Esophageal Diverticulum Research Articles

The A to Z of Peroral Endoscopic Myotomy

Peroral endoscopic myotomy (POEM) is a novel technique within the field of third space endoscopy. The overarching principal is creation of a mucosal incision, careful dissection of the submucosal space using an electrosurgical knife to reach the muscularis (ie, tunneling), performing a controlled myotomy, and finally, closure of the mucosal incision. POEM was first developed for the management of achalasia, and now a decade of evidence shows the procedure is safe, effective, and highly reproducible. Since then, the indications for POEM have expanded to a range of benign upper gastrointestinal (GI) pathologies including cricopharyngeal bar (C-POEM), Zenker’s diverticulum (Z-POEM), esophageal diverticula (D-POEM), and gastroparesis (G-POEM). POEM offers the benefit of a minimally invasive alternative to surgical intervention with high clinical success and low rate of adverse events. As the field expands, there is need for more high-quality prospective evidence for the use of POEM within the upper GI tract akin to the ground-breaking work that has been achieved in achalasia. Within this review, we discuss the 5 main indications for POEM, the technical aspects of each corresponding procedure, and analyze the current evidence supporting their use in clinical practice.

S717 Middle Term Outcome of Z-POEM and D-POEM For Treatment of Esophageal Diverticula: A Single Center Experience

S717 Middle Term Outcome of Z-POEM and D-POEM For Treatment of Esophageal Diverticula: A Single Center Experience

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

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.

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

778. ROBOTIC-ASSISTED EPIPHRENIC DIVERTICULECTOMY: 9 YEAR EXPERIENCE OF A TERTIARY CENTER

Abstract Background Epiphrenic esophageal diverticula are rare and often associated with esophageal motor disorders. Surgery is reserved for larger diverticula with symptoms that significantly impair quality of life. When possible, a transhiatal approach can reduce pulmonary complications by preserving pleural integrity; more proximal diverticular openings require a combined transthoracic and abdominal approach to achieve complete excision. Robotic surgery assists in precise dissection and preservation of delicate mediastinal structures. Currently, few reports are available on larger patient cohorts of robotic diverticulectomy. We describe all consecutive cases of robotic-assisted epiphrenic diverticulectomy performed at a high-volume tertiary center, since robotic surgery became available in 2015. Methods A retrospective chart review was conducted and, for all consecutive diverticulectomy cases, surgical techniques, patient characteristics and short and long-term outcomes were recorded. All patients underwent preoperative EGDS and esophagogram. Diverticulectomy was always accompanied by esophagogastric Heller myotomy (>7 cm) and Dor fundoplication with the Xi DaVinci system was performed. One to two SIGNA linear stapler firings were used for diverticular resection. Symptoms, demographic data, and short and long-term surgical outcomes were recorded, including morbidity and mortality and post-operative symptoms. Results Four cases required both an abdominal and intrathoracic approach, none was converted. Intraoperative complications included one occurrence of splenic bleeding controlled by hemostatic. Intraoperative blood loss was negligible. In two cases an esophageal leiomyoma was found incidentally and excised. The only postoperative complication was trocar-related abdominal wall bleeding that led to reintervention for cauterization; mortality was zero. All patients underwent a post-op esophagogram, negative for leaks or strictures, and resumed soft feeding within 7 days. All reported substantial symptom relief at six months. At one year, one patient reported reflux, and two reported dysphagia recurrence without evident structures or recurrences. Conclusion Robotic-assisted diverticulectomy is safe and effective for epiphrenic diverticula. The abdominal approach allows for a thorough esophageal myotomy associated with a For antireflux procedure to reduce recurrences of the disease and long-term dysphagia. In some cases a transthoracic approach is also needed, when employed by experienced upper GI surgeons it doesn't significantly affect surgical outcomes. Quality of life improves after surgery, although symptomatic reflux might occur. Further prospective or experimental studies are needed to evaluate short and long-term outcomes of the robotic approach compared to other surgical approaches.

One stone two birds - Submucosal tunneling endoscopic resection for a large esophageal submucosal mass and esophageal diverticulum.

