Esophageal intramural pseudodiverticulosis.

Esophageal intramural pseudodiverticulosis (EIPD) is a disease of unknown pathogenesis characterized by usually systemic, cystic dilatation of the excretory ducts of esophageal submucosal glands. In this article, I review the epidemiology, clinical manifestations, endoscopic findings, esophagographic findings, and histopathology of EIPD. I also discuss the etiology and possible pathogenesis of EIPD based on my experiences with this disease and a review of the literature. EIPD usually presents with dysphagia in middle-aged individuals. It is often complicated with secondary infections, most commonly candidiasis. On esophagography, EIPD is delineated as small, multiple, flask-shaped outward projections within the esophageal wall. In recent years, EIPD has been mainly diagnosed by endoscopic findings of multiple, localized, small mucosal depressions. The orifices of the "pseudodiverticula" periodically open and close, and excrete mucus onto the mucosal surface. On histopathological examination, the luminal surface of dilated ducts in EIPD is covered by multilayered, hyperplastic epithelial cells, but myoepithelial cells in the glandular acini are well preserved. Treatment of EIPD is usually symptomatic therapy, and prevention of the infectious complications is important. The etiology and pathogenesis of EIPD are largely unknown, but functional abnormalities of autonomic nerve fibers innervating the esophageal glands likely play an important role, since the structures of the glands are basically preserved in this disease.

Differences between intentional and accidental ingestion of foreign body in China.

BACKGROUNDS: Previous reports of foreign-body ingestion focused primarily on accidental ingestion and very few studies focused on intentional ingestion of foreign body (FB) in China. Our study aimed to compare the prevalence of different age, gender, types, locations and management of FB ingested between intentional ingestion and accidental ingestion of FB in Northern China. METHODS: A retrospective case series studied all patients with suspected FB ingestion in Digestive Endoscopy Center of Beijing Friendship Hospital, between January 2011 and January 2019. The patients were divided into 2 groups. Group A included the patients who intentionally ingested FBs, and Group B included the patients who accidentally ingested FBs. Patients' database (demographics, past medical history, characteristics of FB, endoscopic findings and treatments) were reviewed. Statistical analyses were conducted using SPSS software. RESULTS: Group A consisted of 77 prisoners, 2 suspects and 11 psychologically disabled persons. Group B consisted of 1020 patients with no prisoners, suspects or psychologically disabled persons. In Group A, there were no food-related foreign bodies, and the majority of FBs were metallic objects (54.44%). However in Group B, food-related FBs were the most common (91.37%). In Group A, 58 cases (64.44%) were located in the stomach, while in Group B, 893 cases (87.55%) were located in the esophagus (P < 0.05). 1096 patients successfully underwent endoscopic removal and 14 failed, including 9 cases in Group A and 5 cases in Group B. The duration of FBs impaction was longer in Group A than that in Group B (P < 0.05). CONCLUSIONS: In our study, the patients who intentionally ingested FB were mainly prisoners, FBs were mostly sharp metallic objects, the duration of FBs impaction was longer, and the rate of successful endoscopic treatment was lower than that of the general population. Attention should be focused on these patients.

Epiphrenic Diverticulum: 20-Year Single-Institution Experience.

Epiphrenic diverticula are pulsion-type outpouchings of the distal esophagus associated with motility disorders. They can present with chronic symptoms of dysphagia, regurgitation, reflux, and aspiration. A prospectively collected surgical outcomes database was queried for patients who underwent surgical treatment of epiphrenic diverticula at a single institution between August 1997 and August 2018. Patient demographics, presenting symptoms, operative intervention, and perioperative data were retrospectively reviewed. Twenty-seven patients with a symptomatic epiphrenic diverticulum were identified. Abnormal esophageal motility was diagnosed in 16 patients (59.2%), most commonly achalasia (29.6%). All patients had a minimally invasive (26 laparoscopic, one thoracoscopic) diverticulectomy with no conversions to open required. Concurrent myotomy was performed in 88.9 per cent patients and anti-reflux procedure in 85.2 per cent patients. There was minimal morbidity with no esophageal leaks, mortalities, or recurrent diverticula noted after 35.8 months of follow-up. Dysphagia was the most common persistent symptom and occurred in 11.1 per cent; overall resolution of symptoms was achieved with surgery in 89.9 per cent of patients. As minimally invasive techniques have advanced, laparoscopic diverticulectomy seems to be an excellent surgical approach for symptomatic epiphrenic diverticula. Long-term resolution of symptoms was achieved in most patients, with a very low complication rate.

