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Yadav A, Nundy S. An Epiphrenic Diverticulum with Previous Perforation Excised Laparoscopically. Case Rep Surg 2024; 2024:3556567. [PMID: 38903609 PMCID: PMC11189677 DOI: 10.1155/2024/3556567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 03/01/2024] [Accepted: 03/28/2024] [Indexed: 06/22/2024] Open
Abstract
An epiphrenic diverticulum (ED) is a rare pseudodiverticulum commonly located at the lower end of the oesophagus. Surgical treatment is only required in patients with worsening dysphagia or repeated chest infection due to microaspirations, and most patients are now treated with minimally invasive surgery (MIS) using the laparoscopic or thoracoscopic approach. Laparoscopic surgery is considered difficult in the presence of previous perforation of the diverticula owing to the intraperitoneal and mediastinal adhesions and is associated with an increased incidence of complications. We were able to perform a laparoscopic transhiatal resection safely on a patient who had a large ED with a wide neck and dense abdominal and mediastinal adhesions due to previous localized perforation.
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Affiliation(s)
- Amitabh Yadav
- Department of Surgical Gastroenterology and Liver TransplantationSir Ganga Ram Hospital, New Delhi, India
| | - Samiran Nundy
- Department of Surgical Gastroenterology and Liver TransplantationSir Ganga Ram Hospital, New Delhi, India
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Mihara K, Tsunoda S, Nishigori T, Hisamori S, Okumura S, Kasahara K, Fujita Y, Sakamoto T, Morimoto T, Kinoshita H, Itatani Y, Hoshino N, Okamura R, Maekawa H, Hida K, Obama K. Midesophageal diverticulum with elevated intrabolus pressure: a case report. Surg Case Rep 2024; 10:108. [PMID: 38700566 PMCID: PMC11068720 DOI: 10.1186/s40792-024-01909-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 04/25/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Esophageal diverticulum is commonly associated with esophageal motility disorders, which can be diagnosed using high-resolution manometry (HRM) according to the Chicago classification. Although midesophageal diverticulum (M-ED) is associated with inflammatory processes, esophageal motility disorders have been recently identified as an etiology of M-ED. CASE PRESENTATION We present the case of a patient with M-ED and elevated intrabolus pressure (IBP), which did not meet the criteria for esophageal motility disorders according to the Chicago classification. A 71-year-old man presented with gradually worsening dysphagia for two years and was diagnosed as having an 8-cm-long M-ED and multiple small diverticula in lower esophagus. HRM revealed a median integrated relaxation pressure of 14.6 mmHg, a distal latency of 6.4 s, and an average maximum IBP of 35.7 mmHg. He underwent thoracoscopic resection of the M-ED and myotomy, which successfully alleviated the symptoms and reduced the intrabolus pressure to normal levels. CONCLUSIONS It is important to recognize the esophageal diverticulum pathology with HRM findings even in cases where the results may not meet the Chicago classification and to include myotomy based on the results.
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Affiliation(s)
- Kaito Mihara
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Shigeru Tsunoda
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Tatsuto Nishigori
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Shigeo Hisamori
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Shintaro Okumura
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Keiko Kasahara
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yusuke Fujita
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Takashi Sakamoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Tomoki Morimoto
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Hiromitsu Kinoshita
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yoshiro Itatani
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Nobuaki Hoshino
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Ryosuke Okamura
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Hisatsugu Maekawa
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Koya Hida
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Kazutaka Obama
- Department of Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-Cho, Shogoin, Sakyo-Ku, Kyoto, 606-8507, Japan
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Marcon S, Anania G, Tamburini N. Laparoscopic Approach to Epiphrenic Diverticula Under Endoscopic Assistance: A Technical Report. J Laparoendosc Adv Surg Tech A 2024; 34:162-166. [PMID: 38109227 DOI: 10.1089/lap.2023.0469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
Introduction: Epiphrenic diverticulum is a rare disease caused by mucosa and submucosa herniation through the muscular layers of the esophageal wall. This study presents a case of a patient with a symptomatic epiphrenic diverticulum treated with surgery under endoscopic assistance. A review of the literature on this unusual condition was conducted, focusing on the pathogenesis, presentation, and surgical challenges. Methods: A 75-year-old woman who underwent an esophagogastroduodenoscopy (EGD) after experiencing worsening dysphagia for food and liquids. The EGD revealed a large epiphrenic diverticulum 36 cm from the upper incisor teeth. The presence of a diverticulum was verified by barium swallow, which revealed a 6 cm diameter epiphrenic diverticulum on the right side of the esophagus. Results: Patient underwent laparoscopic diverticulectomy associated with Heller's myotomy and anterior partial fundoplication. A gastroscope was placed intraoperatively to calibrate the esophagus to prevent stenosis during diverticulectomy, and it was also used to check the integrity of the esophageal wall. The patient tolerated clear liquids on postoperative day 2. Postoperative course was complicated by right pleural effusion and fever managed with antibiotics and pleural drainage. Conclusion: Epiphrenic diverticulectomy in conjunction with management of the underlying motor dysfunction and avoidance of gastroesophageal reflux disease is an effective procedure. Laparoscopy is considered the approach of choice for the majority of patients. Endoscopic assistance during surgery can help the identification of the diverticulum and verify the integrity of the staple line.
