Large symptomatic esophageal diverticulum.

A 72-year-old woman was referred from primary care to the gastroenterology clinic because of heartburn and occasional dysphagia for the last 8 years, with some isolated food regurgitation events and no other warning signs; she is currently asymptomatic on omeprazole. Gastroscopy revealed a dilated esophagus and food remnants with inability to reach the gastric lumen, which led to the suspicion of achalasia. The study was completed with pH-metry, which found no pathological reflux; esophageal manometry, with absence of esophageal motor abnormalities; and barium swallow, which revealed a large diverticulum on the posterior wall of the lower third of the esophagus, which had food remnants but no other changes or evidence of achalasia. Given these findings, a repeat gastroscopy was carried out that revealed a large diverticulum in the distal third of the esophagus that occluded 50 % of the esophageal lumen, with a length of 4-5 cm and abundant semi-liquid food remnants; upon aspiration of the latter a whitish mucosa with erythematous areas was revealed, as well as a 1.5-cm sliding hiatal hernia. No changes were found on advancing to the second duodenal portion. In view of the above findings and symptoms, the patient was referred to the surgery department to be evaluated for diverticulectomy.

A superficial esophageal cancer with a diverticulum cured by endoscopic submucosal dissection.

Esophageal diverticulum are rare. However, Esophageal cancer that involves diverticula is relatively rare. Here we reported a rare case of a superficial esophageal cancer with an esophageal diverticulum, which was invisible before the endoscopic submucosal dissection. The cancer was successfully removed by ESD with no perforation.

Over-The-Scope clip closure of an acquired bronchoesophageal fistula secondary to an esophageal diverticulum.

Esophagorespiratory fistula is a rare entity that occurs as a result of malignant and non-malignant causes. This condition is associated with high morbidity and mortality. Surgical repair has traditionally been the most common treatment and self-expandable metal stent are the first choice among non-surgical techniques. Here, we report a non-malignant bronchoesophageal fistula secondary to an esophageal diverticulum that was successfully closed using an over-the-scope clip.

Treatment of Achalasia and Epiphrenic Diverticulum.

BACKGROUND: Epiphrenic diverticulum (ED) is a pulsion pseudodiverticulum found in the distal 10 cm of the esophagus. Motility disorders are present in the majority of patients with ED explaining the pathophysiology of this rare disease. Achalasia is the most common underlying disorder. We present a review on the diagnosis and management of ED in the setting of achalasia. METHODS: Literature review. RESULTS: Symptoms are most related to the underlying motility disorder. The diagnostic workup should always include an upper digestive endoscopy and a barium esophagogram. Esophageal manometry identifies the motility disorder in most patients. Therapeutic options include laparoscopic, thoracoscopic and endoscopic procedures. While a myotomy must always be performed, diverticulectomy is not always necessary. CONCLUSIONS: Epiphrenic diverticulum is a rare condition whose pathophysiology involves an underlying motility disorder-achalasia in most cases. Symptoms usually include dysphagia, regurgitation, heartburn, and respiratory complaints and correlate with the motility disorder rather than the diverticulum per se. Upper digestive endoscopy and barium esophagogram are needed for the diagnosis-manometry may add useful information but is not imperative for the treatment. Laparoscopic Heller myotomy with a partial fundoplication is the procedure of choice, with satisfactory symptom relief and several advantages over the thoracic approach. Diverticulectomy may be performed in selected patients. Peroral endoscopic myotomy (POEM) are novel techniques, effective and minimally invasive that can be an option for patients unfit for surgery.

[Update Esophageal Diverticula]. / Update Ösophagusdivertikel.

Update Esophageal Diverticula Abstract. Esophageal diverticula are rare diseases typically associated pathophysiologically with esophageal dysmotility. The most common location (about 80%) is pharyngo-oesophageal. The therapy must be adapted to the location, the size, the symptoms and also the individual perioperative risk of the patient. In this context, following Herbella et al. [1] summarize that a) asymptomatic diverticula do not require therapy; b) small (< 1cm) diverticula do not usually need to be resected; c) medium-sized (1-3cm) and large (> 4cm) diverticula should be treated either by resection, pex, invagination or (for Zenker's diverticulum) by transoral diverticulo-esophagostomy, and d) a simultaneous myotomy should always be performed. Due to the rarity of esophageal diverticula and due to the wide range of therapeutic options, the expertise required for an individual therapy concept is often not available even in larger clinics, which is why we recommend treatment in a reference center. In our opinion, the counseling and treatment of patients with esophageal diverticula by an experienced interdisciplinary team using all the options of today's established endoscopic and surgical procedures is the prerequisite for a low-complication management of this unusual clinical picture.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

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.

