Management Of Esophageal Diverticula Research Articles

Recurrent Esophageal Stricture as a Result of Esophageal Diverticulum: Case Report

Esophageal stricture is a disorder that limiting patients’ capability to get adequate intake. Dysphagia and regurgitation are main problem that makes patient admit to the hospital. There are several causes that narrowing esophageal lumen; those could be intraluminal or extraluminal. Esophageal diverticulum is one of a kind. It is not easy to establish the diagnosis of diverticulum in esophagus segment since supporting examination needed were complex. Esophageal stricture treatment should be interdisciplinary approach because inappropriate management would increase risk of complication and lowering patient’s quality of life. The management of esophageal diverticulum could be challenging and its prognosis depends on the patient’s characteristic and comorbidity.

Minimally Invasive Techniques in the Contemporary Management of Esophageal Diverticula

INTRODUCTION: Management of esophageal diverticulum has shifted from an expansive, open operative approach to a varied open and select endoscopic intervention. This study examines operative outcomes in patients with esophageal diverticula treated with varied approaches at a single academic center. METHODS: A retrospective review of a prospectively maintained database was performed for all patients who underwent operation for esophageal diverticula at a single institution. The patients were grouped by location: Group A (Zenker’s), group B (mid-esophageal), and group C (epiphrenic diverticula). Measured outcomes include postoperative complication, symptoms, and recurrence. RESULTS: A total of 27 patients who underwent operation for symptomatic esophageal diverticula from June 2010 to June 2018 were identified. The mean age was 66.6 years, and 29.6% were women. Mean follow-up was 14 months. Group A consisted of 14 patients, group B 7, and group C 6. Preoperative dysphagia occurred in 81.5% of all patients. Underlying motility disorders were present in 92.3% of group B and C patients. A total of 92% of patients in group A underwent attempted endoscopic resection, with 42.9% converting to open. Robotic-assisted surgery was performed in 100% of group B and 83.3% of group C patients. One esophageal leak occurred in group A; there were no mortalities. Only group A demonstrated radiographic recurrence at 42.8%. Recurrent dysphagia in group A was 50%, group B 28.6% (2/7), and group C 0%. CONCLUSION: Minimally invasive management of esophageal diverticula provides effective symptom resolution. This study verifies the safety of endoscopic, laparoscopic, and robotic approaches with a 0.04% leak rate.

Management of esophageal diverticula through an open surgical approach: A 16 year experience

Introduction: Esophageal diverticula are rare. There are controversies over the indication for surgery and the optimal surgical approach in these patients. In this study, we target to evaluate the complications and outcomes of 34 surgery candidates with esophageal diverticula undergoing an open approach. Method: This is a retrospective review of patients with either cervical or thoracic diverticula who underwent surgery by thoracic surgery teams over a 16-year period. The selected surgical approach was postero-lateral thoracotomy for mid-esophageal and epiphrenic diverticula and left side neck incision for cervical esophageal diverticula. Myotomy was performed only in the case of esophageal motility disorders in patients with thoracic diverticula and in all patients with cervical diverticula. The postoperative intermediate-term outcomes were assessed. Results: Of the 34 patients, 9 patients had cervical diverticula, 13 (38%) had mid-esophageal diverticula and 12 (35%) of those had epiphrenic diverticula. All the patients with epiphrenic and mid-esophageal diverticula underwent postero-lateral thoracotomy, and those with cervical esophageal diverticula underwent cervical approach. 21 patients underwent diverticulectomy and myotomy (61%), and 6 patients underwent diverticulectomy alone (17%). There were a total postoperative (4 patients). None of the patients had in-hospital or 30-day mortality. Conclusion: Although in this era, minimally invasive approach is the first choice for diverticulectomy; however, we observed that in our study the mortality and leak rates were as low as those of the previous studies. Hence, open approach could be safe and effective if it is performed by surgeons with high degree of expertise.

Management of esophageal diverticula through an open surgical approach: A 16 year experience

Management of esophageal diverticula through an open surgical approach: A 16 year experience

Peroral endoscopic myotomy (POEM) for esophageal diverticula.

