Epiphrenic Esophageal Diverticulum Research Articles

Achalasia and epiphrenic diverticulum.

Esophageal epiphrenic diverticulum (EED) is a pseudodiverticulum of pulsion type located in the distal 10 cm of the esophagus and frequently associated to achalasia. The symptoms and the pathophysiology of achalasia and EED may overlap, leading to the speculation that achalasia may be responsible for the symptoms. Similarly to patients with achalasia without EED, a careful preoperative evaluation is essential in patients with EED. Endoscopy and an esophagram are mandatory in the workup of these patients, while esophageal manometry confirms the associated motility disorder. Treatment is indicated in all patients fit for an operation except those who are asymptomatic with a small EED and no prior history of aspiration. Laparoscopic Heller's myotomy and partial fundoplication is the most adequate therapy. Diverticulectomy must be added to the procedure in large diverticula. Experience with endoscopic therapy is very limited.

Epiphrenic esophageal diverticulum within a leiomyoma: A rare cause of dysphagia

Introduction: The diagnosis of symptomatic epiphrenic esophageal diverticulum is rare (15-20%). Esophageal leiomyoma and epiphrenic diverticula are both uncommon, but may rarely occur together. In this patient a leiomyoma was found within an epiphrenic diverticulum. Methods: We report the case of a 58-year-old man referred to our unit with a 4-year history of progressive and intermittent dysphagia, mainly to solids, and weight loss. Barium swallow revealed a distal esophageal stenosis secondary to a diverticulum; upper endoscopy showed an extrinsic submucosal compression of the cardia; and CT scan showed an infradiaphragmatic saccular dilation of the esophagus with a thickened wall. The patient was diagnosed with distal esophageal diverticulum with a submucosal tumor inside. Laparoscopic hiatal diverticulectomy including tumor, cardiomyotomy and a partial fundoplication was performed. Our objective is to discuss the diagnosis and treatment of this disease. Results: The pathological study confirmed a leiomyoma of 5x4 cm in an esophageal diverticulum. On the 3rd postoperative day, barium swallow confirmed good esophageal passage and gastric emptying. The patient was discharged on day 4. In the follow-up monitoring after one month and one year the patient was asymptomatic with good quality of life. Discussion: Traditionally, treatment for an epiphrenic diverticulum consists of a diverticulectomy with or without myotomy, performed through a thoracotomy. Hiatal laparoscopy obviates the need for thoracotomy and placement of a chest tube. It would also allow an easier fundoplication after myotomy and diverticulectomy. This case has several unique aspects. Firstly, an esophageal diverticulum with a leiomyoma inside, which is in a subdiaphragmatic location; and secondly, the fact that it is not associated with primary motor disorder. Here, the leiomyoma causes the epiphrenic diverticulum. Conclusion: Whenever a submucosal tumor within the diverticulum is present careful consideration should be given to the possibility of an associated neoplasm. We suggest that the majority of epiphrenic diverticula of the distal esophagus can be treated successfully by laparoscopic approach, which makes it possible to remove the associated tumor; and that it is at least as safe and effective as conventional transthoracic access but with the advantages of an early postoperative recovery.

Tu1592 Is Resection of an Esophageal Epiphrenic Diverticulum Always Necessary in the Setting of Achalasia?

Tu1592 Is Resection of an Esophageal Epiphrenic Diverticulum Always Necessary in the Setting of Achalasia?

Surgical treatment of epiphrenic oesophageal diverticulum.

