Esophageal Diverticulum Research Articles

A Killian-Jaimeson Diverticulum Masquerading as a Thyroid Nodule

Background: A Killian-Jaimeson diverticulum is a rare outpouching in the cervical esophagus, just below the cricopharyngeus muscle, that can be easily mistaken for a thyroid nodule on ultrasonography (1). Clinical Case: A 65-year-old woman underwent a thyroid ultrasound after her primary care physician noted left-sided thyromegaly. The ultrasound described a 33 mm solid, hypoechoic, wider-than-tall nodule in the left mid gland with an obscured posterior margin as well as macro- and microcalcifications. Given the size and highly suspicious features on ultrasound, she was referred to endocrinology clinic for a fine needle aspiration (FNA). She underwent ultrasound-guided FNA of what appeared to be the previously described thyroid nodule. Surprisingly, the pathology report noted degenerative changes with amorphous debris and possible foreign materials (vegetable or food) without any thyroid tissue. She was sent for an MRI neck, which showed the left neck mass communicating with the esophagus, favoring a left lateral projecting Killian-Jamieson esophageal diverticulum with internal debris. She was referred to head and neck surgery. Given only minimal symptoms of dysphagia, there are no current plans for surgery. Conclusion: This case illustrates the possibility of mistaking a Killian-Jaimeson diverticulum as a thyroid nodule. Recognition of this rare disease process in the differential diagnosis of thyroid nodules with high risk ultrasound characteristics may prompt more advanced imaging with MRI or CT, and lead to an accurate diagnosis prior to subjecting patients to unnecessary and potentially harmful FNAs (2).

A Narrative Review of update in per oral endoscopic myotomy (POEM) and endoscopic esophageal surgery.

The field of endoscopic esophageal surgery is based on the concept of natural orifice transluminal endoscopic surgery (NOTES). Submucosal space surgery or third space surgery with the use of flexible endoscopy allows for decreased morbidity and hospital length of stay with equivalent outcomes for patients. In the case of achalasia, per oral endoscopic myotomy (POEM) allows for management of refractory cases in setting of previous Heller Myotomy or in patients whom laparoscopic or thoracoscopic surgery is contraindicated. Lastly, POEM more directly divides circular muscular layer of esophagus without destroying surrounding structures that exist to prevent reflux. The innovations in endoscopic surgery began in the animal lab with experiments in the porcine model to develop a way to access the peritoneal cavity through an entry point in the gastric mucosa. Over the last 10 years, the biggest treatment innovations in endoscopy have focused on management of achalasia with the use of POEM. POEM became possible as technology was developed that revolutionized the use of flexible technology and the methods of mucosal closure. In addition to benign esophageal disease, endoscopic methods improved in management of esophageal malignancy with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). The innovations of endoscopic surgery have been developed through the utilization of the submucosal space as a method to ensure adequate closure of the mucosal entry point into the peritoneal cavity. The goal of this review paper is to explore POEM and other techniques in endoscopic esophageal surgery for the management of esophageal diverticulum, submucosal tumors, gastroparesis, and gastrointestinal esophageal reflux disease.

Robotic video-assisted thoracoscopic surgery using multiport triangular trocar configuration: initial experience at a single center

