Three-dimensional laparoscopic approach to distal oesophageal diverticula: Single-centre experience.

Background: Epiphrenic oesophageal diverticula are rare and often asymptomatic. When symptoms are present, minimally invasive diverticulectomy is considered the gold standard of treatment. While there is an agreement on the pre-operative assessment, no consensus is achieved when it comes to surgical technique. In the present study, we report our experience and propose a standardised approach to manage this rare oesophageal disorder. Materials and Methods: We prospectively analysed data of all consecutive patients who underwent three-dimensional (3D) laparoscopic distal oesophageal diverticulum resection during 2015-2020 at Upper gastrointestinal surgical department, St Thomas' Hospital, regarding pre-operative assessment, surgical technique, peri-and post-operative outcomes. Results: Six patients were submitted to 3D laparoscopic diverticulectomy, five of which with additional anterior myotomy and fundoplication and one with additional hiatal hernia repair only. Three patients followed a specific diet in preparation for surgery. Median pre-operative Eckardt symptom score was five. Two patients had normal manometry. Median operative time was 180 min, median estimated blood loss was <100 ml, neither intraoperative complications nor conversions to open approach occurred. All patients reported a complete resolution of symptoms directly after surgery. Median follow-up was 66 months. Five patients have none or minimal residual symptoms. One had recurrence requiring a revision operation for intermittent dysphagia. Conclusions: 3D laparoscopic diverticulectomy offers a reasonable chance of treatment in patients with epiphrenic diverticula. Optimal selection of patients, optimisation for surgery, gaining the surgical experience of carrying out these techniques and impact on short- and long-term results are issues that still remain under debate.

Per-oral Endoscopic Myotomy with Division of Septum (D-POEM) in Epiphrenic Esophageal Diverticula: Outcomes at a Median Follow-Up of Two Years.

Esophageal epiphrenic diverticula (EED) are rare pulsion-type outpouchings at the lower end of esophagus. Traditionally, surgery has been performed in EED. More recently, per-oral endoscopic myotomy with septotomy (D-POEM) has emerged as an option in these cases. In this study, we aim to determine the efficacy and safety of D-POEM in cases with EED. The data of cases who underwent D-POEM in cases with EED from March 2013 to Nov 2020 were analyzed, retrospectively. The primary outcome of the study was clinical success. Secondary outcomes included technical success, procedure duration, reflux esophagitis, and adverse events. 13 patients (males 9, 48.07 ± 17.55 years) with EED underwent D-POEM during the study period. Median size of the EED was 45 mm (range 25-70). Associated esophageal motility disorder was found in 10 (76.9%) cases including type II achalasia (3), type I (3), hypercontractile esophagus (2), and unspecified (2). Technical success was achieved in 12 (92.3%) cases. Median length of total and gastric myotomies were 10 cm (range 6-20) and 3 cm (1-3), respectively. At a median follow-up of 25 months, clinical success was achieved in 84.6% cases. Mean integrated relaxation pressures reduced significantly after POEM procedure (25.80 ± 13.24 vs 9.40 ± 3.10, p = 0.001). There was one major adverse event requiring surgical intervention. D-POEM is an effective procedure in cases with EED. Long-term follow-up studies are required to ascertain the durability of response in these cases.

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 12 months with a mean diverticulum size of 68.8 ± 1.9 mm. The mean procedure time was 64.80 ± 12.6 min. with a mean septotomy/myotomy length of 79.44 ± 12.2 mm. 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 280 days (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.

Laparoscopic transhiatal oesophageal diverticulectomy: An experience of large epiphrenic oesophageal diverticulum and review literature.

Epiphrenic diverticulum is a rare abnormality of the distal oesophagus. Both thoracic and abdominal approaches are suitable for this diverticulum. A 46-year-old male presented with complaints of regurgitation and chest pain for 2 years. Contrast-enhanced computed tomography of the neck, thorax, abdomen and oesophageal endoscopy revealed 12 cm × 10 cm size large intrathoracic oesophageal diverticulum. He underwent an elective laparoscopic transabdominal oesophageal diverticulectomy. Gastrograffin study on the first post-operative day did not reveal any leak. In this case report, we are sharing our experience in the management of large epiphrenic oesophageal diverticulum through a laparoscopic approach. The benefits of the laparoscopic approach include decreased morbidity because we can avoid large thoracotomy or laparotomy incision.

Surgical resection of voluminous epiphrenic diverticula.

