Epiphrenic Esophageal Diverticulum Research Articles

A Case of a Giant Epiphrenic Esophageal Diverticulum

Abstract The esophageal diverticula are divided into pharyngoesophageal, parabronchial and epiphrenic. They could also be divided into congenital and acquired, true and false, pulsion and traction. Pulsion diverticula are usually formed in motor disorders of the esophagus, above the place of hypertension and uncoordinated peristalsis. They are pseudo-diverticula caused by increased intramural pressure, leading to herniation of the mucosa and submucosa through the focal areas of the esophageal wall. We present a 65-year-old woman who underwent left-sided transthoracic diverticulectomy, modified Heller esophagocardiomyotomy, and modified Belsey-Mark IV fundoplication due to a huge epiphrenic esophageal diverticulum.

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

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

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

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

A Rare Case of Bleeding Epiphrenic Esophageal Diverticulum From Arteriovenous Malformations

Epiphrenic esophageal diverticula (EED) is a rare condition that usually presents with dysphagia in patients with a known motility disorder. In this article, we present a unique case of EED presenting with hemoptysis with clinical workup negative for any pulmonary pathology. Esophagogastroduodenoscopy revealed arteriovenous malformations within the EED successfully managed with argon plasma coagulation (APC), leading to a resolution of the patient’s symptoms.

EPIPHRENIC OESOPHAGEAL DIVERTICULUM – A CASE REPORT

Epiphrenic oesophageal diverticulum is rare world-wide and account for less than 10% of all oesophageal diverticula. We present Mrs O.E. a 64-year old Nigerian of the Yoruba tribe who presented with early satiety and upper abdominal discomfort of five months duration. The early satiety was of insidious onset and had been progressive. This initially made her to reduce the size of her meal intake but eventually progressively led her to taking just a meal per day. This is in contrast with her premorbid intake of three meals per day. She has associated history of regurgitation worse in the recumbent position which she described as containing undigested food. She has no abdominal swelling, odynophagia or dysphagia. No history of haematemesis or melaena. She has weight loss and easy fatigability. The upper abdominal (epigastric) discomfort is characterized as a feeling of peppery, burning sensation which radiates to the back and had no association with meals or with time of the day. It has no relation to posture and said to be worse with consumption of peppery or spicy food substance. Minimally relieved with the use of antacids. No other significant contributory history. Review of systems was also not contributory. Clinical examination was not remarkable. A provisional diagnosis of a suspected Gastric Tumour was made likely a Gastric Lymphoma or Adenocarcinoma to rule out Gastrointestinal Stromal Tumour(GIST). Barium swallow revealed a Distal (Epiphrenic) oesophageal diverticulum. Findings at upper GI Endoscopy include: (1) Distal (Epiphrenic) oesophageal diverticulum (2) Reflux oesophagitis (3) Gastric Atrophy; probably age-related to rule out chronic Helicobacter pylori-infection. Histology revealed Reflux oesophagitis, Mildly active chronic corporeal gastritis with mild atrophy and Chronic non-specific antral gastritis. She was managed conservatively with long term proton pump inhibitor therapy, modification of dietary habits and liberal oral fluid intake with significant clinical improvement and resolution of her symptoms within eight weeks of treatment. She is presently on regular follow-up at our out-patient department. Distal (Epiphrenic) oesophageal diverticulum is rare in our environment. The diagnosis can only be made through radiographic or endoscopic studies. Patients may present with non-specific or dyspeptic symptoms similar to those of acid peptic disorders. In view of this, it is important to carefully evaluate patients with dyspepsia or non-specific upper gastrointestinal symptoms and investigate them in order to ascertain the cause. A delay in the diagnosis and treatment of epiphrenic oesophageal diverticulum may lead to complications which could have been prevented if diagnosed early.

Greater-curvature peroral endoscopic myotomy with diverticuloseptotomy for the treatment of achalasia in a patientwith a large epiphrenic diverticulum.

Greater-curvature peroral endoscopic myotomy with diverticuloseptotomy for the treatment of achalasia in a patientwith a large epiphrenic diverticulum.

