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

BACKGROUND: 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. METHODS: This is a multicenter, international, retrospective study involving three centers. D-POEM was performed using the principles of submucosal endoscopy. RESULTS: 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). CONCLUSION: 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.

Esophageal strictures and diverticula.

Esophageal disease and dysfunction of the lower esophageal sphincter (LES) manifesting as gastroesophageal reflux disease (GERD) particularly, is the most common of all gastrointestinal conditions impacting patients on a day-to-day basis. LES dysfunction can lead to anatomic changes to the distal esophagus, with GERD-mediated changes being benign stricture or progression of GERD to Barrett's esophagus and even esophageal cancer, and LES hypertension impairing esophageal emptying with subsequent development of pulsion esophageal diverticulum. This article details the causes, clinical presentation, workup, and treatment of esophageal stricture and epiphrenic esophageal diverticulum. Other types of esophageal diverticula (Zenker's and midesophageal) are also covered.

Oesophageal pouches and diverticula: a pictorial review.

Diverticula of the oesophagus are rare. They can occur at any level, and are often defined by their anatomical location. Three categories are recognised, namely pharyngo-oesophageal, parabronchial and epiphrenic. Although these diverticula are often asymptomatic, patients can develop significant problems with dysphagia, regurgitation and aspiration. The causation of oesophageal diverticula is controversial; however, the popular current belief is that most occur because of oesophageal dysmotility. This paper demonstrates the categories of oesophageal diverticula pictorially, including the radiological features and underlying pathology.

[Esophageal diverticula]. / Diverticules de l'oesophage.

Esophageal diverticula are classified by location-phrenoesophageal (Zenker's diverticulum-70%), thoracic and mediastinal (10%), and epiphrenic (20%). Almost all esophageal diverticula are acquired pulsion diverticula. The most common symptoms are dysphagia, regurgitation, thoracic pain, and pulmonary manifestations related to aspiration. Barium swallow and upper endoscopy will help to establish the diagnosis while esophageal manometry may reveal underlying dysmotility. Diverticula should not be treated unless they are symptomatic. The treatment of Zenker's diverticulum is surgical and consists of either diverticulectomy or diverticular suspension with a myotomy of the cricopharyngeus muscle via cervical approach. Transoral endoscopic stapled diverticulostomy is a new and simple approach which may become the treatment of choice, particularly in elderly and high-risk patients. Treatment of diverticula of the mid and low esophagus must take into account any motor anomalies or associated lesions. Diverticulectomy with esophageal myotomy and an anti-reflux procedure through a left thoracotomy is the standard approach, but endoscopic approaches seem feasible, particularly for epiphrenic diverticula, and may become the norm in years to come.

Esophageal diverticula: current classification and important complications.

Esophageal diverticula, although often asymptomatic or discovered incidentally during the workup of unrelated symptoms, may serve as a sign to clinicians of an ongoing dysmotility process involving the esophagus, particularly in our aging population. As well, esophageal diverticula may lead to unexpected complications as a result of instrumentation such as endoscopy or nasogastric tube placement that may result in significant morbidity and mortality including esophageal perforation. This article discusses these topics in detail with special emphasis on radiologic diagnosis and information for clinicians for management and avoidance of potentially serious complications.

[Esophageal diverticula].

Esophageal diverticula are considered to be rare but this has not deterred interest in the condition, either historically or in the present era. Most parabronchial esophageal diverticula are traction diverticula, and resection is thought to be unnecessary. The majority of pharyngoesophageal diverticula and epiphrenic diverticula are pulsion diverticula. It is now well accepted that they correlate with underlying motor disturbance and that surgery is indicated. If there is motor disturbance is preoperative manometry, it is necessary to add myotomy. However, if there is no motor disturbance, the surgical management remains controversial. Recently, minimal access surgery with laparoscopy or thoracoscopy has been successful in the treatment of epiphrenic diverticulum.