Endoscopic Transversal Incision and Longitudinal Septostomy (TILS): An Updated Technique for Treating Esophageal Diverticulum.

An esophageal diverticulum is a protruding pouch in a weak portion of the esophageal lining. Previously, our team had reported an endoscopic tunneling technique (submucosal tunneling endoscopic septum division) for diverticulum treatment. However, it does not perform well for the diverticulum located in the upper esophagus, where most diverticula are located. Herein, we report a new endoscopic technique, called endoscopic transversal incision and longitudinal septostomy (TILS). TILS provides both larger operational spaces and complete septostomy and can be performed on most types of diverticula, including Zenker's diverticulum.

Not always eosinophilic esophagitis - intramural pseudodiverticulosis of the esophagus - a case report and literature review.

BACKGROUND: Intramural pseudodiverticulosis of the esophagus (EIPD) is a rare disease leading to dysphagia, chest pain, and weight loss. The diagnosis is difficult, and the disease can be confounded with eosinophilic esophagitis (EoE). We present a patient with esophageal intramural pseudodiverticulosis and a literature review. CASE REPORT: The 45-year-old white caucasian woman with a history of nicotine and alcohol abuse had progressive hoarseness and severe dysphagia for solid food. Esophagogastroduodenoscopy (EGD) showed proximal esophageal stenosis, thrush esophagitis, and mucosal alteration with trachealization suspicious of EoE. However, repeated bouginage EGD and barium swallow revealed typical signs of esophageal intramural pseudodiverticulosis (EIPD). The patient was treated successfully by bougingage, acid suppression, and antifungal therapy. The literature analysis revealed the characteristics of EIPD according to age, sex, risk factors, and therapy modalities. CONCLUSION: The case report and the literature overview suggest that EIPD can be confounded with EoE.

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.

The oesophageal diverticulum of Dirioxa pornia studied through micro-CT scan, dissection and SEM studies.

BACKGROUND: Dirioxa pornia (Diptera, Tephritidae) (Island fly) is an Australian native species related to a number of pestiferous fruit flies but, unlike many of the pest species, has not been studied extensively due to its non-pest status. However, due to D. pornia's apparent reliance on the bacteria for survival it is an ideal species to undertake studies into interaction between Tephritid species and bacteria associated with the intestinal tract. The oesophageal diverticulum, which is a blind-ended protrusion of the oesophagus, has been studied, described and characterised in many other Tephritid species. Unlike many other species where the oesophageal diverticulum has been observed the organ was only observed in male D. pornia. It is speculated that this sexual dimorphism the organ may be the primary location to host beneficial bacteria in the involved in the production of the nuptial gift and the mating success of this Tephritid species. In case of D. pornia, however, no study on any area of the digestive system has been conducted. This study was conducted to locate and characterize the oesophageal diverticulum in D. pornia. A virtual dissection of the alimentary tract was made through micro-computer tomography studies. These studies were followed by dissection and scanning microscopy studies to elucidate the presence of bacteria. RESULTS: The oesophageal diverticulum of D. pornia is part of the foregut and distends from the oesophagus within the head of the fly. The shape of the oesophageal diverticulum corresponds with the Ceratitis type. Scanning microscopy studies of the oesophageal diverticulum show rod-shaped bacterial cells residing along with yeast cells in the lumen. The organ was only observed in male specimens. CONCLUSIONS: This study classifies the oesophageal diverticulum of D. pornia under the "Ceratitis type" of oesophageal diverticula in Tephritid species. The study also proves that micro-CT scanning is possible to locate soft tissues in Tephritid species and the Avizo® Fire software can be successfully used to visualize 3 dimensional (3D) images from x-rays. The methods used in this experiment can be used in future studies for visualising soft tissues of adult Tephritid species through micro tomography. There is sexual dimorphism with the organ only found in males. Finally this study shows that bacteria are present in the oesophageal diverticulum of D. pornia.

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.

Giant esophageal diverticulum as a new clinical indication for endoscopic gastrostomy.

Persistent mechanical or functional dysphagia is the most common clinical indication for endoscopic gastrostomy (PEG), however less common conditions may justify prolonged enteral feeding to avoid malnutrition and prevent aspiration. The authors report the case of a 76 year old man referred to the artificial feeding outpatient clinic presenting dysphagia, malnutrition and several episodes of aspiration pneumonia. Upper endoscopy showed a giant esophageal diverticulum, ineffective peristalsis and transient lumen narrowing. X-ray and CT scan confirmed a 9cm long diverticulum. Due to a high surgical risk and unsuitability of endoscopic therapy, the patient underwent PEG, which solved aspiration and improved nutritional status. Dysphagia and aspiration due to giant esophageal diverticula emerges as a new clinical indication for PEG in malnourished patients with respiratory aspiration, not previously reported in the literature.