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Affiliation(s)
- Salvatore Marcon
- Department of Surgery, Sant'Anna University Hospital, Ferrara, Italy
| | - Gabriele Anania
- Department of Surgery, Sant'Anna University Hospital, Ferrara, Italy
| | - Nicola Tamburini
- Department of Surgery, Sant'Anna University Hospital, Ferrara, Italy
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Uchi Y, Ozawa S, Ando T, Hayashi K, Aoki T, Shimazu M. Combined thoracoscopic and laparoscopic surgery for epiphrenic diverticulum with associated gastroesophageal reflux disease: a case report. Surg Case Rep 2024; 10:17. [PMID: 38221572 PMCID: PMC10788325 DOI: 10.1186/s40792-024-01813-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 01/05/2024] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND Surgery is indicated for symptomatic epiphrenic esophageal diverticula. Based on the features of a case, thoracoscopic or laparoscopic approaches may be used. Epiphrenic diverticula are often associated with esophageal motility disorders, but cases of reflux esophagitis have rarely been reported. In this report, we describe a case of an epiphrenic esophageal diverticulum with reflux esophagitis, which was successfully treated by thoracoscopic diverticulectomy and laparoscopic fundoplication. CASE PRESENTATION A 69-year-old man visited the hospital with a chief complaint of eructation and hiccup. Upper gastrointestinal endoscopy revealed a diverticulum in the left wall of the esophagus, which was 37-45 cm distal to the incisors. High-resolution manometry (HRM) showed no esophageal motility disorders. Due to the large size of the diverticulum, a thoracoscopic resection of the esophageal diverticulum was performed. Additionally, the patient had reflux esophagitis due to a hiatal hernia. The anti-reflux mechanism would be more impaired during the diverticulectomy; therefore, we decided that anti-reflux surgery should be performed simultaneously. Thoracoscopic esophageal diverticulectomy and laparoscopic Dor fundoplication were performed. The patient had an uncomplicated postoperative course and was discharged on the tenth operative day. He has been symptom-free without acid secretion inhibitors for 21 months after the surgery. CONCLUSIONS We described a rare case of a large epiphrenic diverticulum with reflux esophagitis. A good surgical outcome was achieved by thoracoscopic resection of the diverticulum and laparoscopic Dor fundoplication.
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Affiliation(s)
- Yusuke Uchi
- Department of Surgery, Tamakyuryo Hospital, 1401 Shimooyamada, Machida, Tokyo, 194-0202, Japan
| | - Soji Ozawa
- Department of Surgery, Tamakyuryo Hospital, 1401 Shimooyamada, Machida, Tokyo, 194-0202, Japan.
| | - Tomofumi Ando
- Department of Surgery, Tamakyuryo Hospital, 1401 Shimooyamada, Machida, Tokyo, 194-0202, Japan
| | - Koki Hayashi
- Department of Surgery, Tamakyuryo Hospital, 1401 Shimooyamada, Machida, Tokyo, 194-0202, Japan
| | - Takuma Aoki
- Department of Surgery, Tamakyuryo Hospital, 1401 Shimooyamada, Machida, Tokyo, 194-0202, Japan
| | - Motohide Shimazu
- Department of Surgery, Tamakyuryo Hospital, 1401 Shimooyamada, Machida, Tokyo, 194-0202, Japan
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Tankel J, Meng A, Gold M, Mueller C, Spicer J, Cools-Lartigue J, Ferri L, Najmeh S. Transabdominal Management of Epiphrenic Diverticula in the Setting of Achalasia: A Single-center Review. Surg Laparosc Endosc Percutan Tech 2023; 33:583-586. [PMID: 37852235 DOI: 10.1097/sle.0000000000001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/22/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The perioperative and functional outcomes of patients with epiphrenic diverticula (ED) on a background of achalasia managed via a minimally invasive transabdominal approach are under-reported. We describe our center's experience over 10 years of treating such patients. METHODS A single-center, retrospective chart of a prospectively maintained hospital database was performed. All patients with a diagnosis of ED and manometrically proven achalasia were identified. Demographic, clinical, and surgical data were extracted from the institution's medical records. Patients were stratified by whether they underwent myotomy only or myotomy plus diverticulectomy and compared in a univariate manner. RESULTS There were 18 patients who met the inclusion criteria. The median age of the cohort was 67.1 years (range 53.1 to 77.8), the maximal size of the diverticula was 3.5 cm (range 2.0 to 7.0), and the distance of the proximal lip of the diverticulum to the incisors was 33.5 cm (range 28.0 to 38.0). In terms of surgical intervention, 14 patients (77.8%) underwent myotomy plus diverticulectomy, and 4 (22.2%) underwent myotomy alone. The duration of surgery was significantly longer in the former (177.5 vs. 75.0 min, P =0.031). In total, 9/18 (50.0%) of patients were discharged on the day of surgery. There was a trend to more major postoperative complications following diverticulectomy plus myotomy, with 2/13 (15.4%) patients suffering staple line leaks. Excellent long-term functional outcomes were achieved, with 81.3% of patients having sustained resolution of their symptoms. CONCLUSIONS Laparoscopic transabdominal approach for the treatment of ED offers an acceptable risk profile and favorable functional outcomes in patients with underlying achalasia.
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Affiliation(s)
- James Tankel
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Mandarino FV, Vespa E, Barchi A, Fasulo E, Sinagra E, Azzolini F, Danese S. Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review. Life (Basel) 2023; 13:2143. [PMID: 38004283 PMCID: PMC10672509 DOI: 10.3390/life13112143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/28/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
Our review delves into the realm of peroral endoscopic myotomies (POEMs) in the upper gastrointestinal tract (UGT). In recent years, POEMs have brought about a revolution in the treatment of UGT motility disorders. Esophageal POEM, the first to be introduced, has now been validated as the primary treatment for achalasia. Subsequently developed, G-POEM displays promising results in addressing refractory gastroparesis. Over time, multiple endoscopic myotomy techniques have emerged for the treatment of Zenker's diverticulum, including Z-POEM, POES, and hybrid approaches. Despite the well-established efficacy outcomes, new challenges arise in the realm of POEMs in the UGT. For esophageal POEM, the future scenario lies in customizing the myotomy extent to the minimum necessary, while for G-POEM, it involves identifying patients who can optimally benefit from the treatment. For ZD, it is crucial to validate an algorithm that considers various myotomy options according to the diverticulum's size and in relation to individual patients. These challenges align with the concept of precision endoscopy, personalizing the technique for each subject. Within our text, we comprehensively examine each myotomy technique, analyzing indications, outcomes, and adverse events. Additionally, we explore the emerging challenges posed by myotomies within the context of the evolving field of precision endoscopy.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Edoardo Vespa
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Ernesto Fasulo
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele Giglio, 90015 Cefalù, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
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Noh JH, Jung HY. Role of Endoscopy in Motility Disorders of Upper Gastrointestinal Tract. J Neurogastroenterol Motil 2023; 29:7-19. [PMID: 36606432 PMCID: PMC9837547 DOI: 10.5056/jnm22170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/19/2022] [Indexed: 01/07/2023] Open
Abstract
Gastrointestinal motility disorders have a wide range of symptoms and affect patients' quality of life. With the advancement of endoscopy, the diagnostic and therapeutic roles of endoscopy in motility disorders is becoming more significant. Endoscopy is necessary to rule out possible organic diseases in patients with suspected motility disorders and provide significant clues for their diagnosis. Moreover, interventional endoscopy may be a primary or alternative treatment option for selected patients with motility disorders, and it is becoming a promising field as new therapeutic applications are developed and utilized for various motility disorders. This review may provide suitable indications for the use of endoscopy in diagnosing and treating motility disorders of the upper gastrointestinal tract.