BackgroundRecent developments in robotic technology have brought significant changes in robotic video-assisted thoracoscopic surgery (r-VATS) worldwide, particularly including the treatment in the thorax for the mediastinal, esophagus, and pulmonary lesions. Currently, there are only a few reports describing the procedural experience and outcomes with r-VATS. The objective of this study is to provide our initial experience using r-VATS at a single center, with specific attention to safety, efficacy, and procedural details.MethodsWe retrospectively reviewed patients who underwent a newly modified r-VATS procedure for various surgical operations at the thoracic department of our hospital, from July 2018 to January 2020. Multiport trocars were placed in the classic triangular arrangement as in conventional VATS (c-VATS) but with modifications based on the type of surgery. The peri- and postoperative outcomes such as duration of surgery, complications, and duration of hospital stay for these patients were reported.ResultsOverall, 142 patients underwent r-VATS for lobectomy (66), wedge resection (15), thymectomy (22), mediastinal tumor resection (30), pneumonectomy (4), transthoracic esophagectomy (1), esophageal tumor resection or esophageal diverticulum repair (2), diaphragm plication (1), and mediastinal tumor resection plus thymectomy (1). For the entire cohort, the median operative time was 110 min, and the median length of hospital stay was 5 days. Conversion to open thoracic surgery was reported only in a total of 3 (2.1%) patients of pneumonectomy (1.4%) and mediastinal tumor resection (0.70%). All our patients were managed successfully with no postoperative complications and mortality.ConclusionOur method of r-VATS was found to be safe and effective and may be applied to different surgical operations. Adequate and proper training of thoracic surgeons is immediately needed for the transition from c-VATS to r-VATS. The utility and advantages of triangular trocar configuration for r-VATS require further refinement and research before it can be routinely adopted in clinical practice.Trial registrationRetrospectively registered.

Robotic-assisted esophageal diverticulectomy

: Esophageal diverticula are relatively uncommon and can occur along any portion of the esophagus. Distal esophageal diverticula generally occur in the setting of motility disorders but can be found in patients who otherwise have normal esophageal motility. Larger esophageal diverticula are generally symptomatic, and intervention is typically indicated. Surgical management of mid or distal esophageal diverticulum was traditionally done via a thoracotomy, but minimally invasive surgery via thoracoscopy or laparoscopy have more recently been shown to be feasible and safe. We present a case here of a robotic-assisted thoracoscopic approach to management of a large mid-esophageal diverticulum.

The incidence of reintervention and reoperation following Heller myotomy across multiple indications.

Achalasia is a debilitating primary esophageal motility disorder. Heller myotomy (HM) is a first-line therapy for the treatment of achalasia patients who have failed other modalities. Other indications for HM include diverticulum, diffuse esophageal spasm, and esophageal strictures. However, long-term outcomes of HM are unclear. This study aims to assess incidence of reintervention, either endoscopically or through minimally invasive or resectional procedures, in patients who underwent HM in New York State. The Statewide Planning and Research Cooperative System (SPARCS) administrative longitudinal database identified 1817 adult patients who underwent HM between 2000 and 2008 for achalasia, esophageal diverticulum, diffuse esophageal spasm, and esophageal strictures, based on ICD-9 and CPT codes. Through the use of unique identifiers, patients requiring reintervention were tracked up to 2016 (for at least 8years follow-up). Primary outcome was incidence of subsequent procedures following HM. Secondary outcomes were time to reintervention and risk factors for reintervention. Of the 1817 patients who underwent HM, 320 (17.6%) required subsequent intervention. Of the 320 patients, 234 (73.1%) underwent endoscopic reinterventions, 54 (16.9%) underwent minimally invasive procedures, and 32 (10%) underwent resectional procedures as their initial revisional intervention. Of the 234 patients who underwent endoscopic reintervention as their initial revisional procedure, only 40 (16.8%) required subsequent surgical procedures. Over a mean follow-up of 7.0years, the mean time to a subsequent procedure was 4.3 ± 3.74years. Reintervention rates after 10years following HM for achalasia, diverticulum ,and other indication were 24.4%, 12.6%, and 37%, respectively. The majority of HM reinterventions were managed solely by endoscopic procedures (60.6%). Heller myotomy remains an excellent procedure to prevent surgical reintervention for achalasia and diverticulum.

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.