Surgical management of esophageal diverticulum: a review of the Nationwide Inpatient Sample database.

BACKGROUND: Esophageal diverticulum is rare in the United States. The mainstay treatment of symptomatic esophageal diverticulum is surgical correction. Much of the available information regarding esophageal diverticulum and its surgical management has been derived from small studies and institutional reviews. Our study objective was to investigate the demographics, perioperative conditions, and predictors of outcomes after surgical treatment of acquired esophageal diverticulum using a nationally representative database. METHODS: A retrospective review using the Nationwide Inpatient Sample database from 2000-2009 was performed for patients with acquired esophageal diverticulum. The patients were stratified into Zenker's diverticulum (ZD) or non-Zenker's diverticulum (NZD) subgroups. The covariates retrieved included age, gender, ethnicity, insurance type, and Charlson comorbidity index. A multivariate analysis was performed to determine the predictors of postoperative morbidity. Discharge-level weights were applied. RESULTS: Overall, a total of 4253 patients met our inclusion criteria, 3197 (75%) with ZD and 1056 (25%) with NZD. In the ZD group, the mean age was 73 ± 12.3 y, and most were men (55%) and white (67%). The mean length of stay was 5.82 ± 8.08 d, and the mortality rate was 1.2%. The most common complication was septicemia or sepsis (2.0%). The black patients had higher odds of postoperative morbidity than the white patients (odds ratio [OR] 2.29, 95% confidence interval [CI] 1.02-5.17). The risk of overall postoperative morbidity was 52% greater for women (OR 1.52, 95% CI 1.01-2.29). An increasing Charlson comorbidity index was an independent predictor of morbidity. In the NZD group, the mean age was 69 ± 13.9 y, and most were also men (51%) and white (63%). The mean length of stay was 8.13 ± 10.56 d, and the mortality rate was 1.6%. The most common complication was air leak (3.1%). The black and Hispanic patients had higher odds of postoperative morbidity than the white patients (OR 1.97, 95% CI 1.05-3.72 and OR 2.37, 95% CI 1.06-5.30, respectively). An increasing Charlson comorbidity index was an independent predictor of morbidity. Compared with laparoscopy, the risk of developing postoperative morbidity was higher with the thoracotomy procedure (OR 7.45, 95% CI 1.11-50.18). CONCLUSIONS: Using a nationally representative database, our study found that female gender, black race, and the presence of comorbidities were associated with increased postoperative morbidity among patients with ZD. Among the patients with NZD, black and Hispanic patients had worse postoperative morbidity than the white patients, and the presence of comorbidities was associated with increased postoperative morbidity. Thoracotomy for the correction of NZD was associated with increased postoperative morbidity compared with the laparoscopic approach.

A retrospective and prospective study of megaesophagus in the parma wallaby (Macropus parma) at the San Diego Zoo, California, USA.

At the San Diego Zoo (California, USA), 22 cases of megaesophagus were diagnosed in the parma wallaby (Macropus parma); a prevalence of 21.1%. Parma wallabies often have no clinical signs until severe and chronic dilation of the esophagus is present. Clinical signs of advanced disease include weight loss, swelling of the cervical region, regurgitation without reswallowing of ingesta, short flight distance, depression, collapse, dyspnea, and sudden death. Retrospective and prospective studies at the San Diego Zoo and a multi-institutional survey in the United States were used to try to determine the cause of megaesophagus. The retrospective study did not identify an etiology. The prospective study revealed megaesophagus and severely delayed esophageal transit time in eight of eight animals. Myasthenia gravis, lead toxicosis, toxoplasmosis, and thyroid disease were eliminated as possible causes. Of 286 living and dead parma wallabies surveyed at other institutions, three cases of esophageal diverticulum and one case of megaesophagus were reported. The cause of megaesophagus in parma wallabies was not determined.

Laparoscopic transhiatal treatment of large epiphrenic esophageal diverticulum.