A-35-year-old woman presented our hospital with half a year's history of solid food dysphagia. An upper gastrointestinal endoscopy revealed a large submucosal mass in an esophageal diverticulum near the gastroesophageal junction. Endoscopic ultrasound (EUS) confirmed a hypoechoic lesion arising from the muscularis propria layer with the size of 25*14 mm. Therefore, submucosal tunneling endoscopic resection (STER) was proposed to remove the large submucosal lesion in addition to targeted septotomy of the esophageal diverticula. A 2-cm longitudinal mucosal access was made at 3 cm above the submucosal lesion, and a submucosal longitudinal tunnel was created until the submucosal lesion revealed using a DualKnife (Olympus, Japan). Meticulous resection was performed with the DualKnife, and the lateral border of the lesion was dissected from muscularis propria layer. It was completely removed the lesion with en bolc resection, and dissected the septum of the diverticulum using the DualKnife. The tunnel access was closed with several hemoclips. Finally, it has been demonstrated to achieve a perfect outcome for the patient. The patient was discharged three days later with symptom resolved on follow-up and to date.

Inspiratory Stridor as the First Rare Presentation of Infantile Esophageal Diverticulum: A Case Report

Inspiratory Stridor as the First Rare Presentation of Infantile Esophageal Diverticulum: A Case Report

Modified submucosal tunneling endoscopic septum division for symptomatic esophageal diverticula: a prospective case series (with video)

Background and aimsSubmucosal tunneling endoscopic septum division (STESD) is a valid endoscopic modality for treating esophageal diverticula. However, it requires highly skilled endoscopists. Here we propose a modified STESD method. MethodsThis is a single center prospective case series. We consecutively enrolled 8 patients diagnosed with esophageal diverticula. All the patients underwent the modified STESD by one experienced endoscopist. ResultsOnly one patient had intraoperative bleeding and was successfully stopped endoscopically. The size of the diverticula were 3.16 ± 1.14 cm as mean ± SD. The operation time ranged from 27 to 68 min with the mean value of 40.88 min. The number of clips ranged from 4 to 8. The success rate was 100%. None of the patients had symptom recurrences during 2 - 25 months of follow-up. ConclusionsThe modified STESD method for esophageal diverticula is effective and safe, further large prospective controlled studies are needed.

C5 palsy following esophageal diverticulum resection.

C5 palsy (C5P) is a recognized potential postoperative complication of cervical spine surgery but has rarely been reported following an open esophageal diverticulectomy. A 61-year-old underwent an open esophageal diverticulectomy for symptomatic Zencker's diverticulum. Postoperatively, she presented with right upper extremity weakness and sensory deficits consistent with a C5P that was later confirmed by electromyography. The potential for C5P after esophageal diverticulectomy for symptomatic Zencker's diverticulum is rare. Postoperative recognition and appropriate management are critical to recovery.

A Case Report of an Adult With Coexistence of Tracheal and Esophageal Diverticulum

A Case Report of an Adult With Coexistence of Tracheal and Esophageal Diverticulum

Midesophageal diverticulum with elevated intrabolus pressure: a case report

BackgroundEsophageal diverticulum is commonly associated with esophageal motility disorders, which can be diagnosed using high-resolution manometry (HRM) according to the Chicago classification. Although midesophageal diverticulum (M-ED) is associated with inflammatory processes, esophageal motility disorders have been recently identified as an etiology of M-ED.Case presentationWe present the case of a patient with M-ED and elevated intrabolus pressure (IBP), which did not meet the criteria for esophageal motility disorders according to the Chicago classification. A 71-year-old man presented with gradually worsening dysphagia for two years and was diagnosed as having an 8-cm-long M-ED and multiple small diverticula in lower esophagus. HRM revealed a median integrated relaxation pressure of 14.6 mmHg, a distal latency of 6.4 s, and an average maximum IBP of 35.7 mmHg. He underwent thoracoscopic resection of the M-ED and myotomy, which successfully alleviated the symptoms and reduced the intrabolus pressure to normal levels.ConclusionsIt is important to recognize the esophageal diverticulum pathology with HRM findings even in cases where the results may not meet the Chicago classification and to include myotomy based on the results.

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.

MSCT study for adult esophageal diverticulum with secondary broncho-esophageal fistula