Airway Bleeding After Double-Lumen Tube Placement

A 78-YEAR-OLD, 45-kg, 165-cm woman, with a history of breast cancer treated with chemoradiation, and esophageal diverticulum, presented for robotic-assisted diverticulectomy. After anesthetic induction, a 37Fr left-sided, double-lumen tube (DLT) was placed without difficulty, and placement was confirmed with fiberoptic bronchoscopy. The tracheal tissue was noted to be mottled throughout. After the patient was placed in the left lateral decubitus position, the DLT position was confirmed once again, and single-lung ventilation was initiated, with inflation of the bronchial cuff with 2.5 mL of air and clamping of the tracheal limb. After entry and insufflation of the right chest, 3-5 mL of blood were noted to be emanating from the tracheal lumen, and the surgeon noted poor lung isolation. Fiberoptic evaluation noted sanguineous secretions, which, despite lavage, failed to identify an obvious cause of bleeding, and slow bleeding persisted. In an attempt to improve single-lung isolation, an additional 2 mL of air were added to the bronchial cuff. After addition of air to the bronchial cuff, bleeding ceased and no additional significant issues occurred during the rest of the surgical procedure. After completion of the surgery, bilateral lung ventilation was reinstated and the authors repositioned the patient supine. Given the lack of obvious bleeding source and the mottled appearance of the tracheal tissue, bronchoscopy was performed for pulmonary toilet and further evaluation. The DLT was exchanged for an 8.5-mm endotracheal tube under direct visualization. The following findings (Fig 1, Fig 2) were noted. What is the diagnosis? Fig 2Bronchoscopic view from the left main stem showing full thickness injury in the membranous portion of the bronchus. Anterior surface of esophagus is visible through defect (yellow star). View Large Image Figure Viewer Download Hi-res image

“Functional approach” to esophageal body diverticula

: Esophageal diverticula should be considered as epiphenomena of an esophageal motility disorder, thus a targeted approach should be taken into consideration when a treatment is indicated. Conventional surgical management consists in diverticulectomy or diverticulopexys, associated or not with a myotomy and/or fundoplication on the basis of the underlying motor disorder. A thorough endoscopic evaluation of the diverticulum, associated with a functional assessment of the esophageal motility is mandatory before the treatment. Surgical management of epiphrenic diverticula is often more challenging due to the long operation time and high postoperative complication and mortality rates, and reserved to referral centres. To date, despite the fact that diagnostic workup is now codified, there is not a solid consensus about the management of the diverticula, including the use of routine versus selective myotomy and whether or not a fundoplication should be included. Beyond its classical indications, recently the POEM technique has been applied for the performance of an endoscopic diverticulectomy by mean the submucosal myotomy of the diverticular septum. No literature data about the comparison between these different approaches are reported, so we reviewed literature data about the treatment modalities of diverticula of the esophageal body (mid-esophageal and epiphrenic), to highlight how to best address the choice.

Diagnosis and Surgical Therapy of Oesophageal Diverticulum in a Heifer

Diagnosis and Surgical Therapy of Oesophageal Diverticulum in a Heifer

A Case of Epiphrenic Esophageal Diverticulum Resected by Laparoscopic Diverticulectomy

A Case of Epiphrenic Esophageal Diverticulum Resected by Laparoscopic Diverticulectomy

Endoscopic treatment of the esophageal diverticula (a single tertiary center experience)

<h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Анализ результатов эндоскопических вмешательств у пациентов с дивертикулами пищевода, выполненных в одном центре. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> За период 2016—2021 гг. эндоскопические вмешательства при дивертикулах пищевода проведены 60 пациентам (31 мужчина, 29 женщин в возрасте от 32 до 86 лет). Давность заболевания составляла от 2 мес до 25 лет. Было 57 пациентов с дивертикулом Ценкера, по 1 пациенту с эпибронхиальным, эпифренальным и дивертикулом Киллиана—Джеймисона. Размеры дивертикулов составили от 10 до 70 мм. У 31 пациента с дивертикулом Ценкера оперативное вмешательство выполнено с использованием гибкого дивертикулоскопа, 25 пациентов оперированы комбинированным методом. У пациентов с дивертикулом Киллиана—Джеймисона, эпифренальным или эпибронхиальным дивертикулом применяли туннельное вмешательство. <h3>РЕЗУЛЬТАТЫ</h3> Длительность выполнения вмешательства составляла от 25 до 100 мин. Интраоперационных осложнений не было. В послеоперационном периоде у 11 пациентов зарегистрированы нежелательные явления: гипертермия, подкожная эмфизема, частичная несостоятельность швов. Пациенты выписаны из стационара на 3—5-е сутки после вмешательства. Повторные вмешательства проведены 2 пациентам с дивертикулами Ценкера более чем через 1 год после операции из-за рецидива. При обследовании в послеоперационном периоде жалоб не было. <h3>ВЫВОДЫ</h3> Применение эндоскопической эзофагодивертикулотомии при лечении пациентов с дивертикулами пищевода является эффективным методом с минимальными сроками пребывания пациентов в стационаре. Особенности вмешательства позволяют в ранние сроки начать энтеральное питание с пероральным приемом пищи. Как правило, нет необходимости в установке назогастрального зонда и проведении энтерального питания, минуя ротовую полость и пищевод. Малая травматичность операций и небольшое время их выполнения позволяют применять данные вмешательства у пациентов любого возраста, с любой локализацией дивертикула, в том числе с сопутствующей патологией. Важным преимуществом эндоскопических вмешательств является отсутствие косметического дефекта.