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Affiliation(s)
- Jin Hee Noh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea,Correspondence: Hwoon-Yong Jung, MD, PhD, Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea, Tel: +82-2-3010-3197, Fax: +82-2-476-0824, E-mail:
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Boutron C, Rebibo L, Duboc H, Antonopulos C, Calabrese D, Coffin B, Msika S. Thoracoscopic approach as surgical management of esophageal epiphrenic diverticulum. J Visc Surg 2023:S1878-7886(23)00005-X. [PMID: 36710123 DOI: 10.1016/j.jviscsurg.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Management of diverticulum of the lower esophagus or epiphrenic diverticulum can be performed using the abdominal or thoracic approach. In some cases, the thoracic approach is preferred, but few studies have described thoracoscopic resection. The objective of the present study was to investigate the thoracoscopic approach for management of epiphrenic esophageal diverticulum. MATERIAL AND METHODS From 2008 to 2018, all patients undergoing surgery for epiphrenic esophageal diverticulum by the thoracoscopic approach were included in this single-center, retrospective, observational study. Data on diverticulum, surgery and follow-up were assessed. RESULTS During the study period, 14 patients underwent surgery. Two patients had two diverticula. The mean location of the superior edge of the diverticulum was 7cm (2-14cm) above the gastro-esophageal junction. The mean size of the diverticulum was 39 millimeters (20-60). Thoracoscopic approach was used in all patients. No conversion to thoracotomy was required. Mean operative time was 168min (120-240). No postoperative mortality occurred. The overall complication rate was 40% (6 complications out of 15 resections), with three major complications including leaks (n=2) and a case of bronchoesophageal fistula (n=1). Median length of hospital stay was 12 days (8-40). At a mean postoperative follow-up of 20.7 months (5-71), 85% of patients had complete disappearance of preoperative symptoms without recurrence of the diverticulum on the barium swallow study test. CONCLUSION Thoracoscopic approach as management of epiphrenic diverticulum is feasible, with acceptable short-term morbidity. The thoracoscopic approach is also effective in resolving preoperative symptoms.
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Affiliation(s)
- C Boutron
- Digestive, esogastric and bariatric surgery department, Bichat Claude Bernard hospital, Paris, France; Sorbonne university, 75013 Paris, France
| | - L Rebibo
- Digestive, esogastric and bariatric surgery department, Bichat Claude Bernard hospital, Paris, France; Department of digestive and oncologic surgery, européen Georges Pompidou hospital, Assistance publique-Hôpitaux de Paris, Paris, France; Inserm UMR 1149, Paris university, 75018 Paris, France
| | - H Duboc
- Inserm UMR 1149, Paris university, 75018 Paris, France; Department of gastroenterology, Louis Mourier university hospital, Colombes, France
| | - C Antonopulos
- Digestive, esogastric and bariatric surgery department, Bichat Claude Bernard hospital, Paris, France
| | - D Calabrese
- Digestive, esogastric and bariatric surgery department, Bichat Claude Bernard hospital, Paris, France; Inserm UMR 1149, Paris university, 75018 Paris, France
| | - B Coffin
- Inserm UMR 1149, Paris university, 75018 Paris, France; Department of gastroenterology, Louis Mourier university hospital, Colombes, France
| | - S Msika
- Digestive, esogastric and bariatric surgery department, Bichat Claude Bernard hospital, Paris, France; Inserm UMR 1149, Paris university, 75018 Paris, France.
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Andrási L, Ábrahám S, Simonka Z, Paszt A, Erdős M, Rovó L, Rosztóczy A, Ollé G, Lázár G. [Minimally invasive surgery for motility disorders of the oesophagus]. Magy Seb 2022; 75:121-132. [PMID: 35895537 DOI: 10.1556/1046.2022.20006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/04/2022] [Indexed: 01/06/2023]
Abstract
Introduction and aims. We present our experience with minimally invasive surgery for pharyngoesophageal (Zenker) diverticulums, epiphrenic diverticulums and achalasia cardiae focusing on the perioperative features and patients’ quality of life. Patients and methods. Between 1 January 2003 and 31 December 2020, patients were selected with a symptom-causing Zenker diverticulum, epiphrenic diverticulum and achalasia cardiae. In 17 cases, transoral stapler diverticulostomy, in 23 cases transcervical diverticulectomy and cricomyotomy were done because of Zenker diverticulum, in 14 cases, laparoscopic transhiatal surgery was performed because of epiphrenic diverticula, while in 63 cases, laparoscopic Heller–Dor operation were carried out because of achalasia cardiae. Perioperative results, the quality of life outcomes of various surgeries were evaluated in mid- and long-term. Results/conclusions. The surgeries were performed with minimal blood loss, zero mortality and low morbidity. According to our result, the two different surgical approaches in the therapy of Zenker’s diverticulum, the laparoscopic Heller–Dor procedure applied in the management of epiphrenic diverticulas and achalasia cardiae are safe and effective operations. In the long term, the symptom control in patients after minimally invasive surgeries is sufficient and only a small percentage of the patients may require additional medication therapy and/or reintervention due to persistent complaints.
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Affiliation(s)
- László Andrási
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Szabolcs Ábrahám
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Zsolt Simonka
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Attila Paszt
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Márton Erdős
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - László Rovó
- 2 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Fül-Orr-Gégészeti és Fej-Nyaksebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Rovó László)
| | - András Rosztóczy
- 3 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Belgyógyászati Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lengyel Csaba)
| | - Georgina Ollé
- 3 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Belgyógyászati Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lengyel Csaba)
| | - György Lázár
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
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Abstract
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.