A 52-year-old male and 55-year-old female underwent surgical resection of a voluminous symptomatic epiphrenic diverticulum via a right thoracotomy. A formal myotomy of the distal esophagus was not performed. The first patient had an uncomplicated recovery whilst the other patient still suffers from an esophageal-cutaneous fistula and repetitive abscesses, treated by intravenous antibiotics and percutaneous drainage. The authors discuss the indication for resection, surgical techniques and complications.

[Diverticula in the gastrointestinal tract]. / Divertikel im Gastrointestinaltrakt.

The prevalence of diverticula varies depending on the location within the gastrointestinal tract. Diverticula of the esophagus, stomach and small intestine are rare, more frequent are peripapillary diverticula and colonic diverticula. Meckel diverticula can also be of relevance in adults. Diverticula have to be differentiated from intramural pseudodiverticulosis of the esophagus and bile duct cysts. An endoscopic and radiological diagnostic work-up is only necessary for symptomatic diverticula or complications. In some cases additional functional diagnostic tests, such as high-resolution esophageal manometry to detect underlying motility disorders (Zenker's diverticulum, epiphrenic diverticulum) or the hydrogen breath test to detect bacterial overgrowth in the small intestine (diverticula of the small intestine) are mandatory. Effective treatment requires the close interdisciplinary cooperation between different specialist disciplines. Therapeutic modalities include pharmacotherapy, endoscopy and surgical methods.

S-POEM in treatment of achalasia and esophageal epiphrenic diverticula - single center experience.

Background: Standard treatment for esophageal epiphrenic diverticula associated with achalasia includes surgical diverticulectomy, myotomy and anterior fundoplication. However, several case reports published recently suggest that endoscopic approach using per oral endoscopic myotomy is a safe and effective alternative.Methods: This is a retrospective review of a single center case series of patients with achalasia and epiphrenic diverticula. During the treatment, the POEM guided on the opposite site of the diverticular neck without diverticulotomy was performed. Symptomatic outcome was evaluated 3 months after procedure and afterwards with the median follow-up time of 24 months. High resolution manometry was performed 3 months after the procedure.Results: Seven patients with esophageal epiphrenic diverticula were included. POEM was successfully performed in all patients, with no complications in the periprocedural period. We observed a significant reduction of Eckardt score and the relaxation pressure of the lower esophageal sphincter (31.8 vs. 8.8 mmHg, p < .0001).Conclusions: POEM is a promising approach in the management of achalasia and esophageal epiphrenic diverticula. We demonstrated its safety, efficiency and ability to provide symptom reduction and decrease of the LES relaxation pressure even without diverticulotomy. Multicentric studies on larger cohorts of patients and with longer follow-up time are required to confirm these results.

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

BACKGROUND: 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. METHODS: 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 3 months post POEM were evaluated in these patients. RESULTS: 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. CONCLUSIONS: POEM alone seemed effective and safe for patients with EMD and ED.

Heller Myotomy for Epiphrenic Diverticula Compared to Nondiverticula Esophageal Motility Disorders, A Single Institution Experience and Appraisal of Patient Characteristics, High-Resolution Manometry and Outcomes.

PURPOSE: The purpose of this study was to compare demographics, symptoms, prior interventions, operation, and outcomes of patients who underwent Heller myotomy for esophageal motility disorders and epiphrenic diverticulectomy with Heller myotomy. METHODS: We identified all patients who underwent Heller myotomy for esophageal motility disorders with and without esophageal diverticulectomy over an 80-month period. Primary data points included patient demographics, presenting symptoms, prior intervention, high-resolution manometry, surgery performed with rate of laparoscopic, conversion to open, and open procedures; postoperative complications, and symptom resolution. RESULTS: Over the study period, 308 Heller esophagomyotomy operations were performed on 301 patients. Of these, 277 cases were without epiphrenic diverticula and 31 included diverticula. One patient with an asymptomatic epiphrenic diverticulum did not undergo surgery was included, for a total of 32 diverticula patients. Six patients in the non-diverticula group and 1 in the diverticula group required a second operation for recurrent symptoms or residual diverticulum. The diverticula group was significantly older, had different manometry findings, required more open operations, and had longer length of stay. The diverticula group had a lower frequency of patients with prior interventions, but similar postoperative leaks, higher overall postoperative complications, and no difference in reported symptomatic improvement. CONCLUSIONS: Esophageal diverticula patients have a unique profile compare to patients with non-diverticula motility disorders. Operations are more complex, with increased complication rate and a longer length of stay. In spite of this, there is no statistically significant difference in symptomatic outcomes between the groups.