Epiphrenic diverticula occur in the lowermost 10 cm of the oesophagus. The main symptoms are dysphagia, regurgitation and pain when swallowing food. The main purpose of the survey was to evaluate the department's results for surgical treatment of this rare and distressing condition. In the period 2002-2012, eleven patients (nine men) underwent surgery for an oesophageal diverticulum consisting of excision (n = 8), myotomy of the lower oesophageal sphincter and Dor fundoplication (n = 2) or all these procedures (n = 1). Two of them were transferred from other hospitals because of complications. Details of pre-operative symptoms and post-operative complications were retrieved retrospectively from patient records. Ten patients who agreed to take part in a retrospective survey responded to a questionnaire a median of 27.5 months (range of 2-105 months) after surgery. There were no fatalities as a result of the treatment. Three patients developed leakage after the diverticulum excision, two of whom required reoperation. The patients experienced considerable symptomatic improvement. According to the retrospective survey, eight of the nine patients with pre-operative dysphagia no longer had it. Four of seven with regurgitation, and all five patients who experienced pain in connection with swallowing, experienced post-operative improvement. The patients reported their condition as completely well (n = 5) or improved (n = 5) after the operation. One patient who had undergone reoperation for leakage and oesophageal mediastinal fistula did not consent to further surgery. Most patients who underwent surgery for epiphrenic oesophageal diverticulum in our department experienced symptomatic improvement after surgery.

Spastic Achalasia and Detrusor Spasm: Combined Visceral Neuromuscular Disorders in a Patient with Williamʼs Syndrome

Introduction: William's syndrome is a rare congenital disorder caused by deletions at chromosomal band 7q11.23. The condition is characterized by distinctive facies, gregarious personality, developmental delay and supravalvular aortic stenosis. Spastic motility disorders and diverticulosis of the bladder are often seen. Abdominal pain, constipation, gastroesophageal reflux and colonic diverticulosis are gastrointestinal manifestations of William's Syndrome. However, spastic motility disorders of the esophagus have not previously been described. Case Description: The patient is a 37-year-old male with William's syndrome. He exhibited neonatal failure to thrive, without the typical swallowing difficulties expected in infants with William's syndrome. Bedwetting was reported until the age of four years old and was corrected by training with an enuresis alarm. At age 25, the patient developed a poor urinary stream, straining, and incomplete bladder evacuation. A urodynamic study showed detrusor spasm. A suprapubic catheter was placed at age 27. When the patient was 33 years old, he was evaluated for severe abdominal pain and mild dysphagia. Abdominal examination was unremarkable. A computed tomography (CT) scan of the abdomen revealed dilation of the esophagus above the esophageal hiatus. An upper endoscopy showed esophageal diverticula. This was confirmed by an esophagram displaying a large epiphrenic esophageal diverticulum (4-5 cm in diameter) and a second more proximal diverticulum (2-3 cm in diameter). The patient began to experience worsening dysphagia and weight loss (from 120 pounds to 100 pounds), and vomiting after eating. An esophageal manometry performed at a tertiary care center showed a large transition zone defect in the mid-esophagus and very rapidly conducted distal contractions. Retrograde escape occurred with about 50% of the esophageal contractions. These findings are consistent with the manometric diagnosis of spastic achalasia. Botulinum toxin A (Botox) injection or esophageal myomectomy were recommended but declined by the patient and his family. A pureed diet was initiated with subsequent weight gain and marked improvement of dysphagia. Discussion: Detrusor spasm and diverticulosis of the bladder are frequently described in patients with William's syndrome. To our knowledge, spastic achalasia (a very rare esophageal motility disorder) and esophageal diverticula are new findings in this condition. We propose that esophageal and bladder motility disorders are part of an overall visceral neuromuscular defect related to the pathophysiology of William's syndrome. Physicians should recognize the potential for esophageal motility disorders in patients with William's syndrome.