1792 An Unusual True Esophageal Epiphrenic Diverticulum in the Setting of Heterotopic Gastric Mucosal Patches: A Case Report

INTRODUCTION: Esophageal diverticula (ED) are a rare structure abnormality with prevalence estimated to be between 0.06% to 4%. Esophageal epiphrenic diverticula (EED) are diverticula in the distal 10cm of the thoracic esophagus and are typically false diverticula with outpouching of only the submucosa and mucosa as the result of an esophageal motility disorder. Within ED, EED constitutes less than 10% of all esophageal diverticula, with an incidence of 1:500,000/year. Here we report a case of a true esophageal epiphrenic diverticula in the setting of heterotopic gastric mucosa patches (HGMPE) found after presentation with epigastric symptoms. CASE DESCRIPTION/METHODS: A 35-year-old female with a past medical history of endometriosis presented with a few months of epigastric pain, nausea, and vomiting with no response to treatment for gastroesophageal reflux disease (GERD) prompting investigation with esophagogastroduodenoscopy (EGD) which revealed a diverticulum 29cm from the incisors with normal surrounding mucosa. She returned for endoscopic ultrasound (EUS) for further evaluation with development of dysphagia with no regurgitation or halitosis. Repeat EGD prior to EUS revealed areas suggestive of ectopic gastric mucosal patches 28 cm from the incisor with a single diverticulum at the posterolateral aspect of the esophagus. Z line was at 38 cm from the incisors. EUS showed a single esophageal diverticulum from 28 to 30 cm with all 4 wall layers indicating a true diverticulum. Pathology from biopsy at the 29 cm showed cardia type mucosa with chronic inflammation without evidence of metaplasia, dysplasia, or intramucosal eosinophils significant for HGMPE. DISCUSSION: ED, particularly EED are a rare entity with varying clinical manifestations including dysphagia, regurgitation, weight loss, chest pain, halitosis, aspiration, and heartburn with the majority of patients being asymptomatic until the diverticula are larger than 5cm. Moreover, EED typically are false diverticula with the involvement of the mucosa and submucosa as a result of a motility disorder. The majority of true ED are located within the mid esophagus secondary to tuberculosis, histoplasmosis, and malignancy. Here, we describe a case with HGMPE resulting in a 2 cm true diverticulum within the distal third of the esophagus not identified on initial evaluation highlighting a cause for ED not previously identified in the literature and the importance for a thorough assessment of patients with esophageal disease.

3093 Epiphrenic Diverticula: An Added Source of Complexity in Achalasia Management

INTRODUCTION: Epiphrenic esophageal diverticula are rare and almost always associated with an underlying esophageal motility disorder. Therapeutic options for epiphrenic diverticula are evolving as per oral endoscopic myotomy (POEM) is increasingly being used for treatment of achalasia. We present two cases of epiphrenic diverticula associated with achalasia at our institution and review the clinical presentation, pathophysiology, and current management of epiphrenic diverticula. CASE DESCRIPTION/METHODS: Case 1 A 77 year old female presented with dysphagia. An esophagram showed two diverticula with a distal narrowing. Upper endoscopy showed two epiphrenic diverticula and a narrowed gastroesophageal junction. Manometry showed an elevated median IRP of 22.5 mmHg and pan-esophageal pressurization with all swallows, consistent with type II achalasia. A CT scan of the chest did not show any evidence of malignancy. She is currently seeking a surgical opinion for consideration of myotomy. Case 2 A 66 year old male presented with dysphagia. An esophagram showed marked dysmotility with a 1.8 cm epiphrenic diverticulum. Upper endoscopy confirmed the presence of the diverticulum. Subsequent manometry showed a median IRP of 28.8 mmHg and spastic contractions in all swallows consistent with type III achalasia. Given his type III achalasia and the smaller size of the diverticulum, he was referred for consideration of POEM. DISCUSSION: Esophageal diverticula can be grouped into pharyngoesophageal, mid-esophageal, and epiphrenic diverticula. Epiphrenic diverticula are “false” diverticula, with herniation of the mucosa and submucosa only, that occur due to increases in intraluminal pressure. They are associated with major esophageal motility disorders. Management of epiphrenic diverticula requires addressing the underlying motility disorder, or else the diverticula may recur after diverticulectomy. Generally, laparoscopic or combined laparoscopic/thorascopic myotomy, diverticulectomy and anterior fundoplication is required. The overall mortality rate for surgical management of epiphrenic diverticula is around 5%, with morbidity rate as high as 20%. POEM without diverticulectomy has also been described for patients who either decline surgical intervention or are not surgical candidates. As POEM technique is refined for this indication, management of epiphrenic diverticula will require close collaboration between gastroenterologists, advanced endoscopists, and surgeons for selection of the optimal treatment for each patient.