Current possibilities of minimally invasive therapy of oesophageal diverticula.

Oesophageal diverticula represent a relatively rare pathology of the oesophagus requiring a specific diagnostic and therapeutic approach. Interventional therapy is indicated for symptomatic diverticula, diverticula with other pathologies (tumour in the diverticulum, gastroesophageal reflux disease, low-malignancy gastroesophageal junction tumours). The open surgical approach is being increasingly replaced by minimally invasive surgical, endoscopic and combined methods. Surgical mini-invasive methods use transaxillary, thoracoscopic or transhiatal laparoscopic approach, often with endoscopic assistance. Endoscopic and transoral surgical procedures include various diverticulotomy techniques and submucosal tunnelling techniques (variants of peroral endoscopic myotomy). The primary concern in therapy is the reduction of symptoms, improvement of the quality of life and the patient´s safety. The resulting quality of life is affected by the frequent presence of functional diseases of the oesophagus (achalasia, hypercontractile oesophagus). Although surgical minimally invasive therapy using the laparoscopic or thoracoscopic approach is safe, it nevertheless does not exclude serious risk of complications. Randomized and observational studies comparing endoscopic and surgical methods are still missing. It is, therefore, necessary to extend the records in order to update the indication algorithm of intervention therapy, focusing mainly on safety with a clear imperative for patient centralization.

Peroral endoscopic myotomy in achalasia and large epiphrenic diverticulum.

Symptomatic epiphrenic diverticula are mostly treated surgically with laparoscopic diverticulectomy, myotomy and anterior fundoplication. However, in case the patient does not agree with surgical therapy or is contraindicated, there are limited ways of alternative treatment. We present a case report of a 72-year-old female patient with severe dysphagia, regurgitation, paroxysmal cough, weight loss and malnutrition who was diagnosed with achalasia and large epiphrenic diverticulum. She did not give consent to the proposed surgical treatment. Alternatively, peroral endoscopic myotomy (POEM) was carried out. In one-year follow up, we observed complete symptom resolution, significant weight gain, improvement of nutritional status and no complications. We suggest that POEM could serve as an effective and safe alternative treatment for patients with achalasia and esophageal epiphrenic diverticula.

A superficial esophageal cancer in an epiphrenic diverticulum treated by endoscopic submucosal dissection.

BACKGROUND: We report a unique case of a superficial esophageal cancer arising in a single diverticulum, diagnosed with magnifying image-enhanced endoscopy and then successfully treated by endoscopic submucosal dissection (ESD). CASE PRESENTATION: A 66-year-old man with alcohol-related liver injury visited our hospital for endoscopy for investigation of varix. Esophagogastroduodenoscopy showed no varix but a large epiphrenic diverticulum with an area of fainted redness just above the esophagogastric junction. Narrow band imaging revealed a sharply demarcated brownish dotted area, and dilated intra-epithelial papillary capillary loops (IPCL) were subsequently seen after magnification. Chromoendoscopy with 1% Lugol's iodine solution demonstrated a well-demarcated unstained area, approximately 20 mm in diameter. Endoscopic biopsy revealed a squamous cell carcinoma (SCC). CONCLUSION: The tumor was completely resected by ESD without perforation. Histologically, it was an intraepithelial SCC without lympho-vascular invasion of cancer cells. No local recurrence or metastasis was detected at the last follow-up of 42 months.

A combined thoracoscopic and laparoscopic approach for high epiphrenic diverticula and the importance of complete myotomy.

BACKGROUND: The traditional approach to epiphrenic diverticula is thoracotomy and diverticulectomy, together with myotomy ± partial fundoplication to address underlying dysmotility. A laparoscopic approach has been advocated but access to more proximal diverticula is problematic. We propose the selective addition of a thoracoscopic approach to overcome these challenges and reviewed our results. METHODS: A retrospective review from 2004 to 2015 identified 17 patients with an epiphrenic diverticulum who underwent surgery. Patients were grouped according to height of the diverticular neck (HDN) above the GEJ: group A < 5 cm, group B > 5 cm. Preoperative evaluation and type of surgery performed were recorded. Postoperative complications, mortality, and clinical outcomes using quality of life metrics and objective testing were assessed. RESULTS: The mean size of the diverticulum was 3.3 cm (2-6 cm) with a mean height above the GEJ of 5.5 cm (0-12 cm). A motility disorder was identified in 15/17. Group A, 9 patients, underwent laparoscopic diverticulectomy, myotomy, and partial fundoplication. For group B, 8 patients, the intended procedure was thoracoscopic diverticulectomy followed by laparoscopic myotomy and partial fundoplication, but this was only completed in 5. In 3 the myotomy was aborted or incomplete with subsequent staple line leaks resulting in 1 death. At a mean follow-up of 21 months, improvement of median QOLRAD scores from 3.42 to 6.2 (p = 0.18); GERD-HRQL from 23 to 1 (p = 0.05), swallowing score from 17.5 to 30 (p = 0.22), and Eckardt scores from 5 to 0 (p < 0.05) were observed. CONCLUSIONS: A minimally invasive strategy for epiphrenic diverticula based HDN above the GEJ and selective thoracoscopy for higher diverticula is feasible and appropriate, and resulted in improved quality of life. Incomplete myotomy was associated with a substantially higher complication rate. Laparoscopic myotomy should precede diverticulectomy for all cases, especially for high diverticula.