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Gallyamov EA, Busyrev YB, Gvozdev AA, Shalygin AB, Fedorov AV. ENDOSCOPIC STENTING IN THE TREATMENT OF RECURRENT EPIPHRENIC DIVERTICULUM AFTER LAPAROSCOPIC DIVERTICULECTOMY. CLINICAL CASE REPORT. SURGICAL PRACTICE 2021. [DOI: 10.38181/2223-2427-2021-2-5-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Epiphrenic diverticulum, also known as a pulsion diverticulum, is a rare type of esophageal diverticulum occurring in the distal 10 centimeters of the esophagus. They are most commonly 4-10 cm above the gastric cardia representing 10% of all esophageal diverticula. Laparoscopic diverticulectomy has become the treatment of choice. This clinical case study is dedicated to minimally invasive treatment of recurrent epiphrenic diverticulum after laparoscopic diverticulectomy. A 74-year-old male patient was admitted to the hospital with complaints of dysphagia, regurgitation and halitosis. The examination revealed a 5 cm epiphrenic diverticulum with sings of inflammation. Laparoscopic transchiatal diverticulectomy, the Dor (anterior) fundoplication, cruroraphia and mediastinal drainage were performed. The patient was discharged on the 11-th postoperative day. The patient exhibited dysphagia relapse during a 3-month follow-up. Taking into account the previous surgical treatment and the habitus endoscopic esophageal stenting was chosen as the technique of choice for management. Under intravenous anesthesia a partially covered metal self-expandable stent 10 cm x 1.8 cm was inserted into the distal esophagus. Next day control fluoroscopy showed stable stent position and no evidence of leakage. The water-soluble contrast agent reached stomach freely. The patient was discharged on the 2nd post-operative day. Within 4 months after having a stent placed, the patient feels well and oral feeding is satisfactory. In terms of literature search we have not come across any reference to the post-epiphrenic diverticulectomy recurrence treatment, so the management was chosen individually based on the comorbid status of the patient. The installation of a partially covered metal self-expandable stent allowed to promptly eliminate dysphagia and design features enabled to achieve stent stable position. A partially covered metal self-expandable stent can be considered effective in the post-epiphrenic diverticulectomy recurrence treatment.
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Affiliation(s)
- E. A. Gallyamov
- Department of General surgery of the I. M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation
| | - Yu. B. Busyrev
- Department of General surgery of the I. M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation; State budgetary institution of health care of the city of Moscow “I. V. Davydovsky City clinical hospital Of the Department of Health of the city of Moscow”
| | - A. A. Gvozdev
- State budgetary institution of health care of the city of Moscow “I. V. Davydovsky City clinical hospital Of the Department of Health
of the city of Moscow”
| | - A. B. Shalygin
- Department of General surgery of the I. M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation; State budgetary institution of health care of the city of Moscow “I. V. Davydovsky City clinical hospital Of the Department of Health of the city of Moscow”
| | - A. V. Fedorov
- State budgetary institution of health care of the city of Moscow “I. V. Davydovsky City clinical hospital Of the Department of Health
of the city of Moscow”
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12
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Andrási L, Paszt A, Simonka Z, Ábrahám S, Rosztóczy A, Lázár G. Laparoscopic Surgery for Epiphrenic Esophageal Diverticulum. JSLS 2018; 22:JSLS.2017.00093. [PMID: 30022807 PMCID: PMC6035909 DOI: 10.4293/jsls.2017.00093] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background and Objectives: We wanted to assess our surgical results focusing on the patients' quality of life. We present our experience with laparoscopic surgery for epiphrenic esophageal diverticulum. Short- and long-term results of surgical therapy were analyzed. Methods: Eight patients were examined with a symptom-causing epiphrenic diverticulum. Patients underwent complex gastroenterologic examinations before and after surgery. Laparoscopic transhiatal epiphrenic diverticulectomy, Heller cardiomyotomy, and Dor anterior partial fundoplication were performed on 7 patients. One patient underwent only diverticulectomy, where no motility disorder was present. Results from surgical treatments and changes in patients' pre- and postoperative complaints were evaluated. Results: In all cases except 1, the preoperative examination showed dysmotility of the esophagus. The average duration of the surgeries was 165 (130–195) minutes; blood loss was minimal. One patient developed bleeding in the early postoperative period, and a second laparoscopy was required. No other intraoperative complication was detected, and no mortality occurred. In one case, a staple line leak developed (1/8 [12.5%]), which was resolved with conservative therapy. Functional check-ups confirmed adequate esophageal function. The total symptom score for the patients was 6.3 points before surgery, and it decreased to 1.6 (P < .001) after surgery, an average of 74% subjective improvement. During the follow-up period (mean, 60 months; 10–138 months), proton pump inhibitor therapy was started in 4 patients to treat gastroesophageal reflux. In 3 cases, drug therapy was successful; in one case, Nissen antireflux surgery was performed. Conclusion: Laparoscopic transhiatal diverticulectomy and Heller–Dor surgery are effective interventions with low morbidity. Patient quality of life significantly improves in the long term, but gastroesophageal reflux disease may occur.
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Affiliation(s)
| | | | | | | | - András Rosztóczy
- 1st Department of Medicine, Albert Szent-Györgyi Health Center, University of Szeged, Szeged, Hungary
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13
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Abstract
Diverticula of the middle and lower third of the esophagus are commonly associated with esophageal motility disorders. The increase of intraluminal pressure leads to an outpouching of the mucosal and submucosal layers through the esophageal muscle coat. These pouches are also called false diverticula, because they only consist of the mucosal and submucosal esophageal layers. In contrast, the more rarely encountered true diverticula that retain the complete esophageal wall are generally associated with periesophageal granulomatous lymph node disease. Treatment of both true and false diverticula is generally indicated in symptomatic patients; however, even state of the art minimally invasive surgery is accompanied by considerable perioperative morbidity and should only be performed in carefully selected patients. This aim of this article is to summarize the available scientific evidence and to provide the reader with an updated guide to best clinical practice in the treatment of esophageal diverticula.
