MSCT study for adult esophageal diverticulum with secondary broncho-esophageal fistula.

BACKGROUND: Broncho-esophageal fistula (BEF) secondary to esophageal diverticulum is a rare clinical condition, which is often misdiagnosed for a long time. The aim of our study is to summarize and clarify the advantages of MSCT in diagnosing BEF secondary to esophageal diverticulum. METHODS: We retrospectively analyzed patients clinically diagnosed with BEF from January 2005 to January 2022 at Jilin University First Hospital. Only those patients with BEF secondary to esophageal diverticulum and complete clinical data met our enrolled standard. All patients' clinicopathologic characteristics and MSCT features were systemically evaluated. RESULTS: 17 patients were eligible for our cohort study, including male 10 and female 7. The patient's mean age was 42.3 ± 12.5. The chronic cough occurred in all seventeen patients and bucking following oral fluid intake was documented in nine patients. MSCT distinctly suggested the fistulous tract between the bronchi and the esophagus in all patients. The mean diameter of the orifices in the wall of the esophagus was 4.40 ± 1.81 mm. The orifice in the midthoracic esophagus side was 15 cases and 2 cases at the lower thoracic esophagus. The involved bronchus included 13 cases at the right lower lobe bronchus, 1 at the right middle lobe bronchus and 3 at the left lower lobe bronchus. The contrast agent was observed in the pulmonary parenchyma in 10 of 13 patients who underwent esophagogram. No definite fistula was observed in 3 of 11 who underwent gastroscopy, while the intra-operative findings supported the existence of fistula. CONCLUSIONS: BEF secondary to esophageal diverticulum tends to occur between the midthoracic esophagus and the right lower lobe bronchus. Compared with esophagography and gastroscopy, MSCT shows more comprehensive information about the fistulous shape, size, course and lung involvement, which are helpful for establishing diagnosis and guiding subsequent treatment.

Characteristics of Esophageal Motility and Associated Symptom Profiles in Patients with Esophageal Diverticulum: A Study Based on High-Resolution Impedance Manometry.

BACKGROUND: Esophageal diverticulum (ED) is an uncommon structural disorder with heterogenous manifestations and elusive pathophysiology. Our aim was to investigate esophageal motility and associated symptom profiles in patients with ED based on high-resolution impedance manometry (HRIM). METHODS: Consecutive patients with ED referred to our motility laboratory between 2015 to 2022 were identified in our electronic database. All patients were evaluated based on an upper endoscopy, HRIM, and standardized symptom questionnaires. Patients with ED were further stratified into upper, middle, and lower (epiphrenic) cases. Esophageal motility was evaluated with HRIM and the updated Chicago Classification v4.0. RESULTS: Twenty-four patients with ED (9 upper, 4 middle, and 11 epiphrenic) were analyzed. Patients with ED were generally older (mean: 65 ± 13.3 years) and predominantly women (58.3%). Most ED cases were unilaterally located (95.8%) and left-side predominant (62.5%). Mean symptom duration was 20 months (range: 1-120) and the most common symptoms were dysphagia (70.8%) and regurgitation (37.5%). Erosive esophagitis was noted in 16 patients (69.6%), while barium stasis was noted in 5 patients (20.8%). Fourteen patients (58.3%) were diagnosed with esophageal motility disorders using HRIM, with achalasia being the most common diagnosis (n = 5, 20.8%). Patients with epiphrenic diverticulum had significantly higher symptom scores and achalasia prevalence. CONCLUSION: Patients with ED tended to be older and was associated with a high prevalence of EMD. A multi-disciplinary evaluation, including complete anatomical and motility surveys, may help clarify the underlying pathophysiology and tailor further treatment strategies.

Technical Success in Performing Esophageal High-Resolution Manometry in Patients with an Epiphrenic Diverticulum.