Su1626 Surgical Management of Esophageal Perforation: A 10-Year Experience

Aim: The objective of this study was to evaluate high-resolution impedance manometry (HRIM) findings in patients with esophageal epiphrenic diverticulum. Methods: Patients with esophageal epiphrenic diverticulum who underwent HRIM between October 2008 and March 2012 are included in the study. Manometric findings were compared to endoscopic (EGD) and barium swallow (BS) findings. Patients with previous foregut surgery were excluded. Results: Six patients (mean age 59.0 years, 3 females) are included in the study. On EGD the diverticulum was 1 to 4 cm above the gastro-esophageal junction (GEJ) and the mouth of diverticulum was 2 to 9 cm in size. Mean lower esophageal sphincter pressure (LESP) and mean Integrated relaxation pressure (IRP) were 50.7 mmHg (range 39.2 to 61.9 mmHg) and 22.4 mmHg (range 13.8 to 30.8 mmHg) respectively. Achalasia was the most common abnormality noted in 3 patients (type I=2 and type II=1). Two additional patients had isolated EGJ obstruction with preserved esophageal motility. One patient had normal IRP but weak peristalsis. A break in peristalsis corresponding to themouth of the diverticulum could be seen in 4 patients. There was decreased bolus transit in three patients. Conclusions: There is a high prevalence of esophageal outflow obstruction and primary peristaltic abnormality in patients with epiphrenic diverticulum. This reconfirms the need to extend the myotomy down on to the GEJ even in patients in whom the diverticulum appears to be well above the GEJ.

Subphrenic Esophageal Diverticulum Associated with Esophageal Dysmotility and Leiomyoma

Lower esophageal diverticula are frequently related to esophageal motor disorders. An epiphrenic esophageal diverticulum can also have a mechanical cause, such as an esophageal web, benign stricture, or leiomyoma. For a good therapeutic outcome, symptomatic patients with an esophageal diverticulum require a tailored approach. Therefore, it is important to evaluate motor disorders and other associated diseases in a patient with an esophageal diverticulum before devising a therapeutic strategy. We report a case of subphrenic diverticulum associated with an esophageal leiomyoma and motility disorder in a 58-year-old man who had suffered from intermittent regurgitation of food and epigastric soreness. (Korean J Med 2013;84:389-394)

Minimally invasive surgery for esophageal epiphrenic diverticulum: the results of 133 patients in 25 published series and our experience

Esophageal epiphrenic diverticula are uncommon. Traditionally, thoracotomy has been the preferred surgical approach. Recently, minimally invasive approaches have been reported in a few series. However, the best surgical approach remains uncertain. In this study, we review the results of 25 articles discussing laparoscopic or thoracoscopic surgery. From January 1995 to December 2008, there were a total of 133 patients reported in English-language journals in PubMed. Nineteen patients (14 %) underwent thoracoscopic surgery, 112 (84 %) laparoscopic surgery and two patients (2 %) were treated using a combination approach. The diverticulectomy was performed using an endostapler device in all patients. A myotomy was added in 103 patients (83 %). A fundoplication was added in 106 patients (85 %). There were two deaths during surgery (2 %). The post-operative morbidity rate was 21 %. The most severe complication was suture-line leakage, which occurred in 20 patients (15 %). Recently, we successfully treated a patient with an epiphrenic esophageal diverticulum by performing a minimally invasive laparoscopic transhiatal resection and Heller myotomy with Dor fundoplication after observing its enlargement on radiological and endoscopic examinations over 2 years. We believe laparoscopic transhiatal resection and Heller myotomy with Dor fundoplication may therefore become the standard treatment modality for minimally invasive surgery for esophageal epiphrenic diverticulum.