The Abdominal Approach for Epiphrenic Esophageal Diverticulum as an Alternative to the Thoracic Approach.

BackgroundThere is no established surgical procedure for the treatment of epiphrenic esophageal diverticulum. The aim of this study was to compare the clinical outcomes of esophageal diverticulectomy using abdominal and thoracic approaches.MethodsWe retrospectively reviewed 30 patients who underwent esophageal diverticulectomy through the thoracic or abdominal approach for an epiphrenic diverticulum at a single center between 1996 and 2018. We compared clinical outcomes, including the postoperative length of stay, time from the operation to oral feeding, leakage rate, and reoperation rate between the 2 groups.ResultsThe median age was 56 years. Of the 30 patients, 18 (60%) underwent diverticulectomy via the thoracic approach and 12 (40%) underwent the abdominal approach. The median hospital stay was 10 days (range, 5–211 days) in the thoracic approach group and 9.5 days (range, 5–18 days) in the abdominal approach group. The median time from the operation until oral feeding was 6.5 days (range, 3–299 days) when the thoracic approach was used and 5 days (range, 1–11 days) when the abdominal approach was used. In the thoracic approach group, the leakage rate was 16.67% and the reoperation rate was 27.78%. However, there were no cases of leakage or reoperation in the abdominal approach group.ConclusionThe abdominal approach for esophageal diverticulectomy is a feasible and appropriate alternative to the thoracic approach.

A Case Report of an Epiphrenic Esophageal Diverticulum was Treated via Laparoscopic Transhiatal Diverticulectomy

A Case Report of an Epiphrenic Esophageal Diverticulum was Treated via Laparoscopic Transhiatal Diverticulectomy

Gastrointestinal: A rare cause of upper gastrointestinal bleeding: Epiphrenic esophageal diverticula

An 87-year-old man presented to the Emergency Department after a syncopal event at home associated with a 3-day history of melena. This was on a background of ischemic heart disease with previous coronary artery bypass graft and recent transesophageal echocardiogram cardioversion for atrial fibrillation 10-days prior. He was commenced on apixaban during this admission and re-commenced on aspirin by his general practitioner on review post discharge. On assessment, he was hemodynamically stable, with melena noted on digital rectal examination. His laboratory results revealed a hemoglobin of 68-g/L, urea of 22.8-mmol/L, and INR of 1.7. He was commenced on intravenous pantoprazole (proton pump inhibitor), transfused with two units of packed red blood cells, and underwent a gastroduodenoscopy the following day. Upper endoscopy revealed a 2–2.5-cm diameter esophageal diverticulum (Fig.-1) just above the gastroesophageal junction (GOJ) in the right posterior-lateral wall. There was no active bleeding, but there was evidence of recent bleeding with altered blood and mild mucosal erythema in the surrounding tissue. The remainder of the endoscopy also identified two further diverticula: one in the gastric fundus within a large hiatus hernia with evidence of some altered blood and a 3rd diverticulum noted in the second portion of the duodenum with no evidence of a recent bleed. No endoscopic therapy was required at the time for hemostatic control due to the absence of active bleeding or visible high-risk stigmata. We proceeded with a computed tomography of the chest and upper abdomen (Fig.-2) as well as a barium swallow that confirmed numerous diverticula involving the GOJ (22-×-6-mm), stomach, and duodenum. Upon further history, the patient did describe having intermittent dysphagia over many years. The patient's melena resolved, and he was discharged home off aspirin with continuation of an oral proton pump inhibitor. Esophageal diverticula have a reported annual incidence of 1:500-000 per year and epiphrenic esophageal diverticula (EED) that occur within 10-cm proximal to the GOJ account for about 15% of these. EED is a very rare cause of upper gastrointestinal bleeding. As far as we are aware, there have been only a handful of these cases published to date. Although EED are largely noted incidentally, some common symptoms of presentation include dysphagia, vomiting, chest pain, and heartburn. Assessment may also involve barium swallow and computed tomography of the chest, especially for pre-operative evaluation. There are no clear guidelines or consensus as to the best course of treatment. Therapeutic interventions that have been described in previous case reports include administration of adrenaline, heater probe thermocoagulation, and hemostasis clips. If endoscopic intervention is not successful, surgical options may include diverticulectomy, myotomy, and fundoplication. Although rare, this case demonstrates that EED could potentially cause significant upper gastrointestinal bleeding and should be considered as a differential in clinical practice.