Divertículos esofágicos: comunicación de 2 divertículos de Zenker / Esophageal diverticula: report of 2 Zenker's diverticula

Se presentaron 2 casos de divertículos faringoesofágicos (DFE) o de Zenker diagnosticados y operados en el Servicio de Cirugía General del Hospital Provincial Docente "Manuel Ascunce Domenech" de Camagüey. Se señaló su clasificación clínica y diagnóstica, así como las enfermedades asociadas, y sus principales diagnósticos diferenciales. En ambos casos las 2 pacientes eran mujeres ancianas que mostraban síntomas de dificultad a la deglución, que luego de un estudio minucioso que llevó al diagnóstico de divertículos de Zenker fueron sometidas a tratamiento quirúrgico, al término del cual tuvieron una evolución posoperatoria satisfactoria, con seguimiento endoscópico, radiográfico y clínico durante un año(AU)

2 cases of Zenker's or pharyngoesophageal diverticula (PED) that were diagnosed and operated on at the the General Surgery Service of "Manuel Ascunce Domenech" Provincial Teaching Hospital were presented. Their clinical and diagnostic classification as well as the associated diseases and their main differential diagnoses were stressed. Both patients were aged females with symptoms of difficulty on deglution that after a detailed study leading to the diagnosis of Zenker's diverticula underwent surgery and had a satisfactory postoperative evolution with endoscopic, radiographic and clinical follow-up for a year(AU)

[Therapy of esophageal diverticula]. / Therapie von Osophagusdivertikeln.

Diverticula of the esophagus can be divided into two categories. Pulsion diverticula result from an increased pressure gradient through the upper esophageal sphincter resulting in herniation of the mucosa through a weak point of the muscle layer. There are two types: hypopharynx (Zenker) diverticulum and epiphrenic diverticulum. Traction diverticula result from inflammatory reactions in neighboring lymph nodes or as a result of embryonic malformation and are composed of all layers of the esophageal wall. The presence of a Zenker diverticulum in a symptomatic patient represents always an indication for surgical therapy. A successful procedure contains a diverticulectomy combined with cervical myotomy. For the treatment of epiphrenic diverticula the underlying motility disorder, determined by preoperative manometry, plays a crucial role in the length of the myotomy. In order to prevent postoperative reflux a partial fundoplication should be added. Independent of location or size surgical therapy of diverticula of the esophagus has a success rate of more than 90 percent.

Association of midoesophageal diverticula with oesophageal motor disorders. Videofluoroscopy and manometry.

PURPOSE: To evaluate the prevalence and clinical significance of associated oesophageal motor disorders in patients with midoesophageal diverticula. MATERIAL AND METHODS: We retrospectively reviewed videofluoroscopic and, if available, manometric studies of 30 patients with midoesophageal diverticula. The type of diverticulum and the presence and nature of oesophageal motor disorders were assessed. RESULTS: Videofluoroscopy showed that 24 patients had 26 pulsion-type diverticula and 6 patients had 7 traction-type diverticula. Oesophageal motor disorders were demonstrated in 21 of the 24 patients with pulsion-type diverticula and in 3 of the 6 with traction-type diverticula. Nineteen patients had nonspecific motor disorders, 5 had achalasia, and 5 had gastrooesophageal reflux or oesophagitis. CONCLUSION: Midoesophageal diverticula are most often of the pulsion-type and tend to be associated with an oesophageal motor disorder. Motor disorders are predominantly nonspecific, but achalasia may be encountered as well.

[Esophageal diverticulum. A case report]. / Diverticolo dell'esofago. Descrizione di in caso.

The authors report a case of epibronchial esophageal diverticula. The patient underwent a diverticulectomy and subdiverticular myotomy was associated. No significant complications were observed in the post-operative period. In the light of the literature the paper discusses anatomic-clinical, diagnostic and therapeutic aspects of esophageal diverticula.