BACKGROUND: Epiphrenic diverticulum is an uncommon disorder of the distal third of the esophagus. We report the case of a 73-year-old woman with a large symptomatic esophageal epiphrenic diverticulum, diffuse nonspecific esophageal dysmotility, and a hiatal hernia. METHODS: Surgery was indicated by the patient's symptoms, the size of the diverticulum (maximum diameter 10 cm), and the associated esophageal motor disorder. Preoperative study included barium swallow, upper gastrointestinal endoscopy, and esophageal manometry. A laparoscopic transhiatal diverticulectomy associated with a Heller myotomy, hiatoplasty, and a Dor's fundoplication was carried out. The overall operative time was 230 minutes. RESULTS: No intraoperative complications occurred. Gastrografin swallow performed on postoperative day 4 did not show any signs of leakage from the staple line. The postoperative hospital stay was 5 days. The patient was readmitted 10 days after discharge complaining of fever and chest pain. A new Gastrografin swallow demonstrated a small leak from the staple line successfully treated with 3 weeks of total enteral nutrition. CONCLUSION: The laparoscopic approach to epiphrenic diverticulum is feasible. Postoperative Gastrografin swallow is not 100% sensitive in detecting small suture-line leaks if a preexisting esophageal motility disorder is present. In case of late postoperative fever and pleural effusion, a suture-line leak should be suspected. Conservative management of the small suture-line leak should be considered as an effective therapeutic option.

Casos quirúrgicos relavantes: divertículo esofágico: reporte de un caso / Relevant surgical caso: esophageal diverticulum: case report

Los divertículos del esófago, son una patología poco frecuente, por lo que el cirujano tendrá la oportunidad de observar pocos durante su carrera. La incidencia de esta entidad, dentro de la afección quirúrgica del esófago, se calcula alrededor del 2.7%. (1). Se presenta el caso de un paciente con un divertículo esofágico verdadero por tracción, tratado en el Hospital General San Juan de Dios.

Intramural pseudodiverticulosis of the esophagus detected on barium esophagograms: increased prevalence in patients with esophageal carcinoma.

OBJECTIVE: We tested the hypothesis that intramural pseudodiverticulosis of the esophagus is more prevalent in patients with esophageal carcinoma than in randomly selected patients who undergo esophagography for other indications. Such an association would prompt a careful search for carcinoma after esophageal intramural pseudodiverticulosis is found. MATERIALS AND METHODS: Single- and double-contrast esophagograms of 245 patients with esophageal carcinoma were retrospectively reviewed. A control group of 6400 esophagograms obtained for indications other than esophageal carcinoma was also reviewed. The statistical significance of the difference in prevalence of esophageal intramural pseudodiverticula between patients with esophageal carcinoma and the control group was tested using the chi-square test. The significance of difference between the number of esophageal intramural pseudodiverticula in patients with esophageal dilatation and the number in those without dilatation was tested using a small-sample nonparametric test. RESULTS: Intramural pseudodiverticulosis of the esophagus was found in 11 patients with esophageal carcinoma (4.5%) and in six control subjects (0.09%). Intramural pseudodiverticulosis of the esophagus was present opposite the tumor as well as both proximally and distally. The number of cases of intramural diverticulosis in patients with esophageal carcinoma and dilatation was not significantly higher than that in patients with carcinoma but without dilatation (p > .1) CONCLUSION: The prevalence of esophageal intramural pseudodiverticulosis is significantly higher in patients with esophageal carcinoma than in patients who underwent esophagography for other indications (p < .0002). This association implies increased risk of esophageal carcinoma in patients with intramural pseudodiverticulosis. Periodic surveillance of patients with intramural pseudodiverticulosis of the esophagus for esophageal carcinoma may be worthwhile.

[The physiopathology and therapy of esophageal diverticula]. / Fisiopatologia e terapia dei diverticoli esofagei.

The authors report their experience in the management of 14 patients affected by esophageal diverticula and surgically treated (9 had cervical diverticula, 2 had epibronchial diverticula and 3 had epiphrenic diverticula). All these patients underwent a diverticulectomy: in 3 cases the diverticulectomy was associated with a subdiverticular myotomy. In the last three cases the resection of the diverticulum was performed using an automatic stapler. The follow-up of these patients was prolonged for a period of 5 years with clinical, radiographic and endoscopic evaluations performed at 6 monthly intervals. The most recently operated patient has a minimum follow-up of 22 months. There were no operative deaths and none of the patients complained of recurrence of the diverticulum or of the preoperative symptomatology. No significant complications were observed in the postoperative period in the patients who underwent a simple diverticulectomy or in the cases in which a subdiverticular myotomy was associated. The scant number of observed patients does not allow us to draw any conclusion about the necessity maintained by most authors of an associated myotomy. It is however evident that this adjunctive procedure doesn't cause any further difficulty and is not loaded with an increased risk of complications. Finally the authors believe in the usefulness of performing the diverticulectomy with an automatic stapler, these devices allow in fact a considerable reduction of the surgical time and prevent dangerous contaminations of the operative field.

Management of epiphrenic esophageal diverticula. A fifteen-year experience.

