Epiphrenic Esophageal 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.

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

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.

Minimally Invasive Approach to Epiphrenic Oesophageal Diverticulum: A Case Report

An oesophageal diverticulum is a relatively rare disorder of the oesophagus which results in the outpouching of the oesophageal mucosa through a weak portion within the oesophageal lining. Oesophageal diverticula occur in <1% of the population and are found in approximately 1-3% of those presenting with dysphagia. A 75-year-old male patient came to the surgical Outpatient Department (OPD) with chief complaints of difficulty in swallowing for 2-3 months, initially with solids which later progressed to difficulty in swallowing liquids. He was diagnosed on a Contrast-Enhanced Computed Tomography (CECT) scan with a large oesophageal diverticulum arising from the right lower lateral thoracic oesophagus just proximal to the oesophagogastric junction in the retrocardiac region with no filling defect or mucosal thickening. The patient was treated with transhiatal laparoscopic oesophageal diverticulectomy with cardiomyotomy and Dor fundoplication. For symptomatic patients, most often, minimally invasive myotomy and removal of the pouch endoscopically are advised, which may pose a surgical challenge due to the rarity of the disease.

The laparoscopic transabdominal approach for resection of the large epiphrenic esophageal diverticulum

Background: Epiphrenic (supradiaphragmatic) esophageal diverticula are epithelial-lined mucosal pouches that protrude through the esophageal wall. Almost all of these pulsion diverticula are acquired and appear within the last 10 centimeters of the distal esophagus. Among others, the main cause of the occurrence of these gigantic diverticula is achalasia. We present a 54-year-old male patient with symptoms of large epiphrenic diverticulum, and achalasia Eckardt score 7. Presentation of case: The results of the gastrografin swallow test, computed tomography, and esophageal manometry showed a large epiphrenic diverticulum, and therefore surgical treatment was indicated. We performed laparoscopic transhiatal diverticulectomy, Heller myotomy, hiatoplasty, and Dor fundoplication. The overall operation time was 180 minutes. While performing Heller myotomy, an iatrogenic lesion of esophageal mucosa appeared within 2 centimeters of the lower esophageal sphincter. The perforation was immediately closed with a single suture. After this, a Dor fundoplication was created. On the fifth postoperative day, a gastrografin swallow test was performed with no evidence of a suture-line leakage. On the sixth postoperative day, the patient was discharged home in good general condition. Discussion and conclusion: Resection of esophageal diverticula by a transabdominal laparoscopic approach is a feasible method that, in the case of intraoperational incidents such as lesions of the esophageal wall, enables prompt and excellent visualisation of the lesion site. Furthermore, primary suturing of iatrogenic perforation of the distal esophagus is a feasible technique for resolving these kinds of surgical complications, also taking into account the fact that a Dor fundoplication is then created over the lesion site.

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.

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.

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.

Magnet-Assisted Diverticuloplasty in the Treatment of a Large Epiphrenic Esophageal Diverticulum.

Magnet-Assisted Diverticuloplasty in the Treatment of a Large Epiphrenic Esophageal Diverticulum.

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.

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.

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．

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

Per-oral Endoscopic Myotomy with Division of Septum (D-POEM) in Epiphrenic Esophageal Diverticula: Outcomes at a Median Follow-Up of Two Years.