A Case of Video Capsule Retention in a Rare Epiphrenic Diverticulum

Purpose: Video capsule endoscopy (VCE) is a minimally invasive method of visualizing the small bowel. Capsule retention is the most common complication of VCE. While VCE retention has been described in various anatomical locations, there are no known reports of retention in an epiphrenic esophageal diverticulum. A 73-year old African-American female, with a long history of iron deficiency anemia, presented for evaluation of obscure gastrointestinal bleeding with VCE. She denied melena, hematochezia, abdominal pain, or dizziness. Her physical exam was unremarkable, with a negative in-office fecal occult blood test. On presentation to our clinic the patient was noted to have hemoglobin and hematocrit values of 9.9g/dL and 29.9%, respectively. VCE was performed using a PillCam SB (Given Imaging, Yoqneam, Israel). After 8 hours of recording, the capsule was noted to be halted in the esophagus. Further evaluation with an esophagram showed a large epiphenic esophageal diverticulum and diffuse esophageal spasms with poor peristalsis. The retained capsule was not observed in this study. The patient remained completely asymptomatic during this time. She underwent a second VCE study, this time with endoscopic deployment of the video capsule. The EGD confirmed a large epiphrenic diverticulum just above the gastroesophageal (GE) junction and a small hiatal hernia. The initial retained capsule, however, was not seen during the EGD and was presumed to have spontaneously passed. To our knowledge, this is the first case of video capsule retention in an epiphrenic esophageal diverticulum, likely due to their rarity. Our case suggests that esophageal diverticula may be a relative contraindication for VCE. In patients with hyper or hypomotility disorders, which are commonly associated with other anatomical problems within the GI tract, endoscopic deployment of the VCE beyond the diverticulum is a much safer alternative. Moreover, symptomatic patients may benefit from diagnostic work-up of esophageal and other GI tract diverticula as a preventative measure of capsule retention.Figure: Esophagram showing distal esophageal diverticulum (epiphrenic diverticulum).

Surgical Management of Two Simultaneously Occurring Epiphrenic Esophageal Diverticula

Among all diverticula of the esophagus, epiphrenic diverticula occur less frequently than those in the pharyngo-esophageal segment. Two simultaneously occurring diverticula in the epiphrenic esophagus are very rarely reported in the English literature. A 52-year-old woman had a 3-year history of troublesome dysphagia, heartburn, chest pain and cough. Initial investigation included a physical examination and a barium swallow, which showed the presence of two diverticula in the epiphrenic esophagus. Esophagoscopy confirmed the presence only of the lower diverticulum. The patient underwent a left thoracotomy, the esophagus was mobilised from the hiatus to the aortic arch. The necks of the diverticula were localised in the posterior wall and between them there was a bridge of circular muscular fibres, which was divided. Diverticulectomy over an intra-esophageal 54 F Maloney dilator was performed. The upper diverticulum was left intact because it disappeared after the bridge of esophageal muscles has been myotomized. A long myotomy was carried out, and a modified Belsey fundoplication was added. The postoperative course was uneventful, and the patient remains well at 10 years with no recurrence of symptoms.

High Resolution Manometry Findings in Patients With Esophageal Epiphrenic Diverticula

High Resolution Manometry Findings in Patients With Esophageal Epiphrenic Diverticula

Migration of a percutaneous endoscopic gastrostomy tube into the transverse colon: a forgotten cause of refractory diarrhea

An 87-year-old demented man had a percutaneous endoscopic gastrostomy (PEG) tube inserted for palliation of dysphagia due to a large, epiphrenic esophageal diverticulum. After PEG feeding for 1 month, he complained of persistent, disabling diarrhea. Potential infective or organic causes were excluded after extensive negative investigations and feeding regimen adjustment. An esophagogastroduodenoscopy (EGD) incidentally performed for investigation of anemia did not reveal the PEG button anywhere inside the stomach. Because of these peculiar findings, a contrast-enhanced computed tomography (CT) scan was performed. Surprisingly, the PEG button was found inside the transverse colon ([Fig. 1]).

Laparoscopic Resection of a Giant Epiphrenic Esophagus Diverticulum: Report of a Case

Esophageal epiphrenic diverticulum is an uncommon disorder. Diverticulectomy is usually applied to patients with symptoms, such as dysphagia or acid regurgitation. Traditionally, the operation is performed via thoracotomy through the thoracoscopic approach. But a mini-invasive method, such as laparoscopic transhiatal diverticulectomy with an anti-reflux procedure has shown to be a better procedure with an less postoperative pain and morbidity according to reports of some authors. We describe a 53-year-old woman who underwent laparoscopic transhiatal diverticulectomy followed by 360 fundoplication. The postoperative condition was uneventful and the patient began receiving regular diet on postoperative day 7, and was discharged on postoperative day 8. A barium swallow showed a normal-size esophagus with a regular emptying and sharp angle at the region of fundoplication. In conclusion, laparoscopic transhiatal diverticulectomy for the treatment of symptomatic esophageal epiphrenic diverticulum is a safe and effective technique with minimal morbidity.