Epiphrenic esophageal diverticula represent an unusual cause of dysphagia, pain, and weight loss. Although commonly associated with motility disorders, distal esophageal diverticula also have been associated with reflux strictures or other lesions. To determine the most appropriate diagnostic evaluation and operative approach, we reviewed the recent 15-year experience with epiphrenic esophageal diverticula at our institution. Over the study period, 18 patients were diagnosed with pulsion epiphrenic diverticula. Nine patients (50%) with symptomatic diverticula were referred for surgical management. All referred patients were evaluated with preoperative manometry, endoscopy, and contrast esophagography. Diverticulectomy was performed via posterolateral thoracotomy in all patients, combined with myotomy in the 6 patients (67%) with abnormal manometric results and in 2 patients with normal manometric results. The third patient with normal manometric results underwent simple diverticulectomy. There was no operative mortality. One complication, a small esophageal leak, was managed successfully by early reoperation. All patients were free of dysphagia at discharge. Follow-up was obtained for 17 patients (94%) ranging from 3 months to 12 years. Good to excellent results (measured by relief of symptoms, weight gain, and absence of clinical recurrence) were seen in all 9 surgical patients; 6 of 9 nonsurgical patients remained or became symptomatic. This experience demonstrates the efficacy of surgical management of symptomatic epiphrenic esophageal diverticula. Diverticulectomy combined with selective myotomy permits excellent operative results and resolution of associated symptoms.

Divertículos faringoesofágicos / Pharyngoesophageal diverticula

Se analizan 77 casos de divertículos faringoesofágicos operados entre l959 y l988. Hasta l968 se trataron l6 pacientes con diverticulectomía simple y desde esa fecha, 58 con diverticulectomía y miotomía. En 3 casos de divertículo incipiente se realizó miotomía del cricofaríngeo como única operación. Las complicaciones postoperatorias inmediatas fueron transitorias y curaron sin secuelas. En el seguimiento alejado se observaron 3 recidivas, todas en el grupo de pacientes tratados con diverticulectomía simple. Los resultados fueron clasificados en muy buenos (pacientes asintomáticos), buenos, regulares y malos.En el 9l,3% de los casos de diverticulectomía y miotomía, los resultados alejados fueron muy buenos. Se discute la conveniencia de la miotomía del músculo cricofaríngeo, indicación de ectomía o pexia, los resultados de la diverticulectomía y miotomía, la miotomía en presencia de hernia hiatal y o reflujo gastroesofágico y la necesidad o no de operación antirreflujo simultánea, y el riesgo de cáncer en la bolsa diverticular. (AU)

Divertículos faringoesofágicos / Pharyngoesophageal diverticula

Se analizan 77 casos de divertículos faringoesofágicos operados entre l959 y l988. Hasta l968 se trataron l6 pacientes con diverticulectomía simple y desde esa fecha, 58 con diverticulectomía y miotomía. En 3 casos de divertículo incipiente se realizó miotomía del cricofaríngeo como única operación. Las complicaciones postoperatorias inmediatas fueron transitorias y curaron sin secuelas. En el seguimiento alejado se observaron 3 recidivas, todas en el grupo de pacientes tratados con diverticulectomía simple. Los resultados fueron clasificados en muy buenos (pacientes asintomáticos), buenos, regulares y malos.En el 9l,3% de los casos de diverticulectomía y miotomía, los resultados alejados fueron muy buenos. Se discute la conveniencia de la miotomía del músculo cricofaríngeo, indicación de ectomía o pexia, los resultados de la diverticulectomía y miotomía, la miotomía en presencia de hernia hiatal y o reflujo gastroesofágico y la necesidad o no de operación antirreflujo simultánea, y el riesgo de cáncer en la bolsa diverticular.

[Diverticula of the pharyngoesophageal area]. / I diverticoli della regione faringo-esofagea.

Hypopharyngeal diverticula are relatively unknown, with the exception of Zenker's diverticulum. Spot-camera and videorecording techniques were employed for the examination of 95 dysphagic and 250 asymptomatic patients. On the whole, 345 cases. 40% of diverticula were found in dysphagic patients, and 14% in asymptomatic ones. Fifty diverticula were detected through the thyrohyoid membrane, and 14 pseudodiverticula, 4 Zenker's diverticula, 4 lateral diverticula at the pharyngoesophageal junction, and 2 outpouchings through the tonsillar fossa. A statistically significant correlation (p less than 0.001) with dysphagia was demonstrated only for diverticula through the thyrohyoid membrane. Most pathologic findings were associated with other swallowing dysfunctions.