Intraoperative intraluminal endoscopic assistance

Purpose of the study. Clarification of indications, assessment of technical aspects and results of intraoperative intraluminal endoscopic assistance in patients with diseases of the gastrointestinal tract, respiratory tract and in cardiosurgical patients.Materials and methods. Intraoperative intraluminal endoscopic assistance was performed for esophageal diverticula (41), gastroesophageal reflux disease and its complications (32), cicatricial stenoses and tracheal neoplasms (28), gastrointestinal tract neoplasms (17), and a mismatch between the diagnosis of the sending organization with intraoperative data (9) and for the anastomoses control (5). Intraoperative sanation tracheo-bronchoscopy with the definition of “background” flora was performed in 60 cardiosurgical patients with chronic diseases of the bronchopulmonary system.Results. The indications for performing the intraoperative intraluminal endoscopic assistance have been specified taking into account the impact of the study on the surgical course and scope, the method of anesthesia and the tactics of further treatment. Various aspects of the formed fundoplication cuff, completeness of diverticulum resection, and suture tightness were assessed. In a number of patients, the localization of neoplasms and stenoses was clarified, which affected the definition of the resection boundaries. In a number of cases, intraoperative intraluminal endoscopic assistance allowed reducing the average time of intervention and helped to minimize complications.Conclusion. Intraoperative intraluminal endoscopic assistance has its own peculiarities of execution, requires experience in data interpretation, requires a clear coordinated work and communication between the endoscopist, anesthesiologist and surgeon. In general, intraoperative endoscopy improves the results of surgical treatment and prevents complications.

Thyroid Gland Flap for Minimally Invasive Reconstructive Head and Neck Surgery.

Background:Head and neck surgery sometimes causes small defects, and salvage surgery after chemoradiotherapy poses some risk because of damage to the surgical site from the previous treatment. We have developed a novel thyroid gland flap for head and neck surgical reconstruction and here we describe elevating the flap, including arc rotation, size, and suture technique, and our outcomes to date.Methods:Thyroid gland flap reconstruction was performed in 13 cases (11 patients) between July 2009 and May 2020. The clinical importance and adverse effects of the procedure were examined. Thyroid function and blood flow of the flap were assessed, and the status of the flap and irradiated recipient tissue was examined histopathologically.Results:Median age at surgery was 64.6 years (range 49–77 years). Two of the patients underwent reconstruction with a thyroid gland flap twice. There were 4 cases of primary head and neck cancer resection with neck dissection in which the flap was harvested from the thyroid gland as reinforcement. In 1 case, surgery was performed for cervical esophageal diverticulum. In all cases, the arc was limited to 6 cm and suturing was basic. There were no complications of the surgical procedure, and the postoperative course was uneventful. Contrast-enhanced computed tomography revealed adequate enhancement of the flap. Postoperative thyroid function was normal. The thyroid gland flap was firmly adapted and fused with the irradiated recipient tissue.Conclusion:The thyroid gland flap could be an effective tissue flap fed by the superior thyroid arteriovenous pedicle for head and neck reconstruction.

