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.

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.

A Rare Case of Bleeding Epiphrenic Esophageal Diverticulum From Arteriovenous Malformations.

Epiphrenic esophageal diverticula (EED) is a rare condition that usually presents with dysphagia in patients with a known motility disorder. In this article, we present a unique case of EED presenting with hemoptysis with clinical workup negative for any pulmonary pathology. Esophagogastroduodenoscopy revealed arteriovenous malformations within the EED successfully managed with argon plasma coagulation (APC), leading to a resolution of the patient's symptoms.

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.

Operative technical tricks and 12-month outcomes of diverticular peroral endoscopic myotomy (D-POEM) in patients with symptomatic esophageal diverticula.

BACKGROUND: Submucosal tunneling diverticular septotomy by diverticular peroral endoscopic myotomy (D-POEM) has emerged as an alternative to surgery for symptomatic esophageal diverticula, but its medium to long-term outcomes are currently unexplored. METHODS: D-POEM for patients with symptomatic esophageal diverticula was prospectively studied to assess its safety and the 12-month outcomes. RESULTS: 25 patients (72 % male; median age 61 years [range 48 - 88]) with a Zenker's diverticulum (n = 20) or epiphrenic diverticulum (n = 5) were included. Major indications were dysphagia, recurrent bronchoaspiration, and foreign body sensation in 20 patients (80 %), with a mean symptom duration of 2.5 years (range 1 - : 4). Complete submucosal tunneling septotomy was achieved in a mean of 36 minutes (range 25 - : 45), with 100 % technical success. The median hospitalization was 5 days (range 4 - : 10). The mean (standard deviation) Eckardt Score improved significantly from 13.2 (1.0) at baseline to 3.2 (1.4) at 12 months (P < 0.001) with clinical success in 19/22 patients (86 %) and no long-term adverse events. CONCLUSIONS: D-POEM appears safe and durable in patients with esophageal diverticula. Further multicenter studies with a larger patient cohort are warranted.

Safety and efficacy of submucosal tunneling endoscopic septum division for epiphrenic diverticula.

BACKGROUND: Symptomatic epiphrenic diverticula are mostly treated with laparoscopic diverticulectomy. Our study aimed to demonstrate the safety and efficacy of submucosal tunneling endoscopic septum division (STESD) for treatment of symptomatic epiphrenic diverticula. METHODS: Data from patients with epiphrenic diverticula who had undergone STESD were retrospectively reviewed. The parameters analyzed were the modified Eckardt score, total procedure time, length of hospital stay (LOS), number of clips used, adverse events, and patient satisfaction. RESULTS: A total of eight patients (5 men; mean [standard deviation (SD)] age 66.25 [7.17] years) were enrolled in our study. The mean (SD) size of epiphrenic diverticula was 3.68 (1.59) cm. The mean (SD) procedure time was 52.87 (22.47) minutes, with a median number of six clips being applied. The modified Eckardt score significantly decreased post-procedure (P < 0.001). The mean (SD) LOS was 5.87 (0.83) days. No adverse events or symptom recurrences were reported. CONCLUSION: STESD is a safe and effective technique to be performed in the submucosal tunnel for the management of patients with epiphrenic diverticula.

Ultrasonography of Extrathyroidal Diseases Mimicking Intrinsic Thyroid Lesions.

Some localized or multisystem diseases as well as congenital anomalies occasionally involve thyroid and unusual findings will be identified during thyroid ultrasonography. Recognition of these entities will minimize unnecessary complementary examination and lead to appropriate management for patients. Therefore, we aim to review sonographic features of these extrathyroidal diseases that affect thyroid in adults. Our review derives from cases diagnosed in our hospital and published literature, with pictures accessible using as illustration. These disorders included intrathyroidal parathyroid adenoma, intrathyroidal cystic findings of nonthyroid origin, metastases to the thyroid, esophageal diverticulum, paratracheal air cysts, and ossification of anterior longitudinal ligament.

Killian-Jamieson diverticulum: real-time sonographic findings.