High-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders, yet it can be poorly tolerated and technically challenging. Epiphrenic diverticula (ED) are located in the distal esophagus and are associated with underlying motility disorders. ED patients (2008-2022) were retrospectively compared to achalasia patients (2008-2022) and all other patients (2021-2022) who underwent HRM at a single center. Complete success was defined as at least 7 interpretable swallows including measurements throughout the esophagus into the stomach. HRM studies involving children, previously treated achalasia, and sedation or endoscopic-assistance were excluded. 20 ED patients (mean age 66; 60% female) were compared to 76 achalasia patients and 199 controls. HRM was completely successful in 70.0% of ED patients, 85.5% of achalasia (p = 0.106 vs ED), and 91.0% of controls (p = 0.004 vs ED). Most failures in the ED and achalasia groups were due to inability to traverse the esophagogastric junction (EGJ), while patient intolerance was the main reason in controls. Half of the ED group had motility disorders (25% achalasia, 15% hypercontractile esophagus, 10% absent contractility). Large diverticulum size was inversely associated with technical success compared to small diverticulum size (40% vs 100%, p = 0.013), while the presence of a motility disorder did not significantly affect success (60% vs 88.9%, p = 0.303). In conclusion, ED is a predictor of unsuccessful HRM. This appears to be mainly related to an inability to traverse the EGJ due to the size of the diverticulum. Consideration should be given to alternative means of evaluating motility, such as endoscopy-assisted HRM, given the high likelihood of failure with traditional HRM.

Killian Jamieson Diverticulum, the Great Mimicker: A Case Series and Contemporary Review.

OBJECTIVE: To assess barium esophagram (BAS) as a diagnostic marker for patients with Killian Jamieson diverticula (KJD). METHODS: Prospective, multicenter cohort study of individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative. Patient demographics, comorbidities, radiographic imaging reports, laryngoscopy findings, patient-reported outcome measures (PROM), and operative reporting were abstracted from a REDCap database and summarized using means, medians, percentages, frequencies. Paired t-tests and Wilcoxon Signed Rank test were used to test pre- to post-operative differences in RSI, EAT-10, and VHI-10 scores. Diagnostic test evaluation including sensitivity, specificity, positive, and negative predictive value with 95% confidence intervals were calculated comparing BAS findings to operative report. RESULTS: A total of 287 persons were enrolled; 13 (4%) patients were identified with confirmed KJD on operative reports. 100% underwent open transcervical excision. BAS has a 46.2% (95% confidence interval [CI]: 23.2, 70.9) sensitivity and 97.8% (95% CI: 95.3, 99.0) specificity in detecting a KJD and 50% (95% CI: 25.4, 74.6) positive predictive value but 97.4% (95%CI: 94.8, 98.7) negative predictive value. Preoperatively, patients reported mean (SD) RSI and EAT-10 of 19.4 (9) and 8.3 (7.5) accordingly. Postoperatively, patients reported mean (SD) RSI and EAT-10 as 5.4 (6.2) and 2.3 (3.3). Both changes in RSI and EAT-10 were statistically significant (p = 0.008, p = 0.03). CONCLUSION: KJD are rare and represent <5% of hypopharyngeal diverticula undergoing surgical intervention. Open transcervical surgery significantly improves symptoms of dysphagia. BAS has high specificity but low sensitivity in detecting KJD. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2110-2115, 2023.

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.

Initial experience in target peroral endoscopic submucosal myotomy combined with septotomy for epiphrenic diverticulum.

The epiphrenic esophageal diverticulum is a rare non-malignant condition that is commonly associated with motility disorders. It would normally be treated surgically, but with the advancement of endoscopy techniques, peroral endoscopic myotomy with septotomy (D-POEM) has shown its benefits in coping with the symptoms. We present a case of a 71-year-old woman with increasing symptoms of dysphagia, weight loss and imaging data showing a large epiphrenic diverticulum. We treated her using peroral endoscopic myotomy combined with septotomy of the diverticular septum. The procedure showed excellent results with reducing the amount of contrast materials retained in it, improving the quality of life of the patient, and increasing her weight. There were minimal adverse events and no perforations or severe adverse effects occurred. D-POEM is a new and rapidly evolving procedure that is proving to be a safe and effective method of treating epiphrenic esophageal diverticulum.