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14
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Feußner H, Hüser N, Wilhelm D, Fingerle A, Jell A, Friess H, Bajbouj M. [Surgical treatment of esophageal diverticula : Endoscopic or open approach?]. Chirurg 2017; 88:196-203. [PMID: 28054111 DOI: 10.1007/s00104-016-0344-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Esophageal diverticula are comparatively rare. The majority are Zenker's diverticula but parabronchial and epiphrenic diverticula can also occur. Parabronchial diverticula are of low clinical relevance, whereas Zenker's and epiphrenic diverticula both belong to the group of pulsion diverticula and can become clinically apparent by dysphagia and regurgitation. Approximately 100 years after the first surgical treatment, peroral approaches (e.g. stapler dissection and flexible endoscopic diverticulotomy) have now achieved a certain level of importance. Both approaches are less invasive than the open approach but are evidently more prone to recurrences. Accordingly, traditional open diverticulectomy with cervical myotomy should be recommended to patients with a reasonable life expectancy and an acceptable operative risk. This holds particularly true for Brombart stages I-III of the disease, as complete myotomy cannot be achieved via the peroral access. The classical surgical treatment of epiphrenic diverticula is open or laparoscopic/thoracoscopic diverticulectomy with distal myotomy, mostly combined with an anterior partial fundoplication; however, the leakage rate is high and several alternative options are currently being evaluated.
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Affiliation(s)
- H Feußner
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland.
| | - N Hüser
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - D Wilhelm
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - A Fingerle
- Institut für Diagnostische und Interventionelle Radiologie, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland
| | - A Jell
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - H Friess
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - M Bajbouj
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland
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15
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Chan DSY, Foliaki A, Lewis WG, Clark GWB, Blackshaw GRJC. Systematic Review and Meta-analysis of SurgicalTreatment of Non-Zenker's Oesophageal Diverticula. J Gastrointest Surg 2017; 21:1067-1075. [PMID: 28108931 PMCID: PMC5443879 DOI: 10.1007/s11605-017-3368-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 01/09/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Oesophageal diverticula are rare outpouchings of the oesophagus which may be classified anatomically as pharyngeal (Zenker's), mid-oesophageal and epiphrenic. While surgery is indicated for symptomatic patients, no consensus exists regarding the optimum technique for non-Zenker's oesophageal diverticula. The aim of this study was to determine the outcome of surgery in patients with non-Zenker's oesophageal diverticula. METHODS PubMed, MEDLINE and the Cochrane Library (January 1990 to January 2016) were searched for studies which reported outcomes of surgery in patients with non-Zenker's oesophageal diverticula. Primary outcome measure was the rate of staple line leakage. RESULTS Twenty-five observational studies involving 511 patients (259 male, median age 62 years) with mid-oesophageal (n = 53) and epiphrenic oesophageal (n = 458) diverticula who had undergone surgery [thoracotomy (n = 252), laparoscopy (n = 204), thoracoscopy (n = 42), laparotomy (n = 5), combined laparoscopy and thoracoscopy (n = 8)] were analysed. Myotomy was performed in 437 patients (85.5%), and anti-reflux procedures were performed in 342 patients (69.5%). Overall pooled staple line leak rates were reported in 13.3% [95% c.i. (11.0-15.7), p < 0.001] and were less common after myotomy (12.4%) compared with no myotomy (26.1%, p = 0.002). CONCLUSIONS No consensus exists regarding the surgical treatment of non-Zenker's oesophageal diverticula, but staple line leakage is common and is reduced significantly by myotomy.
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Affiliation(s)
- David S. Y. Chan
- 0000 0001 0169 7725grid.241103.5Department of Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW UK
| | - Antonio Foliaki
- 0000 0001 0169 7725grid.241103.5Department of Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW UK
| | - Wyn G. Lewis
- 0000 0001 0169 7725grid.241103.5Department of Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW UK
| | - Geoffrey W. B. Clark
- 0000 0001 0169 7725grid.241103.5Department of Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW UK
| | - Guy R. J. C. Blackshaw
- 0000 0001 0169 7725grid.241103.5Department of Surgery, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW UK
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16
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Andolfi C, Wiesel O, Fisichella PM. Surgical Treatment of Epiphrenic Diverticulum: Technique and Controversies. J Laparoendosc Adv Surg Tech A 2016; 26:905-910. [DOI: 10.1089/lap.2016.0365] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Ciro Andolfi
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Ory Wiesel
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - P. Marco Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA, Boston, Massachusetts
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17
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Bencini L, Moraldi L, Bartolini I, Coratti A. Esophageal surgery in minimally invasive era. World J Gastrointest Surg 2016; 8:52-64. [PMID: 26843913 PMCID: PMC4724588 DOI: 10.4240/wjgs.v8.i1.52] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 09/18/2015] [Accepted: 12/08/2015] [Indexed: 02/06/2023] Open
Abstract
The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.