Killian-Jamieson diverticulum (KJD) is a pharyngoesophageal diverticulum that can be observed during a neck ultrasound examination. Because of its position, it is frequently misinterpreted as a thyroid nodule. We present a case of an incidental finding of KJD, where changes in shape during dynamic scanning led to the correct diagnosis, preventing from invasive procedures such as fine needle aspiration.

Killian-Jamieson Diverticulum: Cervical Oesophageal Diverticulum.

Killian-Jamieson (K-J) diverticulum is an outpouching from the lateral wall of the proximal cervical oesophagus and is less commonly encountered compared to Zenker's diverticulum (ZD). These diverticulae arise between the fibers of the cricopharyngeus muscle superiorly and longitudinal muscle of the oesophagus inferiorly. In this report we present a case of a symptomatic Killian Jamieson diverticulum and review the clinical presentation, differential diagnosis and radiological findings that distinguish it from the more common Zenker's diverticulum.

Modern pathophysiology and treatment of esophageal diverticula.

INTRODUCTION: Esophageal diverticula are rare. They may occur in the pharyngoesophageal area (Zenker's), midesophagus, or distally (epiphrenic). A motility disorder (either at the level of the esophageal sphincters or body) is frequently associated with esophageal diverticula. The risk of malignant transformation is low. METHODS: A literature search was performed using Medline/PubMed database. RESULTS: The treatment of esophageal diverticula must be based on the pathophysiology and natural history of the disease: (a) asymptomatic diverticula do not need a specific treatment, (b) small diverticula may be left in place and not resected, (c) medium-size diverticula may be either treated by diverticulectomy, diverticulopexy, or esophagodiverticulostomy in case of pharyngoesophageal diverticula, (d) resection is probably the ideal therapy for larger diverticula, and (e) a myotomy should always be included to the procedure. CONCLUSIONS: Due to its rarity, esophageal diverticula must be treated by esophageal surgeons since even in experienced hands the complication rate can be significant.

[Surgical treatment of esophageal diverticula]. / Tratamentul chirurgical al diverticulilor esofagieni.

The aim of this paper is to evaluate the methods and therapeutic principles of esophageal diverticula pathology. We analyze the main pathological mechanisms which establish the therapeutic attitude linked with a complex pretherapeutic evaluation. In our study we enrolled 12 patients operated between 2001-2009 for esophageal diverticula with different topography. In this period of time there were much more patients diagnosed with this pathology, but the need for surgery was establish very tight regarding the actual practical guide which impose the identification and interception of physiological mechanisms by the surgical procedure. We highlight the particular technical details, as well as the important differences of postoperatory complications according to the topography of the diverticula pouch.

High resolution manometry findings in patients with esophageal epiphrenic diverticula.

The pathophysiology of esophageal epiphrenic diverticula is still uncertain even though a concomitant motility disorder is found in the majority of patients in different series. High resolution manometry may allow detection of motor abnormalities in a higher number of patients with esophageal epiphrenic diverticula compared with conventional manometry. This study aims to evaluate the high resolution manometry findings in patients with esophageal epiphrenic diverticula. Nine individuals (mean age 63 ± 10 years, 4 females) with esophageal epiphrenic diverticula underwent high resolution manometry. A single diverticulum was observed in eight patients and multiple diverticula in one. Visual analysis of conventional tracings and color pressure plots for identification of segmental abnormalities was performed by two researchers experienced in high resolution manometry. Upper esophageal sphincter was normal in all patients. Esophageal body was abnormal in eight patients; lower esophageal sphincter was abnormal in seven patients. Named esophageal motility disorders were found in seven patients: achalasia in six, diffuse esophageal spasm in one. In one patient, a segmental hypercontractile zone was noticed with pressure of 196 mm Hg. High resolution manometry demonstrated motor abnormalities in all patients with esophageal epiphrenic diverticula.

Epiphrenic diverticulum of the esophagus. From pathophysiology to treatment.