Myotomy-First Approach to Epiphrenic Esophageal Diverticula.

Introduction: Epiphrenic esophageal diverticula are typically treated with concurrent cardiomyotomy and diverticulectomy. However, resection of these diverticula can be technically difficult and associated with significant morbidity with a staple line leak rate ranging up to 27%. For this reason, and because the diverticulum is secondary to a primary esophageal motility disorder such as achalasia, we decided to adopt a laparoscopic myotomy-first strategy, reserving the diverticulectomy for patients with persistent or recurrent symptoms. Methods: From 2004 to 2018, 22 patients with epiphrenic diverticula were treated by laparoscopic Heller myotomy and partial fundoplication alone, with the plan to add the diverticulectomy as a second stage if needed. There were 13 women and 9 women, with a mean age of 68 years. Results: Patients had been symptomatic for an average of 36 months. The most common presenting symptom was dysphagia (91%), followed by regurgitation (77%). More than half of the diverticula were solitary and on the right side. Esogphagoscopy ruled out cancer. Esophageal manometry (18 patients) showed achalasia in 14 patients, nutcracker esophagus in 3 patients, and nonspecific motility disorder in 1 patient. There were no perioperative complications, and average length of stay was 2.5 days. At a mean follow-up of 68 months, dysphagia resolved in 77% and regurgitation in 86% of patients. Three patients had persistent symptoms: 2 patients underwent a transthoracic diverticulectomy (1 patient with resolution of symptoms and 1 patient with no improvement). Another patient had per oral endoscopic myotomy, but his dysphagia persisted. Conclusions: The laparoscopic myotomy-first approach reduces risk and unnecessary surgery. A laparoscopic Heller myotomy and partial fundoplication provide excellent resolution of symptoms for most, whereasonly a few will need a staged resection of the diverticulum.

A Large Epiphrenic Esophageal Diverticulum Communicating with the Left Lower Lobe

Epiphrenic diverticula are known to cause a series of complications. We report the case of a 54-year-old woman who was diagnosed with an epiphrenic diverticulum at a regular checkup in November 2006. Ten years later, she presented with massive hematemesis. Imaging studies revealed an epiphrenic diverticulum measuring 7.8 cm in diameter and a large amount of bleeding inside the diverticulum. Computed tomography showed fistula formation between the diverticulum and the left lower lobe of the lung, leading to the development of a pulmonary abscess. Diverticulectomy and 180° posterior partial fundoplication were performed transabdominally. The pulmonary abscess was treated with antibiotics alone. She was discharged 16 days after the operation without any complications over 7 months of follow-up.

Laparoscopic Surgery for Epiphrenic Esophageal Diverticulum.

Background and Objectives:We wanted to assess our surgical results focusing on the patients' quality of life. We present our experience with laparoscopic surgery for epiphrenic esophageal diverticulum. Short- and long-term results of surgical therapy were analyzed.Methods:Eight patients were examined with a symptom-causing epiphrenic diverticulum. Patients underwent complex gastroenterologic examinations before and after surgery. Laparoscopic transhiatal epiphrenic diverticulectomy, Heller cardiomyotomy, and Dor anterior partial fundoplication were performed on 7 patients. One patient underwent only diverticulectomy, where no motility disorder was present. Results from surgical treatments and changes in patients' pre- and postoperative complaints were evaluated.Results:In all cases except 1, the preoperative examination showed dysmotility of the esophagus. The average duration of the surgeries was 165 (130–195) minutes; blood loss was minimal. One patient developed bleeding in the early postoperative period, and a second laparoscopy was required. No other intraoperative complication was detected, and no mortality occurred. In one case, a staple line leak developed (1/8 [12.5%]), which was resolved with conservative therapy. Functional check-ups confirmed adequate esophageal function. 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 (mean, 60 months; 10–138 months), 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.