Esophageal diverticula (ED) are uncommon, mostly seen in elderly and can present with a multitude of symptoms. Of the three types of ED, epiphrenic and mid-esophageal diverticulum are still rare. These are often associated with esophageal motility disorder, which contributes to its development. The key step in the management of such symptomatic ED is the division of the septum and tackling the underlying motility dysfunction, if any. Traditional surgical options have high morbidity and mortality while flexible endoscopic septal division cannot adequately manage epiphrenic diverticulum with motility dysfunction. The technique of submucosal space creation and peroral endoscopic myotomy (POEM) has been used to treat a host of esophageal diseases such as achalasia. POEM has been recently described for the management of ED. Two different strategies have been described for tackling using POEM, namely, diverticular POEM (D-POEM) and salvage POEM (S-POEM). While D-POEM entails division of the septum and esophageal myotomy, S-POEM requires only esophageal myotomy without septum division. Multiple retrospective studies in the recent years have described use of POEM for the management of different types of ED with good safety and efficacy with low recurrence rate. This review encompasses a detailed account of the technical steps, pre- and post-procedure evaluation and literature review of safety, efficacy, adverse events, and recurrence rates of the use of POEM for ephiprenic and mid-esophageal diverticulum. We have also proposed a management algorithm based on the type of underlying motility dysfunction and the size of the diverticulum.

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.

Peroral endoscopic myotomy for the treatment of esophageal diverticulum: an experience in China.

With the development of minimally invasive endoscopic approaches for the esophagus in recent years, peroral endoscopic myotomy (POEM) in the treatment of esophageal diverticulum has been described recently in some reports due to its successful outcomes. The aim of this study is to report our experience with the use of diverticular POEM (D-POEM) technique in the management of esophageal diverticulum. This retrospective study included consecutive patients with symptomatic esophageal diverticulum who visited our endoscopy center between April 2014 and January 2019. D-POEM was performed based on the principles of submucosal endoscopy. A new symptomatic scoring system was introduced to evaluate the severity of diverticular symptoms. A total of 10 patients with esophageal diverticulum (Zenker's 2, mid-esophagus 5, and epiphrenic 3) were included. The overall technical success rate of D-POEM was 100%, with a mean procedure time of 38.9 ± 20.5 (range 16-70) min. No serious complications occurred. Clinical improvement was achieved in 90% (9/10) of patients. The symptomatic score was significantly decreased from 2.5 (IQR 2.00-3.25) to 1.0 (IQR 0-1.25) (P = 0.007) during a median follow-up period of 11.0 (IQR 10.25-17.25) months. These findings suggested complete septotomy by D-POEM. Our preliminary data and experience put forwarded D-POEM as a safe and effective technique for esophageal diverticulum.

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.

An international study on the use of peroral endoscopic myotomy (POEM) in the management of esophageal diverticula: the first multicenter D-POEM experience.

The aim of this study is to report a novel, multicenter experience with the diverticular peroral endoscopic myotomy (D-POEM) technique in the management of esophageal diverticula. This is a multicenter, international, retrospective study involving three centers. D-POEM was performed using the principles of submucosal endoscopy. A total of 11 patients with an esophageal diverticulum (Zenker's 7, mid-esophagus 1, epiphrenic 3) were included. The mean size of the esophageal diverticula was 34.5 mm. The overall technical success rate of D-POEM was 90.9 %, with a mean procedure time of 63.2 minutes. There were no adverse events. Clinical success was achieved in 100 % (10 /10), with a decrease in mean dysphagia score from 2.7 to 0.1 (P < 0.001) during a median follow-up of 145 days (interquartile range 126 - 273). Endoscopic management of esophageal diverticula using the novel technique of D-POEM appears promising. This first case series on D-POEM suggests that the procedure is feasible, safe, and effective in the management of esophageal diverticula. D-POEM offers the distinct advantage of ensuring a complete septotomy. Larger studies are needed to confirm these intriguing results.

Surgical Management of Esophageal Diverticulum: A Review From The Nationwide Inpatient Sample

Surgical Management of Esophageal Diverticulum: A Review From The Nationwide Inpatient Sample