Minimally invasive therapy for epiphrenic diverticula: Systematic review of literature and report of six cases.

INTRODUCTION: Epiphrenic diverticula (ED) are infrequent and conventional surgical treatment entails aggressive open or transthoracic surgery. Minimally invasive treatment has changed the surgical approach but some surgical controversies are not resolved. OBJECTIVE: The objective of this study is to describe our experience in minimally invasive treatment of the ED and to perform a systematic review of the current literature in this subject. MATERIALS AND METHODS: We reviewed all data from the Hospital de Sant Pau, focusing on patients that underwent minimally invasive treatment for an ED since 1998 to date. Furthermore, we performed a systematic literature review focused on the minimally invasive approach for ED. RESULTS: A total of 6 patients have been treated (5 transhiatal and 1 with abdominal and thoracic approach). We found a predominance of males with a median age of 63. The diagnosis was made with an endoscopy, barium swallow and manometry. Half of the manometry results were pathologic. The surgical technique involved a diverticulectomy, myotomy and a Dor partial founduplication. Two patients that presented suture line leakage (SLL) were treated conservatively. No mortality was reported. The systematic review was carried out under the Preferred Reporting Items for Systematic Reviews and Meta-analyses scheme, with a total of 20 studies where 189 patients were found. No comparative or prospective randomised trials were found. Overall morbidity was 24%, with a SLL rate of 12%, hospital stay of 5 days and mortality of 1.5%. After a median follow-up of 42 months, 81.5% of the patients were asymptomatic. CONCLUSION: The minimally invasive approach for ED is a safe and feasible procedure.

Epiphrenic esophageal diverticula.

Epiphrenic esophageal diverticula (EED) are rare. The estimated incidence is about 1:500,000/year. EED usually result from a combination of esophageal obstruction, functional or mechanical and a point of weakness of the muscularis propria. Most of the symptoms are unspecific, but dysphagia is most common. Chest radiograph, barium esophagogram, endoscopy and manometry are diagnostic tools. The treatment methods are conservative medical therapy, myotomy, diverticulectomy and fundoplication. In addition, endoscopic pneumatic dilation and botulinum toxin injection are a good alternative for symptomatic patients with motility disorders who are unfit for or unwilling to undergo surgery.

Robotic-Assisted Laparoscopic Epiphrenic Esophageal Diverticulectomy with Myotomy.

Introduction: A large epiphrenic esophageal diverticulum can cause troublesome symptoms for patients, including dysphagia and reflux, ultimately, leading to debilitating weight loss. Case Description/Technique Description: We present a case of a 68-year-old female with a history of systemic lupus erythematosus presented with a large epiphrenic esophageal diverticulum with dysphagia, gastroesophageal reflux disease, and associated weight loss. The patient underwent a robotic-assisted laparoscopic epiphrenic diverticulectomy with esophageal myotomy. Intraoperative findings were consistent with epiphrenic esophageal diverticulum 7.5 × 6.0 × 4.0 cm with severe adhesions to the pericardium and pleura bilaterally. The diverticulum was transected using a stapler, and a myotomy was performed on the opposite side of the diverticulectomy. The patient tolerated the surgery without complication and was discharged home on postoperative day 5. Pathology was consistent with moderate chronic inflammation. Discussion: The robotic trans hiatal approach offers a safe alternative to the transthoracic approach for the surgical management of epiphrenic diverticula.

Combined thoracoscopic and laparoscopic surgery for epiphrenic diverticulum with associated gastroesophageal reflux disease: a case report.