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18
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Bowman TA, Sadowitz BD, Ross SB, Boland A, Luberice K, Rosemurgy AS. Heller myotomy with esophageal diverticulectomy: an operation in need of improvement. Surg Endosc 2015; 30:3279-88. [PMID: 26659233 DOI: 10.1007/s00464-015-4655-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 10/28/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study was undertaken to evaluate the outcomes after laparoscopic Heller myotomy with anterior fundoplication and diverticulectomy for patients with achalasia and esophageal diverticula. METHODS 634 patients undergoing laparoscopic Heller myotomy and anterior fundoplication from 1992 to 2015 are prospectively followed up; patients were stratified for those undergoing concomitant diverticulectomy. Patients graded symptom frequency and severity before and after myotomy, using a Likert scale (0 = never/not bothersome to 10 = always/very bothersome). Median data are presented (mean ± SD). RESULTS Forty-four patients, age 70 years (65 ± 14.2), underwent laparoscopic Heller myotomy, anterior fundoplication, and diverticulectomy. Operative time was 182 min (183 ± 54.6). Fifty percentage of patients had a postoperative complication: Most notable were leaks at the diverticulectomy site (n = 8) and pulmonary complications (n = 11; 10 effusion, 1 empyema). Length of stay (LOS) was 3 days (5 ± 8.3). All leaks occurred after discharge and resolved without sequelae using transthoracic catheter drainage and parenteral nutrition; two patients received endoscopic esophageal stents. Median follow-up is 39 months. Symptoms amelioration was significant postoperatively, including severity of dysphagia [6 (6 ± 3.9) to 2(4 ± 3.6)]. Seventy-six percentage of patients rated their symptoms at last follow-up as satisfying/very satisfying. Seventy-seven percentage of patients had symptoms once per week or less. Eighty-one percentage would have the operation again knowing what they know now. CONCLUSIONS Laparoscopic Heller myotomy, anterior fundoplication, and diverticulectomy well palliate the symptoms of achalasia with accompanying esophageal diverticulum. The operations are generally longer than those without diverticulectomy and are accompanied by a relatively longer LOS. Complications are relatively frequent and severe (e.g., leaks and pneumonia). In particular, leaks at the diverticulectomy site are unpredictable, occur after discharge, and remain vexing. Nevertheless, for this advanced form of achalasia, long-term symptom relief and patient satisfaction are high after anterior fundoplication with concomitant diverticulectomy. New and innovative techniques are needed to decrease the frequency of leaks at the diverticulectomy site.
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Affiliation(s)
- Ty A Bowman
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, 3000 Medical Park Drive, Suite 310, Tampa, FL, 33613, USA
| | - Benjamin D Sadowitz
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, 3000 Medical Park Drive, Suite 310, Tampa, FL, 33613, USA
| | - Sharona B Ross
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, 3000 Medical Park Drive, Suite 310, Tampa, FL, 33613, USA.
| | - Andrew Boland
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, 3000 Medical Park Drive, Suite 310, Tampa, FL, 33613, USA
| | - Kenneth Luberice
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, 3000 Medical Park Drive, Suite 310, Tampa, FL, 33613, USA
| | - Alexander S Rosemurgy
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Florida Hospital Tampa, 3000 Medical Park Drive, Suite 310, Tampa, FL, 33613, USA
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19
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Bhandarwar AH, Tungenwar PN, Sawakare YM, Wagh AN, Patel CB, Gandhi SS. Large Epiphrenic Diverticula: A Rare Case Presentation. Clin Pract 2015; 5:784. [PMID: 26918097 PMCID: PMC4745591 DOI: 10.4081/cp.2015.784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 08/21/2015] [Accepted: 09/28/2015] [Indexed: 11/22/2022] Open
Abstract
A 70-year old female was admitted to hospital with heartburn and chronic halitosis since 5 years. She was on proton pump inhibitors for the same. Her complaints worsened during the last one-year. Workup comprising of esophago-gastro-duodenoscopy, esophageal manometry, 3D computed tomography scan showed right-sided epiphrenic diverticula measuring 10x10 cm with wide mouth about 5 cm with hypertensive lower esophageal sphincter. Patient underwent a video assisted thoracoscopic surgery for esophageal diverticulectomy using two 45 mm staplers. On day 5, the patient developed leak, which was managed by a covered esophageal stent placement. Patient started on oral feeds from day 3 and the esophageal leak healed completely within 2 weeks. Literature suggests that esophageal leaks treated conservatively took approximately 30-40 days on an average for healing. Literature search did not reveal esophageal leak managed by stent with faster recovery (2 weeks). This is one of the largest epiphrenic diverticuli reported in literature.
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Affiliation(s)
- Ajay H Bhandarwar
- Department of General Surgery, Grant Medical College & Sir JJ Group of Hospitals , Byculla, Mumbai, India
| | - Pravin N Tungenwar
- Department of General Surgery, Grant Medical College & Sir JJ Group of Hospitals , Byculla, Mumbai, India
| | - Yogesh M Sawakare
- Department of General Surgery, Grant Medical College & Sir JJ Group of Hospitals , Byculla, Mumbai, India
| | - Amol Nanasaheb Wagh
- Department of General Surgery, Grant Medical College & Sir JJ Group of Hospitals , Byculla, Mumbai, India
| | - Chintan Babubhai Patel
- Department of General Surgery, Grant Medical College & Sir JJ Group of Hospitals , Byculla, Mumbai, India
| | - Saurabh S Gandhi
- Department of General Surgery, Grant Medical College & Sir JJ Group of Hospitals , Byculla, Mumbai, India
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20
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Fitzgerald CA, Fisher JG, Santore MT. Epiphrenic esophageal diverticulum in an adolescent with a history of a Nissen fundoplication: A case report. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2015. [DOI: 10.1016/j.epsc.2015.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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21
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Sonbare DJ. Pulsion Diverticulum of the Oesophagus: More than just an Out Pouch. Indian J Surg 2015; 77:44-48. [PMID: 25829711 PMCID: PMC4376845 DOI: 10.1007/s12262-013-0955-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 07/19/2013] [Indexed: 10/26/2022] Open
Abstract
Oesophageal diverticulum is divided into two types based on the aetiology: the pulsion and the traction diverticula. Pulsion diverticulum occurs due to increased intraluminal pressure. This can be of three types based on the location along the oesophagus: the Zenker's diverticulum (ZD), the mid-oesophageal diverticulum (MD) and the epiphrenic diverticulum (ED). A PubMed search was conducted for the words 'pulsion', 'diverticulum' and 'oesophagus' for all studies published from January 1980 to March 2013 in the English language. A total of 31 studies were identified, and out of which, five were not included in the review. The pulsion diverticulum of the oesophagus is an uncommon disorder. Its aetiology is related to the motility disorders of the oesophagus. Patients usually present with chest-related symptoms or oesophageal symptoms, which are related to the underlying motility disorder. Evaluation includes barium studies, gastrointestinal endoscopy, CT scan and oesophageal manometry. Surgery is the treatment of choice for symptomatic and large diverticula, although the outcome in asymptomatic patients is unknown. The surgical options include diverticulectomy or diverticulopexy with an adequate myotomy. Most patients with ZD are now treated by using endoscopic techniques, although no randomised trial has shown its superiority over the open technique. Minimally invasive surgery has also been used for patients with MD and ED. Although isolated case series has shown good improvement in symptoms and reduction in mortality with minimally invasive techniques in patients with ED, its role in thoracic oesophageal diverticulum is debated.