INTRODUCTION: Epiphrenic diverticula of the esophagus are usually associated with a concomitant esophageal motility disorder. The main symptoms experienced by patients are dysphagia, regurgitation, and aspiration. The best surgical treatment is still debated, particularly the need for a myotomy in addition to resection of the diverticulum. DISCUSSION: While for many decades the traditional approach was through a left thoracotomy, more recently, minimally invasive techniques have been successfully used and are now the procedure of choice in most cases. The purpose of this article was to review (a) the current understanding of the pathophysiology of epiphrenic diverticulum, (b) how this understanding should guide the surgical treatment, and (c) the surgical approach.

Lower oesophageal sphincter dysfunction is part of the functional abnormality in epiphrenic diverticulum.

BACKGROUND: The pathophysiology and management of epiphrenic diverticula remain controversial. This study investigated the underlying functional abnormalities and long-term results of surgical treatment. METHODS: Patients with symptoms and epiphrenic diverticula who had undergone long myotomy and Belsey Mark IV fundoplication were reviewed retrospectively. They were assessed before and after surgery by radiology, functional testing and endoscopy, and compared with a group of 40 normal volunteers. RESULTS: The study included 23 consecutive symptomatic patients who had surgery, 20 of whom had oesophageal spastic disorders. Lower oesophageal sphincter (LOS) incoordination was considered the most constant functional abnormality (P < 0.001). After operation oesophageal diameter increased, contraction pressures decreased and peristalsis was reduced. LOS resting and gradient pressures decreased (P = 0.001). Despite unchanged acid exposure values, endoscopy revealed increased mucosal damage after operation (P = 0.003). New columnar-lined metaplasia was documented in eight patients (P = 0.013). Symptoms had decreased after a median of 61 months (P = 0.001). CONCLUSION: Epiphrenic diverticulum was associated with spastic dysfunction and LOS abnormalities. A long myotomy including the LOS relieved functional obstruction and symptoms, but partial fundoplication did not prevent reflux damage.

Esophageal manometric characteristics and outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication for epiphrenic diverticula.

PURPOSE: The purpose of this study is to characterize the esophageal motor and lower esophageal sphincter (LES) abnormalities associated with epiphrenic esophageal diverticula and analyze outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication. METHODS: The endoscopic, radiographic, manometric, and perioperative records for patients undergoing laparoscopic esophageal diverticulectomy, anterior esophageal myotomy, and partial fundoplication from 8/99 until 9/06 were reviewed from an Institutional Review Board (IRB)-approved outcomes database. Data are given as mean +/- standard deviation (SD). RESULTS: An esophageal body motor disorder and/or LES abnormalities were present in 11 patients with epiphrenic diverticula; three patients were characterized as achalasia, one had vigorous achalasia, two had diffuse esophageal spasm, and five had a nonspecific motor disorder. Presenting symptoms included dysphagia (13/13), regurgitation (7/13), and chest pain (4/13). Three patients had previous Botox injections and three patients had esophageal dilatations. Laparoscopic epiphrenic diverticulectomy with an anterior esophageal myotomy was completed in 13 patients (M:F; 3:10) with a mean age of 67.6 +/- 4.2 years, body mass index (BMI) of 28.1 +/- 1.9 kg/m2 and American Society of Anesthesiologists (ASA) 2.2 +/- 0.1. Partial fundoplication was performed in 12/13 patients (Dor, n = 2; Toupet, n = 10). Four patients had a type I and one patient had a type III hiatal hernia requiring repair. Mean operative time was 210 +/- 15.1 min and mean length of stay (LOS) was 2.8 +/- 0.4 days. Two grade II or higher complications occurred, including one patient who was readmitted on postoperative day 4 with a leak requiring a thoracotomy. After a mean follow-up of 13.6 +/- 3.0 months (range 3-36 months), two patients complained of mild solid food dysphagia and one patient required proton pump inhibitor (PPI) for gastroesophageal reflux disease (GERD) symptoms. CONCLUSION: The majority of patients with epiphrenic esophageal diverticula have esophageal body motor disorders and/or LES abnormalities. Laparoscopic esophageal diverticulectomy and anterior esophageal myotomy with partial fundoplication is an appropriate alternative with acceptable short-term outcomes in symptomatic patients.

Assessment of a pathophysiology-directed treatment for symptomatic epiphrenic diverticulum.

