, occurred in one patient, but no fatal adverse events occurred. The median Eckardt score significantly decreased from 5 [range 2-11] pre POEM to 0 [range 0-2] post POEM (P < 0.0001). The median integrated relaxation pressure significantly decreased from 22.5 [13.9-34.3] mmHg pre POEM to 10.2 [0.7-23.9] mmHg post POEM (P < 0.0001). Of 14 patients, only one patient complained of gastroesophageal reflux disease symptoms, which could be controlled with a potassium-competitive acid blocker. POEM alone seemed effective and safe for patients with EMD and ED.

Advanced squamous cell carcinoma in an asymptomatic, large, epiphrenic esophageal diverticulum.

An asymptomatic epiphrenic diverticulum (ED) was diagnosed in a man undergoing annual esophagogastroduodenoscopy (EGD) at another hospital 40years before he presented to our hospital at age 63years for his annual EGD. However, because substantial food retention was found in the ED, we could not confirm a lesion. After the retained food was removed endoscopically, a second EGD showed a reddish, flat lesion with an elevated mass within the ED. Endoscopic ultrasonography indicated that the elevated mass was deep in the submucosal layer. An esophagram showed that the ED was approximately 80mm in diameter, which is considered large. An endoscopic biopsy of the lesion confirmed squamous cell carcinoma. Total esophagectomy was performed. Microscopic examination revealed well-differentiated to moderately differentiated squamous cell carcinoma invading the adventitia at the elevated lesion. The final pathological stage was pT3N0M0. There was no evidence of recurrence for 3years during the quarterly follow-up examinations. To our knowledge, this case involved the longest asymptomatic term (40years) since the ED was detected. A review of 18 reported cases of carcinoma in an ED indicated that advanced cancer has a poor prognosis. Periodic follow-up of ED patients is essential for early diagnosis.

Epiphrenic diverticulum of the lower third of the esophagus after previous antireflux surgery

In this article is described a rare postoperative complication: epiphrenal diverticulum of the esophagus of the lower third of the esophagus in patient after antireflux surgery. Brief description of the main stages of surgical treatment. 96 patients with cardiofundal, subtotal or total hiatal hernias underwent operation. There were complications of I-II degree according to Clavien-Dindo in the early postoperative period in 11 patients (11.4%). Complications of IIIb degree were revealed in 2 patients (2.1%) in the early postoperative period and in 1 patient (1.0%) in the late postoperative period (2 months after hospitalization) - epiphrenal diverticulum of the esophagus. Laparotomy, the sagittal diafragmalnaya, diverticulectomy, valisesta pyloroplasty were performed. Postoperative period without complications. The patient's nutrition through the mouth is restored on the 5-th day. No dysphagia and reflux esophagitis were detected radiologically and endoscopically.