Squamous Cell Carcinoma in a Large Epiphrenic Esophageal Diverticulum

Carcinoma is rare in an esophageal diverticulum. The case of a 53-year-old man with a large mass in a long-standing symptomatic epiphrenic esophageal diverticulum is presented in this study. Squamous cell carcinoma in the diverticulum with pleural invasion was diagnosed after surgical diverticulectomy. The patient underwent subtotal esophagectomy with locoregional lymph node dissection and reconstruction with gastric tube because of micro-invasion at the surgical margin. The patient developed malignant pleural effusion at 6 months after surgery, and he eventually expired 3 months later. Carcinoma can develop in esophageal diverticula and is usually diagnosed at an advanced stage with poor prognosis.

Esophagoscopy-guided thoracoscopic resection of large epiphrenic esophageal diverticulum

A diverticulum in the lower third of the esophagus is rare. A 62-year-old woman presented with symptoms of dysphagia and regurgitation associated with recurrent aspiration. Endoscopic examination disclosed a large epiphrenic diverticulum, for which esophagoscopy-guided thoracoscopic surgery was performed. The postoperative course was uneventful. It is proposed that this method could be a possible alternative to the standard classical thoracotomy approach for a large epiphrenic diverticulum of the esophagus.

Esophageal manometric characteristics and outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication for epiphrenic diverticula

The purpose of this study is to characterize the esophageal motor and lower esophageal sphincter (LES) abnormalities associated with epiphrenic esophageal diverticula and analyze outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication. The endoscopic, radiographic, manometric, and perioperative records for patients undergoing laparoscopic esophageal diverticulectomy, anterior esophageal myotomy, and partial fundoplication from 8/99 until 9/06 were reviewed from an Institutional Review Board (IRB)-approved outcomes database. Data are given as mean +/- standard deviation (SD). An esophageal body motor disorder and/or LES abnormalities were present in 11 patients with epiphrenic diverticula; three patients were characterized as achalasia, one had vigorous achalasia, two had diffuse esophageal spasm, and five had a nonspecific motor disorder. Presenting symptoms included dysphagia (13/13), regurgitation (7/13), and chest pain (4/13). Three patients had previous Botox injections and three patients had esophageal dilatations. Laparoscopic epiphrenic diverticulectomy with an anterior esophageal myotomy was completed in 13 patients (M:F; 3:10) with a mean age of 67.6 +/- 4.2 years, body mass index (BMI) of 28.1 +/- 1.9 kg/m2 and American Society of Anesthesiologists (ASA) 2.2 +/- 0.1. Partial fundoplication was performed in 12/13 patients (Dor, n = 2; Toupet, n = 10). Four patients had a type I and one patient had a type III hiatal hernia requiring repair. Mean operative time was 210 +/- 15.1 min and mean length of stay (LOS) was 2.8 +/- 0.4 days. Two grade II or higher complications occurred, including one patient who was readmitted on postoperative day 4 with a leak requiring a thoracotomy. After a mean follow-up of 13.6 +/- 3.0 months (range 3-36 months), two patients complained of mild solid food dysphagia and one patient required proton pump inhibitor (PPI) for gastroesophageal reflux disease (GERD) symptoms. The majority of patients with epiphrenic esophageal diverticula have esophageal body motor disorders and/or LES abnormalities. Laparoscopic esophageal diverticulectomy and anterior esophageal myotomy with partial fundoplication is an appropriate alternative with acceptable short-term outcomes in symptomatic patients.