Epiphrenic diverticulum is a rare disease associated with distal esophageal obstruction and a weakened muscularis propria. We have adhered to an operative strategy of excision (diverticulectomy), repair of esophageal wall, and relief of functional and mechanical obstruction. We sought to assess this pathophysiology-directed treatment strategy. From 1987 to 2005, 44 patients underwent surgery for epiphrenic diverticulum. Diverticulectomy, repair, and relief of distal obstruction was performed in 35 (80%) and esophagectomy in nine (10%). Outcome (symptoms, diet, subsequent therapies and morbidity) was assessed by follow-up. Forty of 44 patients had preoperatively identifiable esophageal obstruction (91%). Distal obstruction was functional in 32 patients and mechanical in 24; these conditions coexisted in 16. After surgery, there were no in-hospital deaths; 15 patients experienced 22 in-hospital complications. Survival was 90% at 5 years and 72% at 10 years. Symptoms improved in most patients (P = 0.0004), except for gastroesophageal reflux; new symptoms of gastroesophageal reflux occurred in 9/27 (33%) without this symptom preoperatively. Diet was less restricted postoperatively (P < 0.0001). Of 35 patients undergoing diverticulectomy, three (8.6%) required dilatation and two (6%) reoperation; 6/9 esophagectomy patients required dilatations. Preoperative assessment must include evaluation for mechanical obstruction. Adherence to a pathophysiology-directed operative strategy is safe and will improve the symptoms of most patients, with little need for reintervention. However, occasional patients will experience new symptoms, particularly reflux. Esophagectomy is the alternative for patients who are not candidates for diverticulectomy, repair of esophageal wall, and relief of distal obstruction.

Esophageal diverticula: pathogenesis, clinical aspects, and natural history.

It has been gradually accepted that esophageal diverticula result from esophageal motor disorders rather than from primary anatomic abnormalities. Twenty-seven patients with these diverticula were evaluated with respect to pathogenesis, clinical aspects, diagnostic tests, therapy, and natural history for a mean of 27 months of followup. Thirteen diverticula were midesophageal, 11 were situated in the distal third of the esophagus, and 3 were in both regions. Esophageal dysmotility was observed in 85% of patients. Specific esophageal motor disorders were more frequent in association with diverticula of the distal third than in midesophageal diverticula, suggesting that they result from a pulsion mechanism. Traction was the possible mechanism in 27% of midesophageal diverticula. Endoscopic esophagitis was seen in one patient and abnormal acid reflux in 25% of the cases, mainly in patients with distal diverticula. Distal diverticula presented with more severe symptoms than did midesophageal diverticula, and 27% of those required surgical treatment. Patients with midesophageal diverticula seem to have a better prognosis than those with more distal disease.

[Dilemmas arising from surgical treatment of epiphrenic diverticulum]. / Az epiphrenalis nyelocso-diverticulum sebészi kezelésének dilemmái.

INTRODUCTION: Epiphrenic diverticulum cannot be considered a primary anatomical alteration, there is a manometrically verifiable motility disturbance in the background. OBJECTIVES: To determine the place, type and time of surgical solution in the treatment. PATIENTS: Between 1999 and 2004 seven patients were treated for epiphrenic diverticulum causing complaints. Average age was 61 years, and the leading symptom was dysphagia and regurgitation. Motility abnormalities characteristic of achalasia in four cases, hypertensive LES in three cases, and incompetent and normal LES, and diffuse esophageal spasm in one patient each could be revealed. The size of diverticuli varied between 5-9 cm. RESULTS: In four cases transthoracic diverticulectomy myotomy and partial antireflux plasty, in two cases esophagus resection, and in the case of one patient myotomy and fundoplication was performed. In the removed diverticuli an ulcer and a malignant transformation in one case each was detected. No major complications could be observed. Six patients are completely satisfied with the operation, only one reported well tolerable occasional regurgitations. CONCLUSION: Even in the era of minimal invasive surgery the traditionally performed, combined - diverticulectomy, myotomy, fundoplication - operative solution should be considered the gold standard. Surgical intervention is justified even for accidentally discovered symptomless patients, due to the considerable potential complications of the disease.