Long-term outcome of patients with epiphrenic diverticula: A retrospective single-center analysis over 20 years.

BACKGROUND: Epiphrenic diverticula are extremely rare. Evidence-based treatment recommendations are scarce. The primary study outcome was to examine whether surgical treatment in patients with epiphrenic diverticula leads to improved quality of life by outweighing the perioperative risks compared with conservative treatment. METHODS: All patients with an epiphrenic diverticula at our institution between 2001 and 2021 were retrospectively reviewed and followed-up using a specific questionnaire, including the Eating Assessment Tool, and Gastrointestinal Quality of Life Index quality-of-life scores. RESULTS: Of 51 patients with epiphrenic diverticula, 28 had surgery and 23 had conservative treatment. The most common symptom at presentation was dysphagia. Although 16 patients underwent open surgery, 12 had minimally invasive procedures. A prophylactic stent was applied intraoperatively in 6 patients. The morbidity rate in surgically treated patients was 50% (14/28), with a leakage in 43% (12/28; 33% for prophylactic stenting). Mortality was nil. At a median follow-up of 139 months, patients with surgery had better outcomes than those without (ie, less dysphagia [6/12 vs 11/12; P = .025]), a less likely pathologic Eating Assessment Tool score (4/12 vs 9/12; P = .041), and a nonsignificant better Gastrointestinal Quality of Life Index score (122 vs 112; P = .929). The rate of recurrence/progression of symptoms was significantly higher for conservatively treated patients (11/18 vs 6/27 for any surgery; P = .008), as well as for patients with minimally invasive procedure (5/12 vs 1/15 for open surgery; P = .030). CONCLUSION: Despite the high perioperative morbidity, surgical treatment of epiphrenic diverticula leads to an improved long-term quality of life and lower recurrence rates than conservative treatment.

Submucosal tunneling endoscopic septum division for esophageal diverticulum with a median follow-up of 39 months: a multicenter cohort study.

BACKGROUND AND AIMS: Submucosal tunneling endoscopic septum division (STESD) is an endoscopic minimally invasive technique for treating esophageal diverticulum. The objectives of this study were to evaluate the safety and efficacy of STESD and its impact on patients' quality of life. METHODS: This study included consecutive patients who underwent STESD for esophageal diverticulum from April 2016 to August 2020 in 2 centers (Zhongshan Hospital, Fudan University and Tianjin First Central Hospital). Esophagogram and endoscopic examination were performed before STESD and 30 days after STESD. Patients completed the 36-item Short Form survey (SF-36) before STESD and 1 year after surgery. Clinical symptoms were assessed via telehealth every 6 months until August 2021. Costamagna and Eckardt scores were used to evaluate changes in symptoms. RESULTS: Twenty-one patients were included. Mucosal injury 1 to 2 cm below the septum occurred in 2 patients. No severe surgical adverse events were observed. Median duration of follow-up was 39 months (range, 12-63). Total SF-36 scores increased from 118.7 ± 18.6 before STESD to 132.4 ± 9.1 at 1 year after the procedure (P = .007). SF-36 subscales of general health (P = .002), vitality (P = .004), social functioning (P = .030), and mental health (P = .020) improved significantly after STESD. The mean Costamagna score decreased from 3.83 ± 1.33 to 1.67 ± 1.51 (P = .010), whereas the mean Eckardt score decreased from 3.50 ± .90 to 1.25 ± 1.76 (P = .002). One patient developed symptom recurrence at 10 months after STESD. CONCLUSIONS: STESD is a safe and valid endoscopic minimally invasive surgery for esophageal diverticulum, which can reduce symptoms and improve quality of life.

Congenital true oesophageal diverticulum: a report and review of the literature.

