Long-term outcome of operated and unoperated epiphrenic diverticula.

INTRODUCTION: The natural history of esophageal epiphrenic diverticula (ED) is not entirely clear; the decision whether to operate or not is often based on the personal preference of the physician and patient. The aim of this study was to evaluate the long-term fate of operated and unoperated patients with ED. MATERIALS AND METHODS: Clinical, radiological, and motility findings, and operative morbidity and long-term outcome of 41 patients with ED (January 1993 to December 2005) were analyzed. All patients were reviewed at the outpatient clinic or interviewed over the phone. A symptom score was calculated using a standard questionnaire and subjective patient assessment. The radiological maximum diameter of the ED was measured. RESULTS: Twenty-two patients (12M:10F; median age, 60 years) were operated. One underwent surgery for spontaneous rupture of a large diverticulum. Operative mortality was nil; postoperative morbidity was 22.7%, the most severe complication being suture leakage (4 patients, all managed conservatively); median follow-up was 53 months. Nineteen patients (9M, 10F; median age 70 years) were not operated: 3 received pneumatic dilations; median follow-up was 46 months. None of the patients in either group died for reasons related to their ED. Symptoms decreased in all operated patients and, to a lesser extent, also in unoperated patients. ED recurrence was observed in one operated patient. Four patients had GERD symptoms with esophagitis and/or positive pH-metry after surgery and 3 patients had persistent dysphagia/regurgitation and were dissatisfied with the outcome of surgery. DISCUSSION: Surgery is an effective treatment for ED, but carries a significant morbidity related mainly to suture leakage. Even in the long-term, unoperated patients do not die of their ED, though a better subjective symptom outcome is reported by operated patients. A non-interventional policy can safely be adopted in cases of small, mildly symptomatic ED.

Intramural pseudodiverticulosis of the esophagus.

Esophageal intramural pseudodiverticulosis (EIPD) is a rare condition seen in the elderly, with a male-to-female ratio of 3:2. Multiple small outpouchings occur in the submucosa of the esophageal wall, caused by dilation of the excretory ducts of the mucus glands. This disorder may be associated with gastroesophageal reflux, motility disorders, candidiasis, or other conditions. Inflammation, resulting in periductal fibrosis and compression of the duct orifices, may be a causative factor. Usually, EPID presents with progressive dysphagia related to esophageal stenosis or strictures in the great majority of patients. Radiologic examination is more sensitive than endoscopy in detecting these tiny saccular diverticula in the esophageal wall. They often are noted to disappear after esophageal dilation, but may persist asymptomatically in some patients. We report two cases of dysphagia associated with reflux and Candida infection in elderly patients. The diagnosis of EIPD was made, and both patients were treated successfully. A review of the available literature suggests that EIPD may be missed easily because of subtle endoscopic and radiologic changes, but that once diagnosed, conservative management leads to satisfactory control of the symptoms.

Long-term results of endoscopic injection of botulinum toxin in elderly achalasic patients with tortuous megaesophagus or epiphrenic diverticulum.

BACKGROUND AND STUDY AIMS: Recent studies suggest that endoscopic injection of botulinum toxin (BTX) for achalasia is a safe procedure giving short-term relief of symptoms mainly in elderly patients (> 50 years). The aim of the study was to evaluate the clinical efficacy of periodic BTX treatments in high risk achalasia patients. PATIENTS AND METHODS: A total of 20 consecutive achalasia patients, aged > 60 years (11 women; 71+/-11 years), with general (ASA class III or IV) and local risk factors (i.e. tortuous megaesophagus or epiphrenic diverticulum) for complications associated with pneumatic dilation, were treated by local injection of 100 U of BTX into the gastric cardia, using the four-quadrant technique. The patients were prospectively followed for a median period of 2 years (range 5-48 months), using a symptom score (1-14 points) and barium esophagograms. RESULTS: Symptomatic improvement (decrease of the symptom score > or = 3 points) was found in 16/20 patients (80%), 6 weeks after the first BTX injection, and the cardia diameter increased from 2.1+/-0.7 to 3.2+/-1.2 mm (P < 0.01) (data are means +/- SD). Those patients who initially responded to BTX treatment developed a symptomatic relapse after a median follow-up of 5+/-2 months. They were treated by subsequent BTX re-injections (2.5+/-1 sessions per patient, range 1-5) resulting in longer lasting symptom relief (10+/-3 months, P < 0.05 vs. initial BTX injection). At completion of the study, 14/20 high risk achalasia patients (70 %) treated with periodic BTX injections are still in clinical remission. One further patient died without relapse 6 months after a single BTX treatment as a consequence of progressive heart failure. Four patients who did not respond to BTX injection were successfully and uneventfully treated by careful pneumatic dilation (n = 3) or percutaneous endoscopic gastrostomy (n = 1). CONCLUSION: Endoscopic botulinum toxin injection has reasonable long-term efficacy and safety in elderly achalasia patients who are at increased risk with regard to pneumatic dilation.

[Study of the antispastic activity of prifinium bromide in motor dysfunction of the esophagus]. / Studio dell'attività antispastica del prifinio bromuro nelle disfunzioni motorie dell'esofago.

Motor disturbances of the oesophagus are attributable to hypermotility or hypomotility, or to peristaltic uncoordination of the upper or lower sphincter, or of the corpus. Endoesophageal manometry has enabled considerable progress to be made in the study of oesophageal dysfunction by allowing the spasm to be quantified. Treatment is poorly effective and its results are uncertain, save in the very few cases where surgery leads to resolution. For this reason, the efficacy of a new drug with marked antispastic properties, prifinium bromide, was investigated in 12 cases of megaoesophagus, of hiatal hernia, 6 of diverticulum, and 4 of dyskinesia in the light of the manometric values observed before and after its administration. The drug relieved spasm of the sphincters and corpus.