Esophageal epiphrenic diverticula (EED) are rare pulsion-type outpouchings at the lower end of esophagus. Traditionally, surgery has been performed in EED. More recently, per-oral endoscopic myotomy with septotomy (D-POEM) has emerged as an option in these cases. In this study, we aim to determine the efficacy and safety of D-POEM in cases with EED. The data of cases who underwent D-POEM in cases with EED from March 2013 to Nov 2020 were analyzed, retrospectively. The primary outcome of the study was clinical success. Secondary outcomes included technical success, procedure duration, reflux esophagitis, and adverse events. 13 patients (males 9, 48.07 ± 17.55years) with EED underwent D-POEM during the study period. Median size of the EED was 45mm (range 25-70). Associated esophageal motility disorder was found in 10 (76.9%) cases including type II achalasia (3), type I (3), hypercontractile esophagus (2), and unspecified (2). Technical success was achieved in 12 (92.3%) cases. Median length of total and gastric myotomies were 10cm (range 6-20) and 3cm (1-3), respectively. At a median follow-up of 25months, clinical success was achieved in 84.6% cases. Mean integrated relaxation pressures reduced significantly after POEM procedure (25.80 ± 13.24 vs 9.40 ± 3.10, p = 0.001). There was one major adverse event requiring surgical intervention. D-POEM is an effective procedure in cases with EED. Long-term follow-up studies are required to ascertain the durability of response in these cases.

A Case of Epiphrenic Esophageal Diverticulum Resected by Laparoscopic Diverticulectomy

A Case of Epiphrenic Esophageal Diverticulum Resected by Laparoscopic Diverticulectomy

S2013 A Rare Cause of Dysphagia – Epiphrenic Esophageal Diverticulum Complicated by Complete Esophageal Obstruction

INTRODUCTION: Epiphrenic esophageal diverticulum (EED) are a rare protrusion of the distal esophagus arising a few centimeters above the lower esophageal sphincter and is estimated to occur in 1:500,000 individuals per year. It results in motility dysfunction and typically presents as dysphagia and weight loss. Complications include upper GI bleed, esophageal carcinoma, and formation of atypical esophagorespiratory fistulas. CASE DESCRIPTION/METHODS: 66-year-old male with known history of Barrett’s esophagus and daily alcohol ingestion presented for 3 months of dysphagia with 22 kg weight loss. The initial esophagogastroduodenoscopy (EGD) demonstrated a large obstructive distal esophageal stricture for which Bougie French #60 dilation was performed at an outlying facility. Biopsy showed normal squamous mucosa. Two weeks later, dysphagia remained in which patient underwent CT chest that showed distended proximal thoracic esophagus and wall thickening with soft tissue mass involving the distal esophageal lumen consistent with obstruction; no extrinsic mass was noted (Figure 1). Laboratory workup including a complete blood count and comprehensive metabolic panel were within normal limits. Subsequent esophagram showed patulous and dilated esophagus with a large obstructive epiphrenic esophageal diverticulum (Figure 2). Esophageal ultrasound demonstrated food content within the esophageal false lumen (Figure 3). The patient subsequently had a PEG tube placed with plan to undergo traditional open transthoracic surgery with diverticulectomy and esophageal myotomy in the future. DISCUSSION: Most cases of epiphrenic esophageal diverticula are asymptomatic and do not warrant treatment though some may present with dysphagia, dyspepsia, and aspiration pneumonia. It is important to have a broad differential diagnosis including EED in patients with dysphagia. Delayed diagnosis and treatment could put patient at risk for life-threatening complications. Esophageal endoscopy is needed to rule out other dysphagia etiologies. Our case demonstrates complete esophageal obstruction leading to significant weight loss because of EED. In contrast to Zenker’s diverticulum, which occur in the proximal esophagus, EED are much rarer and occur in the distal esophagus. To contrast their rarity, EED occur at a ratio of 1:5 with that of Zenker’s. Traditionally, surgical resection is the treatment of choice. However, endoscopic techniques are being investigated.Figure 1.: CT chest shows dilated, obstructed, and irregular-shaped distal esophagus (red arrow) posterior to the pulmonary artery (PA). There is no extrinsic paraesophageal mass compression.Figure 2.: Esophagram shows epiphrenic esophageal diverticulum (red arrow) with complete distal esophageal obstruction indicates by the absence of contrast in the distal esophagus (black arrow); only an occasional trickle of contrast can be seen to transgress the distal esophagus into the fundus of the stomach. Note the proximity of the diverticulum to the cardiac silhouette.Figure 3.: Esophageal ultrasound showing food content within the esophageal false lumen at the 6 o’clock position.

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.

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.