Oesophageal diverticulum occurring secondary to motility disorders or gastro-oesophageal reflux disease (GERD) is common in adults but true congenital oesophageal diverticula are rare in infants and children. We present a case of a toddler boy who presented with dysphagia and vomiting after feeds after weaning was attempted starting at 6 months of age. Barium esophagogram revealed a diverticulum in the upper one-third of the oesophagus within the thoracic cavity. The child underwent multiple interventions elsewhere without definitive surgery that highlights the rarity of this condition. Thoracotomy and repair were performed by us with a satisfactory outcome. The review of the literature on the clinical presentation and management of this rare condition has been discussed, highlighting similar reported cases.

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.

A Giant Esophageal Epiphrenic Diverticulum Causing Dysphagia, Fungal Infection and Aspiration Pneumonia in an Elderly Patient.

Esophageal epiphrenic diverticulum is a rare condition. We present a case of a 70-year male with no known comorbidities who presented with dysphagia, cough, fever, and weight loss for 3 months. CT chest with contrast showed an out-pouching arising from the distal dorsal oesophagus, 15.6 cm long with 0.9 cm neck, containing food particles causing compression and consolidation of adjacent lung segments. His upper gastrointestinal endoscopy showed a large diverticulum arising at 30 cm from incisors with overlying ulcerated and necrotic mucosa. A biopsy of diverticular mucosa showed fungal hyphae and spores and was negative for malignancy. The patient was given antifungals and showed significant improvement of symptoms but considering the huge size of the diverticulum, he was referred to a thoracic surgeon. Key Words: Epiphrenic diverticulum, Dysphagia, Aspiration pneumonia, Fungal infection.

Peroral Endoscopic Myotomy for the Treatment of Esophageal Diverticula: A Systematic Review and Meta-analysis.

BACKGROUND: There is limited evidence on the efficacy of peroral endoscopic myotomy (POEM) in patients with esophageal diverticula. AIMS: This meta-analysis aimed to assess the efficacy and safety profile of POEM in patients with Zenker (ZD) and epiphrenic diverticula. METHODS: With a literature search through August 2020, we identified 12 studies (300 patients) assessing POEM in patients with esophageal diverticula. The primary outcome was treatment success. Results were expressed as pooled rates and 95% confidence intervals. RESULTS: Pooled rate of technical success was 95.9% (93.4%-98.3%) in ZD patients and 95.1% (88.8%-100%) in patients with epiphrenic diverticula. Pooled rate of treatment success was similar for ZD (90.6%, 87.1%-94.1%) and epiphrenic diverticula (94.2%, 87.3%-100%). Rates of treatment success were maintained at 1 year (90%, 86.4%-97.4%) and 2 years (89.6%, 82.2%-96.9%) in ZD patients. Pooled rate of symptom recurrence was 2.6% (0.9%-4.4%) in ZD patients and 0% in patients with epiphrenic diverticula. Pooled rates of adverse events and severe adverse events were 10.6% (4.6%-16.6%) and 3.5% (0%-7.4%) in ZD and 8.4% (0%-16.8%) and 8.4% (0%-16.8%) in epiphrenic diverticula, respectively. CONCLUSION: POEM represents an effective and safe therapy for the treatment of esophageal diverticula.

Transmucosal diverticular myotomy for the treatment of oesophageal diverticula associated with spastic motility disorders.

Thoracic oesophageal diverticula are often associated with spastic motility disorders. Despite correction of the underlying motility disorder, in a subgroup of patients, symptoms persist, primarily regurgitation. Surgical diverticulectomy is then proposed; however, as the approach is thoracoscopic or via thoracotomy, it is associated with significant morbidity and cost. Descriptions of endoscopic techniques for the treatment of symptomatic midoesophageal diverticula are few. We propose the novel technique of diverticular myotomy (DM) to treat this disorder. In this case series, we describe two patients who successfully underwent DM with no adverse outcomes and excellent clinical results at 24-month follow-up.