Achalasia Associated With Esophageal Intramural Pseudodiverticulosis: A Rarely Reported Condition

Intro: Esophageal intramural pseudodiverticulosis (EIP) is a benign, rare condition that most commonly presents in patients ages 50-70. It is often associated with diabetes mellitus, chronic alcoholism, malnutrition, or achalasia as depicted in the case below. It was first reported in 1960 with roughly 250 cases worldwide, and only 2 reports are associated with achalasia.Figure: Barium esophagram showing multiple classic button and flask shaped EIP in the upper esophagus.Figure: Barium esophagram depicting dilatation of the mid esophagus with tortuosity of the mid to distal portion.Case: An 87 year old male with a history diabetes and progressive dysphagia with regurgitation of solids and liquids over many years presented to the ER in septic shock secondary to aspiration pneumonia. He had endoscopy three years prior showing candidal esophagitis, epiphrenic diverticulum, and a schatzki ring. Follow-up endoscopy revealed tertiary contractions and he was prescribed a calcium channel blocker, which he did not take. Two months prior to this admission, a barium esophagram showed dilatation of the mid esophagus, several pseudodiverticula in the upper esophagus, tortuosity of the mid to distal portion, a 4.2x4.3cm epiphrenic esophageal diverticulum proximal to the gastroesophageal junction, silent aspiration of contrast, incomplete emptying and regurgitation to the oropharynx. High resolution manometry was significant for esophageal aperistalsis and lower esophageal sphincter pressure indicating achalasia. He presented with aspiration before achieving outpatient management. Given the patient's age and multiple comorbidities, palliative endoscopic treatment was given with botox injection and symptomatic improvement.Figure: Barium esophagram depicting a large 4.2x4.3 cm epiphrenic esophageal diverticulum proximal to the gastroesophageal junction, and regurgitation of contrast into the upper esophageal pseudodiverticula.Discussion: EIP is a rare condition caused by reactive hypertrophy and increased intramural pressure creating dilation and outpouching of the esophageal submucosal gland excretory ducts caused by a distal obstruction from chemical, infectious, or mechanical processes, such as achalasia. Dysphagia, reflux, and odynophagia are common presenting symptoms with stricture formation in up to 90% of cases. Barium esophagram shows flask or button-shaped outpouchings and may reveal dysmotility. The main goal of treatment is to correct the underlying disorder, which involved botox injection to palliate the patient's achalasia. EIP is generally benign though complications include aspiration pneumonia, candidal infection, fistulas, mediastinitis, and perforation. We present this case to raise physician awareness of this rare condition to aid in prompt diagnosis and management, in hopes of avoiding complications that result in increased patient morbidity and mortality.

Surgical Management of Esophageal Epiphrenic Diverticula: A Transthoracic Approach Over Four Decades

Epiphrenic esophageal diverticula are infrequent. Although surgical treatment is generally recommended, technique varies widely and optimal management remains controversial. This study evaluated a single-institution experience for surgical treatment of epiphrenic diverticula. A retrospective review was made of medical records of 31 patients undergoing surgical treatment for epiphrenic diverticula from 1974 to2016. There were 17 men (55%); median age was 65 years. Dysphagia (87%) and regurgitation (71%) were the most common symptoms. Three patients (10%) presented acutely: 2 with ruptured diverticula and 1 with hematemesis. All patients underwent an open transthoracic approach. Diverticulectomy was performed in 28 patients (90%), myotomy in 28 (90%), and a concomitant antireflux procedure in 6 (19%). A total of 22 patients (71%) underwent diverticulectomy and myotomy, 4 (13%) underwent diverticulectomy with myotomy and antireflux procedure, 2 (6%) had myotomy and antireflux, 2 had diverticulectomy alone, and 1 patient had imbrication of the diverticulum after myotomy. Overall, morbidity occurred in 11 patients (35.5%), with major morbidity in 6 (19.4%). There was one postoperative esophageal leak (3%). Ninety-day mortality was zero. Mean follow-up was 30 ± 43 months in 28 patients. Additional procedures (ie, reoperation, balloon dilation) were needed in 7 patients (25%). An excellent outcome (ie, absence of symptoms) was accomplished in 21 patients (75%). Acute presentation was associated with need for further procedures (p=0.011) and symptoms at follow-up (p= 0.011). A tailored transthoracic approach to the surgical management of epiphrenic diverticula can provide excellent results. The need for a concomitant antireflux procedure remains controversial and may not be routinely necessary. Acute presentation is associated with poor functional outcome.