BACKGROUND: Surgery is indicated for symptomatic epiphrenic esophageal diverticula. Based on the features of a case, thoracoscopic or laparoscopic approaches may be used. Epiphrenic diverticula are often associated with esophageal motility disorders, but cases of reflux esophagitis have rarely been reported. In this report, we describe a case of an epiphrenic esophageal diverticulum with reflux esophagitis, which was successfully treated by thoracoscopic diverticulectomy and laparoscopic fundoplication. CASE PRESENTATION: A 69-year-old man visited the hospital with a chief complaint of eructation and hiccup. Upper gastrointestinal endoscopy revealed a diverticulum in the left wall of the esophagus, which was 37-45 cm distal to the incisors. High-resolution manometry (HRM) showed no esophageal motility disorders. Due to the large size of the diverticulum, a thoracoscopic resection of the esophageal diverticulum was performed. Additionally, the patient had reflux esophagitis due to a hiatal hernia. The anti-reflux mechanism would be more impaired during the diverticulectomy; therefore, we decided that anti-reflux surgery should be performed simultaneously. Thoracoscopic esophageal diverticulectomy and laparoscopic Dor fundoplication were performed. The patient had an uncomplicated postoperative course and was discharged on the tenth operative day. He has been symptom-free without acid secretion inhibitors for 21 months after the surgery. CONCLUSIONS: We described a rare case of a large epiphrenic diverticulum with reflux esophagitis. A good surgical outcome was achieved by thoracoscopic resection of the diverticulum and laparoscopic Dor fundoplication.

Atypical presentation of an epiphrenic esophageal diverticulum 20 years post fundoplication: a case report and review.

Esophageal diverticulum is a rare condition characterized by the herniation of the esophageal mucosa outside the esophageal wall. Here, we explore the prevalence of ED and its associated esophageal dysmotility. We also shed light on the potential impact of previous surgical interventions, such as Nissen's fundoplication, on the development of ED. This manuscript presents the case of a 72-year-old woman with a history of Nissen's fundoplication surgery who experienced worsening symptoms of dysphagia, heartburn and postprandial cough. Despite exhibiting a normal motility pattern, upper endoscopy revealed a large epiphrenic esophageal diverticulum. The patient underwent successful surgical resection with myotomy, resulting in the resolution of symptoms with no complications. This case highlights the rarity of symptomatic ED and the need to recognize it while choosing the optimal treatment modality.

Laparoscopic Approach to Epiphrenic Diverticula Under Endoscopic Assistance: A Technical Report.

Introduction: Epiphrenic diverticulum is a rare disease caused by mucosa and submucosa herniation through the muscular layers of the esophageal wall. This study presents a case of a patient with a symptomatic epiphrenic diverticulum treated with surgery under endoscopic assistance. A review of the literature on this unusual condition was conducted, focusing on the pathogenesis, presentation, and surgical challenges. Methods: A 75-year-old woman who underwent an esophagogastroduodenoscopy (EGD) after experiencing worsening dysphagia for food and liquids. The EGD revealed a large epiphrenic diverticulum 36 cm from the upper incisor teeth. The presence of a diverticulum was verified by barium swallow, which revealed a 6 cm diameter epiphrenic diverticulum on the right side of the esophagus. Results: Patient underwent laparoscopic diverticulectomy associated with Heller's myotomy and anterior partial fundoplication. A gastroscope was placed intraoperatively to calibrate the esophagus to prevent stenosis during diverticulectomy, and it was also used to check the integrity of the esophageal wall. The patient tolerated clear liquids on postoperative day 2. Postoperative course was complicated by right pleural effusion and fever managed with antibiotics and pleural drainage. Conclusion: Epiphrenic diverticulectomy in conjunction with management of the underlying motor dysfunction and avoidance of gastroesophageal reflux disease is an effective procedure. Laparoscopy is considered the approach of choice for the majority of patients. Endoscopic assistance during surgery can help the identification of the diverticulum and verify the integrity of the staple line.

Symptomatic Epiphrenic Diverticulum in an Older Patient Successfully Treated Nonsurgically.

Epiphrenic diverticulum is a rare condition commonly diagnosed in middle-aged adults. Symptoms include dysphagia and regurgitation, which are associated with underlying esophageal motility disorders. We herein report a 93-year-old woman with dysphagia diagnosed with symptomatic epiphrenic diverticulum by computed tomography, esophagogastroduodenoscopy, and esophagography. The patient was successfully treated non-surgically without any complications. This case demonstrates that conservative treatment is an option for older high-risk patients.