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Affiliation(s)
- Dhiraj John Sonbare
- Christian Medical College and Hospital, 4/2, New PG Quarters, Vellore, Tamil Nadu 632004 India
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22
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Rossetti G, Fei L, del Genio G, Maffettone V, Brusciano L, Tolone S, Cimmino M, Moccia F, Terrone A, Romano G, Guerriero L, del Genio A. Epiphrenic diverticula mini-invasive surgery: a challenge for expert surgeons--personal experience and review of the literature. Scand J Surg 2014; 102:129-35. [PMID: 23820690 DOI: 10.1177/1457496913482242] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS While in the past, thoracotomy represented the traditional surgical approach for the treatment of epiphrenic diverticula, actually mini-invasive approach seems to be the preferred treatment as many series have been published in the recent years. This article describes the authors' experience with the laparoscopic approach for performing diverticulectomy, myotomy, and Nissen-Rossetti fundoplication. MATERIAL AND METHODS From 1994 to 2010, 21 patients (10 men and 11 women), mean age 58.5 years (range 45-74 years), with symptomatic epiphrenic diverticulum underwent laparoscopic diverticulectomy, myotomy and Nissen-Rossetti fundoplication. RESULTS The mean operative time was 135 min (range = 105-190 min). Mean hospital stay was 14.2 days (range = 7-25 days). In 5 patients (23.8%), a partial suture staple line leak was observed. Conservative treatment achieved leak resolution in all the cases. One patient (4.8%) died of a myocardial infarction in the postoperative period. After a mean clinical follow-up period of 78 months (range = 6-192 months), excellent or good outcome was referred with no dysphagia in 16 patients (80%) and only mild occasional dysphagia in 4 patients (20%). CONCLUSIONS Surgical treatment of epiphrenic diverticula remains a challenging procedure also by mini-invasive approach, with major morbidity and mortality rates. For this reason, indications must be restricted only to selected and symptomatic patients in specialized centers.
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Affiliation(s)
- G Rossetti
- I Division of General and Gastrointestinal Surgery, Second University of Naples, Naples, Italy
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Gonzalez-Calatayud M, Targarona EM, Balague C, Rodriguez-Luppi C, Martin AB, Trias M. Minimally invasive therapy for epiphrenic diverticula: Systematic review of literature and report of six cases. J Minim Access Surg 2014; 10:169-74. [PMID: 25336815 PMCID: PMC4204258 DOI: 10.4103/0972-9941.141498] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 10/29/2013] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION: Epiphrenic diverticula (ED) are infrequent and conventional surgical treatment entails aggressive open or transthoracic surgery. Minimally invasive treatment has changed the surgical approach but some surgical controversies are not resolved. OBJECTIVE: The objective of this study is to describe our experience in minimally invasive treatment of the ED and to perform a systematic review of the current literature in this subject. MATERIALS AND METHODS: We reviewed all data from the Hospital de Sant Pau, focusing on patients that underwent minimally invasive treatment for an ED since 1998 to date. Furthermore, we performed a systematic literature review focused on the minimally invasive approach for ED. RESULTS: A total of 6 patients have been treated (5 transhiatal and 1 with abdominal and thoracic approach). We found a predominance of males with a median age of 63. The diagnosis was made with an endoscopy, barium swallow and manometry. Half of the manometry results were pathologic. The surgical technique involved a diverticulectomy, myotomy and a Dor partial founduplication. Two patients that presented suture line leakage (SLL) were treated conservatively. No mortality was reported. The systematic review was carried out under the Preferred Reporting Items for Systematic Reviews and Meta-analyses scheme, with a total of 20 studies where 189 patients were found. No comparative or prospective randomised trials were found. Overall morbidity was 24%, with a SLL rate of 12%, hospital stay of 5 days and mortality of 1.5%. After a median follow-up of 42 months, 81.5% of the patients were asymptomatic. CONCLUSION: The minimally invasive approach for ED is a safe and feasible procedure.
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Affiliation(s)
| | - Eduardo M Targarona
- Deparment of General Surgery, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
| | - Carmen Balague
- Deparment of General Surgery, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
| | - Carlos Rodriguez-Luppi
- Deparment of General Surgery, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
| | - Ana B Martin
- Deparment of General Surgery, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
| | - Manuel Trias
- Deparment of General Surgery, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
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Is Resection of an Esophageal Epiphrenic Diverticulum Always Necessary in the Setting of Achalasia? World J Surg 2014; 39:203-7. [DOI: 10.1007/s00268-014-2770-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Bagheri R, Maddah G, Mashhadi MR, Haghi SZ, Tavassoli A, Ghamari MJ, Sheibani S. Esophageal diverticula: Analysis of 25 cases. Asian Cardiovasc Thorac Ann 2013; 22:583-7. [PMID: 24867034 DOI: 10.1177/0218492313515251] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND esophageal diverticula are classified as 2 types: true diverticula and pseudodiverticula. These disorders result in clinical manifestations such as dysphagia and esophageal reflux. In this study, we evaluated the results of surgical treatment for diverticula. METHODS all patients suffering from symptomatic esophageal diverticulum, who underwent surgical treatment in Ghaem Hospital from 2000 to 2012 and were followed up for at least for one year, were included in the study. Age, sex, clinical manifestations, location, surgical approach, and mortality were evaluated. There were 25 patients (15 men and 10 women) with a mean age of 41 ± 8.3 years. RESULTS the most common site of involvement was inferior (epiphrenic diverticulum). Barium swallow was diagnostic. After surgical treatment, complications occurred in 4 (16%) patients, comprising anastomosis site leakage, hoarseness, atelectasis, and wound infection; all were treated medically. There was no postoperative mortality. All patients experienced an improvement in symptoms during one year of follow-up. CONCLUSION due to the good results and minimal complications postoperatively, surgical treatment is recommended for patients with symptomatic esophageal diverticulum.