Divertículos esofagicos epibronquicos: tratamiento quirúrgico / Esophagueal diverticula by traction: surgical treatment

Los divertículos esofágicos epibrónquicos en escasas oportunidades son de tratamiento quirúrgico, pero cuando lo requieren plantean problemas respecto de la vía de abordaje y la táctica quirúrgica que debe relacionarse con su etiopatogenia. Se reseñan las diferentes patogenias, destacando como estudios imprescindibles la radiología y la endoscopía. El estudio manométrico se considera complementario. En caso de hallarse patología asociada se le deberá dar prioriedad estudiándola y resolviéndola previamente. Se analizan 2 casos tratados quirúrgicamente, destacándose a la toracotomía derecha como vía de abordaje y a la diverticulectomía como el procedimiento ideal

Selective use of myotomy for treatment of epiphrenic diverticula. Manometric and clinical analysis.

The pathogenesis and treatment of epiphrenic diverticula remain controversial subjects. Most surgeons recommend esophagomyotomy in association with diverticulectomy in every patient. We believe that selective use of myotomy, based on manometry, should be used. From 1960 to 1990, 16 patients underwent surgical treatment for epiphrenic diverticulum at the Lahey Clinic Medical Center, Burlington, Mass. Six patients, three of whom underwent diverticulectomy alone and three who underwent an associated long myotomy, had the lower esophageal sphincter left intact; long-term results were good in all patients. The remaining 10 patients underwent myotomy of the lower esophageal sphincter. Reflux esophagitis developed in two of these patients who had a normal lower esophageal sphincter. Clinical results support the selective use of esophagomyotomy applied to areas of demonstrated dysmotility. A normal lower esophageal sphincter should be left intact to prevent reflux complications.

[Esophageal diverticulum].

During a 25-year period, nineteen patients with esophageal diverticulum were treated surgically in PUMC Hospital. Of them, eleven cases underwent resection of the diverticulum (10 pulsion type and 1 traction type); and four cases were treated by inversion suturing of the diverticulum (all traction type). The results of follow-up showed that pulsion diverticulum resection was satisfactory, and the resection was better than inversion suturing for traction-type diverticula. In this series, diverticulitis and esophagitis were present in all cases. Carcinoma of the esophagus developed at site near the diverticulum in 4 cases. Pathologic examination demonstrated severe submucosal inflammatory infiltration and epithelial hyperplasia of the esophagus associated with the diverticulum, with these changes being increasingly severe with the precondition of the carcinoma to the diverticulum. Carcinoma of the esophagus as a complication of diverticulum may be associated with chronic diverticulitis and esophagitis.

Etiopathogenesis and classification of esophageal diverticula.

The classification and etiopathogenesis of esophageal diverticula is discussed on the basis of our experience with the surgical management of 74 such diverticula (51 parapharyngeal, 7 thoracic, 167 epiphrenic). Parapharyngeal diverticula always represent true diverticula, their walls comprising muscular tissue as well as mucosa and submucosa. A causal relationship between esophageal reflux disease and Zenker's diverticulum has not yet been proved. Thoracic diverticula are probably more often of a congenital than traction origin. Epiphrenic diverticula result either from hypertonia of the lower esophageal sphincter (esophageal achalasia) or, if the latter functions normally, are of congenital origin. Traction etiology can in special cases be due to the presence of a leiomyoma in the esophageal wall.

Oesophageal diverticula: principles of management and appraisal of classification.

In this paper we review a consecutive series of 50 oesophageal diverticula, appraise clinical features and methods of management, and suggest an improvement on the World Health Organization classification. The link between oesophageal diverticula and motor disorders as assessed by oesophageal manometry is stressed. It is necessary to correct the functional disorder as well as the diverticulum if it is causing symptoms. A revised classification could be as follows: congenital--single or multiple; acquired--single (cricopharyngeal, mid-oesophageal, epiphrenic other) or multiple (for example, when cricopharyngeal and mid-oesophageal present together, or when there is intramural diverticulosis.