Long-term Outcome of Operated and Unoperated Epiphrenic Diverticula

IntroductionThe natural history of esophageal epiphrenic diverticula (ED) is not entirely clear; the decision whether to operate or not is often based on the personal preference of the physician and patient. The aim of this study was to evaluate the long-term fate of operated and unoperated patients with ED. Materials and MethodsClinical, radiological, and motility findings, and operative morbidity and long-term outcome of 41 patients with ED (January 1993 to December 2005) were analyzed. All patients were reviewed at the outpatient clinic or interviewed over the phone. A symptom score was calculated using a standard questionnaire and subjective patient assessment. The radiological maximum diameter of the ED was measured. ResultsTwenty-two patients (12M:10F; median age, 60 years) were operated. One underwent surgery for spontaneous rupture of a large diverticulum. Operative mortality was nil; postoperative morbidity was 22.7%, the most severe complication being suture leakage (4 patients, all managed conservatively); median follow-up was 53 months. Nineteen patients (9M, 10F; median age 70 years) were not operated: 3 received pneumatic dilations; median follow-up was 46 months. None of the patients in either group died for reasons related to their ED. Symptoms decreased in all operated patients and, to a lesser extent, also in unoperated patients. ED recurrence was observed in one operated patient. Four patients had GERD symptoms with esophagitis and/or positive pH-metry after surgery and 3 patients had persistent dysphagia/regurgitation and were dissatisfied with the outcome of surgery. DiscussionSurgery is an effective treatment for ED, but carries a significant morbidity related mainly to suture leakage. Even in the long-term, unoperated patients do not die of their ED, though a better subjective symptom outcome is reported by operated patients. A non-interventional policy can safely be adopted in cases of small, mildly symptomatic ED.

Large epiphrenic diverticulum of esophagus

Esophageal diverticula are rare pathologies and are commonly classified according to their location as pharyngo-esophageal, midthoracic or epiphrenic diverticula [1]. Epiphrenic diverticulum, or diverticulum of distal esophagus, usually occurs in the distal 10 cm of the esophagus. The patients with epiphrenic diverticulum present with clinical symptoms and signs mimicking those associated with other distal esophageal motility disorders, including hiatal hernia, achalasia and reflux esophagitis [2]. We report a case of epiphrenic diverticulum of esophagus in a 70 year old male.

A case of giant esophageal epiphrenic diverticulum resected laparoscopically, followed by Heller myotomy and Dor fundoplication

A 66-year-old male patient visited our hospital with the chief complaints of difficulty in swallowing and vomiting. The upper gastrointestinal radiographic contrast study revealed a diverticulum with a diameter of about 10 cm in the diaphragm to the right of the esophagus. Upper gastrointestinal endoscopy revealed the inlet of the diverticulum on the right wall of the esophagus at a distance of 44–46 cm from the incisors. The patient was diagnosed as having a giant epiphrenic esophageal diverticulum with obstruction; dysfunction of the lower esophageal sphincter was also considered. Therefore, he was treated by laparoscopic resection of the diverticulum, followed by Heller myotomy and Dor fundoplication. The postoperative course was satisfactory, and the patient showed substantial improvement in his dysphagia. He was discharged from our hospital on the 9th postoperative day. At present, 2 years after the operation, he remains well without any recurrence of the symptoms.

Laparoscopic transhiatal resection of giant epiphrenic esophageal diverticulum

Epiphrenic diverticula are rare. Their true incidence is unknown. Thoracotomy or thoracoscopy with resection and myotomy is the most common reported approach for the surgical treatment of epiphrenic esophageal diverticula. In patients with large epiphrenic diverticula, the laparoscopic approach is an uncommon procedure. In this case, the laparoscopic transhiatal approach was shown to be safe and effective over with short-term follow-up. However, long-term follow-up of this procedure is needed.