Multiple huge epiphrenic esophageal diverticula with motility disease treated with video-assisted thoracoscopic and hand-assisted laparoscopic esophagectomy: a case report

BackgroundEpiphrenic esophageal diverticulum is a rare condition that is often associated with a concomitant esophageal motor disorder. Some patients have the chief complaints of swallowing difficulty and gastroesophageal reflux; traditionally, such diverticula have been resected via right thoracotomy. Here, we describe a case with huge multiple epiphrenic diverticula with motility disorder, which were successfully resected using a video-assisted thoracic and laparoscopic procedure.Case presentationA 63-year-old man was admitted due to dysphagia, heartburn, and vomiting. An esophagogram demonstrated an S-shaped lower esophagus with multiple epiphrenic diverticula (75 × 55 mm and 30 × 30 mm) and obstruction by the lower esophageal sphincter (LES). Esophageal manometry showed normal peristaltic contractions in the esophageal body, whereas the LES pressure was high (98.6 mmHg). The pressure vector volume of LES was 23,972 mmHg2 cm. Based on these findings, we diagnosed huge multiple epiphrenic diverticula with a hypertensive lower esophageal sphincter and judged that resection might be required. We performed lower esophagectomy with gastric conduit reconstruction using a video-assisted thoracic and hand-assisted laparoscopic procedure. The postoperative course was uneventful, and the esophagogram demonstrated good passage, with no leakage, stenosis, or diverticula.ConclusionsThe most common causes of mid-esophageal and epiphrenic diverticula are motility disorders of the esophageal body; appropriate treatment should be considered based on the morphological and motility findings.

Epiphrenic diverticulum of esophagus: a rare case report

A rare acquired epiphrenic diverticulum of esophagus was identified in a 60-year-old male patient. He was presented with 8 months history of dysphagia and regurgitation. Barium swallow study and upper gastrointestinal endoscopy confirmed the diagnosis and showed normal mucosa. No suspicion of malignancy was present. Manometry was normal. The diverticulum was surgically excluded by continuous suturing, along with esophagomyotomy. Avoidance of diverticulectomy facilitated early oral feeding and speedy recovery.

A Case Report on Large Epiphrenic Diverticula

Esophageal epiphrenic diverticulum is not common clinical presentation. They result from various pathologies, usually due to the motility disorder that leads to the formation of the pouch through the weakened esophageal wall. Most of such large lesions usually associated with severe aggravating symptoms. Here we present a case of large epiphrenic diverticula with misleading nonspecific features of gastroesophageal reflux disease, where spontaneous recovery of symptoms was achieved with conservative treatment.

Epiphrenic esophageal diverticulum in an adolescent with a history of a Nissen fundoplication: A case report

Abstract Epiphrenic esophageal diverticuli (EED) are exceedingly rare in children. While esophageal dysmotility is often associated with this diagnosis in adults, the few reports in children implicate retained foreign bodies as the cause. The patient presented here is an 18 year-old female with a distant history of a Nissen fundoplication who developed dysphagia, gastroesophageal reflux, and weight loss, and was found to have an EED. Her symptoms completely resolved following laparoscopic diverticulectomy and hiatal hernia repair. Though the exact etiology of her EED remained unclear, it may have been related to her fundoplication. This potential late complication may be seen more frequently as a large number of children with a history of fundoplication are reaching adulthood.