Первый успешный опыт эндоскопического лечения дивертикула Ценкера в Казахстане

Zenker's diverticulum tends to occur in the elderly and is generally a relatively rare disorder; the prevalence of Zenker's diverticulum is 1.5–5% of all esophageal diverticula. Men are affected 2-3 times more frequently than women. To date, Zenker's diverticulum is treated mostly by surgery in Kazakhstan, however, with the development of endoscopy the minimally invasive method, endoscopic diverticuloesophagostomy, is being implemented. The transoral treatment is aimed at creating the common cavity between the esophagus and the diverticulum in order to prevent food accumulation in the diverticulum. The anterior wall between these two structures consists of the diverticular wall, m. сricopharyngeus and esophagus wall, the septum transsection automatically ensures myotomy. Both open surgery and endoscopic transoral treatment of Zenker's diverticulum result in reduced symptoms in 94–100% of patients. The paper reports the first successful experience of the Zenker's diverticulum treatment by endoscopic submucosal tunnel dissection in Kazakhstan.

Role of Peroral Endoscopic Myotomy (POEM) in the Management of Esophageal Diverticula.

Esophageal diverticula are uncommon; however, when present, they can cause symptoms of dysphagia, regurgitation, and chest pain. Based on location and pathophysiological characteristics, they are classified as pulsion- and traction-type diverticula. In the past, the open surgical approach was the only treatment available; however, in the past few decades, transoral incisionless approaches in the form of rigid and flexible endoscopy have gained popularity. Diverticular peroral endoscopic myotomy has emerged as an alternative treatment option. In this paper, we reviewed the role of peroral endoscopic myotomy as a treatment option for different types of esophageal diverticula. Although a safe and effective procedure, this novel submucosal tunneling technique for the treatment of esophageal diverticula requires further validation, and head-to-head comparisons between the different approaches for the treatment of esophageal diverticula are warranted.

Peroral Endoscopic Myotomy Is a Safe and Feasible Option in Management of Esophageal Diverticula: Systematic Review and Meta-Analysis.

Esophageal diverticula can cause significant symptoms and affect the quality of life. There has been recent interest in the use of peroral endoscopic myotomy in the management of esophageal diverticula (D-POEM). In this meta-analysis, we have evaluated the efficacy and safety of D-POEM in the management of esophageal diverticula. Several databases were reviewed from inception to 6/19/2020 to identify the studies evaluating the feasibility, efficacy and safety of D-POEM in the management of esophageal diverticula. Our outcomes of interest were technical success, adverse events and difference in mean pre- and post-procedure symptom score. We performed subgroup analysis including patients with Zenker's diverticulum who underwent POEM (Z-POEM). Pooled rates with 95% confidence intervals (CI) for all outcomes were calculated using random effect model. We calculated standard mean difference (SMD) with 95% CI to compare mean pre- and post-procedure symptom score. We included 7 studies with 233 patients. For D-POEM, pooled rates (95% CI) for technical success and adverse events were 95% (91%, 97%) and 6% (3%, 10%) respectively. For Z-POEM, pooled rates (95% CI) for technical success and adverse events were 95% (90%, 97%) and 6% (3%, 10%) respectively. Mean post-procedure symptom score for all patients who underwent D-POEM was significantly lower compared to mean pre-procedure symptom score, SMD (95% CI) 2.17 (1.51, 2.83). This meta-analysis demonstrated that D-POEM is a safe and feasible option for patients with symptomatic esophageal diverticula.

Acquired noncaustic esophageal strictures in children.