BackgroundBroncho-esophageal fistula (BEF) secondary to esophageal diverticulum is a rare clinical condition, which is often misdiagnosed for a long time. The aim of our study is to summarize and clarify the advantages of MSCT in diagnosing BEF secondary to esophageal diverticulum.MethodsWe retrospectively analyzed patients clinically diagnosed with BEF from January 2005 to January 2022 at Jilin University First Hospital. Only those patients with BEF secondary to esophageal diverticulum and complete clinical data met our enrolled standard. All patients’ clinicopathologic characteristics and MSCT features were systemically evaluated.Results17 patients were eligible for our cohort study, including male 10 and female 7. The patient’s mean age was 42.3 ± 12.5. The chronic cough occurred in all seventeen patients and bucking following oral fluid intake was documented in nine patients. MSCT distinctly suggested the fistulous tract between the bronchi and the esophagus in all patients. The mean diameter of the orifices in the wall of the esophagus was 4.40 ± 1.81 mm. The orifice in the midthoracic esophagus side was 15 cases and 2 cases at the lower thoracic esophagus. The involved bronchus included 13 cases at the right lower lobe bronchus, 1 at the right middle lobe bronchus and 3 at the left lower lobe bronchus. The contrast agent was observed in the pulmonary parenchyma in 10 of 13 patients who underwent esophagogram. No definite fistula was observed in 3 of 11 who underwent gastroscopy, while the intra-operative findings supported the existence of fistula.ConclusionsBEF secondary to esophageal diverticulum tends to occur between the midthoracic esophagus and the right lower lobe bronchus. Compared with esophagography and gastroscopy, MSCT shows more comprehensive information about the fistulous shape, size, course and lung involvement, which are helpful for establishing diagnosis and guiding subsequent treatment.

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 &lt;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.

Zenker’s diverticulum co-existing with a duodenal ulcer: A case report

Abstract Oesophageal diverticula are relatively rare, with Zenker’s diverticulum (ZD) being the most common type. ZD is a relatively rare disease in the pharyngoesophageal area. It is a pulsion diverticulum, or false diverticulum, located dorsally at the wall between the pharynx and esophagus. We present a case of an incidental finding of a ZD in an elderly woman who presented with upper gastrointestinal bleeding from a co-existing duodenal ulcer.

Characteristics of Esophageal Motility and Associated Symptom Profiles in Patients with Esophageal Diverticulum: A Study Based on High-Resolution Impedance Manometry.

Esophageal diverticulum (ED) is an uncommon structural disorder with heterogenous manifestations and elusive pathophysiology. Our aim was to investigate esophageal motility and associated symptom profiles in patients with ED based on high-resolution impedance manometry (HRIM). Consecutive patients with ED referred to our motility laboratory between 2015 to 2022 were identified in our electronic database. All patients were evaluated based on an upper endoscopy, HRIM, and standardized symptom questionnaires. Patients with ED were further stratified into upper, middle, and lower (epiphrenic) cases. Esophageal motility was evaluated with HRIM and the updated Chicago Classification v4.0. Twenty-four patients with ED (9 upper, 4 middle, and 11 epiphrenic) were analyzed. Patients with ED were generally older (mean: 65 ± 13.3years) and predominantly women (58.3%). Most ED cases were unilaterally located (95.8%) and left-side predominant (62.5%). Mean symptom duration was 20months (range: 1-120) and the most common symptoms were dysphagia (70.8%) and regurgitation (37.5%). Erosive esophagitis was noted in 16 patients (69.6%), while barium stasis was noted in 5 patients (20.8%). Fourteen patients (58.3%) were diagnosed with esophageal motility disorders using HRIM, with achalasia being the most common diagnosis (n = 5, 20.8%). Patients with epiphrenic diverticulum had significantly higher symptom scores and achalasia prevalence. Patients with ED tended to be older and was associated with a high prevalence of EMD. A multi-disciplinary evaluation, including complete anatomical and motility surveys, may help clarify the underlying pathophysiology and tailor further treatment strategies.

A case of esophageal cancer in a diverticulum treated by surgical resection: a case report

BackgroundAn esophageal diverticulum is a relatively rare disease, with reports of treatment for esophageal cancer in the diverticulum even rarer.Case presentationThe case involved a 72-year-old male with a chief complaint of dysphagia. He was diagnosed with an esophageal diverticulum (Zenker’s diverticulum) measuring 10 cm in diameter. Five years later, an upper gastrointestinal endoscopy revealed an iodine-unstained 0–IIb lesion of 20 mm in diameter with type B1 vessels in the diverticulum. An endoscopic biopsy and CT revealed it to be squamous cell carcinoma, cT1a-EP/LPM N0 M0, cStage 0. Because the lesion was in the diverticulum and endoscopic resection was difficult with the risk of perforation, surgical resection was set as the course of treatment. Diverticulectomy was performed via a cervical approach, using a stapler, and the patient was discharged on the 16th day without any complications. The pathological diagnosis was pTis-EP, ly0, v0, R0.ConclusionsWe think this case is very rare and diverticulectomy of early esophageal cancer in the diverticulum is available and safe.

Chronic esophagotracheal fistula secondary to esophageal diverticulum successfully treated by endoscopic submucosal dissection and dual action tissue clip.

Chronic esophagotracheal fistula secondary to esophageal diverticulum successfully treated by endoscopic submucosal dissection and dual action tissue clip.