Background Esophageal stricture (ES) is an uncommon clinic entity in pediatrics that may be congenital or acquired in childhood. Acquired noncaustic ES is very rare, and clinical features of affected patients are unknown.Purpose We aimed to evaluate the clinical findings, and outcomes of patients with acquired noncaustic ES to aid physicians in the early referral of patients to gastroenterologists.Methods The medical data of patients with acquired noncaustic ES who were followed in our gastroenterology clinic between January 2009 and December 2019 were reviewed.Results Acquired noncaustic ES was found in 12 of the 4,950 patients (0.24%) who underwent endoscopy during the study period. The main symptoms were dysphagia (58.3%), vomiting (33.3%), and chronic anemia (8.3%). Chronic malnutrition and underweight were found in 66.6% of the patients. The most common etiological factors were radiotherapy, peptic reflux, and achalasia (16.6%, each), while chemotherapy, squamous-cell carcinoma (SC) of the esophagus, eosinophilic esophagitis (EoE), esophageal web, epidermolysis bullosa, and esophageal diverticulum (8.2%, each) were the other etiological factors. Patients with EoE underwent endoscopic bougie dilation in addition to steroid use and elimination diet. Patients with epidermolysis bullosa and esophageal web underwent bougie dilation. Patients with peptic reflux-related ES were initially put on antireflux therapy, but during follow-up, one patient required esophageal replacement with colonic interposition. Patients with radiotherapy-related ES recovered with medical therapy. The patient with initially underwent surgical gastrostomy and tumoral mass excision. The patient then received chemotherapy and radiotherapy and underwent jejunal interposition. Patients with achalasia underwent surgical esophagomyotomy.Conclusion The presence of solid dysphagia, malnutrition, and an associated disease may alert physicians to the presence of ES.

Submucosal tunneling endoscopic septum division for treatment of esophageal diverticulum: A pilot study

Submucosal tunneling endoscopic septum division for treatment of esophageal diverticulum: A pilot study

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.

S1896 Not Your Average Diverticulum: A Unique Case of a Massive Esophageal Diverticulum After Laparoscopic Gastric Banding

INTRODUCTION: Food impactions are a common gastrointestinal emergency, occasionally requiring urgent retrieval of an obstructing food bolus from the esophagus. This is a case of food impaction in a large esophageal diverticulum that developed as a long-term complication of laparoscopic adjustable gastric banding (LAGB) for obesity. CASE DESCRIPTION/METHODS: A 76-year-old woman presented to the emergency room complaining of dysphagia and neck discomfort after eating turkey. Her medical history includes gastroesophageal reflux disease, heart failure and morbid obesity, treated with LAGB several years prior and subsequently removed four years prior to the current presentation. She had previous food impactions that resolved spontaneously without endoscopic intervention. On presentation she was anxious, uncomfortable-appearing, mildly hypoxic, but able to handle her oral secretions. Computed tomography (CT) imaging of the chest showed a dilated esophagus with a right lateral diverticulum containing an impacted 10 cm × 7.4 cm food bolus and lung opacities concerning for aspiration pneumonia. The patient underwent an endoscopy with partial removal of the massive food bolus that was lodged in the diverticulum. The GIF-190 and GIF- XP scopes could not be advanced into the true esophageal lumen due to compression of the lumen by the huge diverticulum. Three days later, an endoscopy was performed with removal of the remnant bolus from the esophageal diverticulum, and placement of an orogastric tube over a guidewire. The mucosa of the upper esophagus was noted to be dusky-appearing, likely from pressure necrosis. The patient had a month-long ICU stay for chronic hypoxic respiratory failure due to aspiration pneumonia and inability to wean off mechanical ventilation. Surgical intervention to repair the esophageal diverticulum was discussed, but was deferred given the patients age, morbid obesity and medical comorbidities. Ultimately a tracheostomy was placed for long-term mechanical ventilation and a gastrostomy tube was placed under fluoroscopic guidance for enteral nutrition. The patient was discharged to a long-term care facility. DISCUSSION: This is a case of a large esophageal diverticulum that developed as a late complication of LAGB. Patients with prior LAGB presenting with dysphagia require imaging and possibly manometric evaluation to assess for pseudoachalasia. This directs need for endoscopic or surgical intervention to avoid progression to large esophageal diverticular disease and subsequent complications.Figure 1.: CT abdomen and pelvis with out contrast demonstrating an axial view of a large esophageal diverticulum with 10 cm food bolus.Figure 2.: CT abdomen and pelvis with out contrast demonstrating a coronal view of a large esophageal diverticulum and right sided aspiration pneumonia.Figure 3.: The upper third of the esophagus with dusky appearing mucosa in the large diverticulum seen during second endoscopy.