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Affiliation(s)
- Reza Bagheri
- Cardiothoracic Surgery & Transplant Research Center, Emam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ghodratollah Maddah
- Endoscopic & Minimally Invasive Surgery Research Center, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammadtaghi Rajabi Mashhadi
- Endoscopic & Minimally Invasive Surgery Research Center, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Ziaollah Haghi
- Cardiothoracic Surgery & Transplant Research Center, Emam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alireza Tavassoli
- Endoscopic & Minimally Invasive Surgery Research Center, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Javad Ghamari
- Endoscopic & Minimally Invasive Surgery Research Center, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shima Sheibani
- Cardiothoracic Surgery & Transplant Research Center, Emam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Fei L, Rossetti G, Moccia F, Marra T, Guadagno P, Docimo L, Cimmino M, Napolitano V, Docimo G, Napoletano D, Guerriero L, Pascotto B. Is the advanced age a contraindication to GERD laparoscopic surgery? Results of a long term follow-up. BMC Surg 2013; 13 Suppl 2:S13. [PMID: 24267613 PMCID: PMC3851262 DOI: 10.1186/1471-2482-13-s2-s13] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background In this prospective non randomized observational cohort study we have
evaluated the influence of age on outcome of laparoscopic total
fundoplication for GERD. Methods Six hundred and twenty consecutive patients underwent total laparoscopic
fundoplication for GERD. Five hundred and twenty-four patients were younger
than 65 years (YG), and 96 patients were 65 years or older (EG). The
following parameters were considered in the preoperative and postoperative
evaluation: presence, duration, and severity of GERD symptoms, presence of a
hiatal hernia, manometric and 24 hour pH-monitoring data, duration of
operation, incidence of complications and length of hospital stay. Results Elderly patients more often had atypical symptoms of GERD and at manometric
evaluation had a higher rate of impaired esophageal peristalsis in
comparison with younger patients. The duration of the operation was similar
between the two groups. The incidence of intraoperative and postoperative
complications was low and the difference was not statistically significant
between the two groups. An excellent outcome was observed in 93.0% of young
patients and in 88.9% of elderly patients (p = NS). Conclusions Laparoscopic antireflux surgery is a safe and effective treatment for GERD
even in elderly patients, warranting low morbidity and mortality rates and a
significant improvement of symptoms comparable to younger patients.
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Andrade RS. Introduction: Laparoscopic repair of epiphrenic diverticulum. Semin Thorac Cardiovasc Surg 2012. [PMID: 23200077 DOI: 10.1053/j.semtcvs.2012.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Rafael S Andrade
- Division of General Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota 55455, USA.
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Minimally invasive surgery for esophageal epiphrenic diverticulum: the results of 133 patients in 25 published series and our experience. Surg Today 2012; 43:1-7. [DOI: 10.1007/s00595-012-0386-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Accepted: 09/05/2010] [Indexed: 11/26/2022]
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SAGES guidelines for the surgical treatment of esophageal achalasia. Surg Endosc 2011; 26:296-311. [PMID: 22044977 DOI: 10.1007/s00464-011-2017-2] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 08/24/2011] [Indexed: 12/19/2022]
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Laparoscopic treatment of epiphrenic diverticula: preoperative evaluation and surgical technique. How I do it. J Gastrointest Surg 2011; 15:1866-71. [PMID: 21786061 DOI: 10.1007/s11605-011-1631-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 07/12/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Traditionally, epiphrenic diverticula have been managed through a left thoracotomy. With the advancement of minimally invasive techniques, a laparoscopic approach has gained widespread popularity. Unfortunately, the preoperative evaluation of patients with epiphrenic diverticula, and their surgical management, is still not well characterized. DISCUSSION The goal of this article is to illustrate our approach to patients with epiphrenic diverticula in terms of preoperative evaluation and surgical technique. The final discussion will focus on the evidence-based rationale for our preoperative assessment and surgical approach.
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Herbella FAM, Patti MG. Modern pathophysiology and treatment of esophageal diverticula. Langenbecks Arch Surg 2011; 397:29-35. [PMID: 21887578 DOI: 10.1007/s00423-011-0843-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 08/22/2011] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil.
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Soares RV, Montenovo M, Pellegrini CA, Oelschlager BK. Laparoscopy as the initial approach for epiphrenic diverticula. Surg Endosc 2011; 25:3740-6. [DOI: 10.1007/s00464-011-1779-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 05/14/2011] [Indexed: 02/08/2023]
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Pernazza G, Monsellato I, Pende V, Alfano G, Mazzocchi P, D'Annibale A. Fully robotic treatment of an epiphrenic diverticulum: Report of a case. MINIM INVASIV THER 2011; 21:96-100. [DOI: 10.3109/13645706.2011.560608] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Laubert T, Hildebrand P, Roblick UJ, Kraus M, Esnaashari H, Wellhöner P, Bruch HP. MIS approach for diverticula of the esophagus. Eur J Med Res 2010; 15:390-6. [PMID: 20952348 PMCID: PMC3351906 DOI: 10.1186/2047-783x-15-9-390] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Purpose Diverticula of the esophagus represent a rare pathological entity. Distinct classifications of the disease imply different surgical concepts. Surgery should be reserved for symptomatic patients only. Minimally invasive surgery (MIS) for treatment of esophageal diverticula encompasses rigid and flexible intraluminal endoscopy, thoracoscopy and laparoscopy. We here give an overview on the pathogenesis of esophageal diverticula, the minimally invasive surgical techniques for treatment and the recent literature. Additionally, we present our own experience with MIS for midthoracic diverticula. Methods We analyzed the cases of patients who underwent MIS for midthoracic diverticula with regard to preoperative symptoms, perioperative and follow-up data. Results Three patients (two female, one male, age 79, 78 and 59 years) received thoracoscopic surgery for midthoracic diverticula. All patients reported of dysphagia and regurgitation. In two patients pH-investigation showed pathological reflux but manometry was normal in all patients. Operating time was 205, 135 and 141 minutes. We performed intraoperative intraluminal endoscopy in all patients. There were no intraoperative complications and although no surgical complications occured postoperatively one patient developed pneumonia which advanced to sepsis and lethal multi organ failure. Upon follow-up the two patients did not have recurrent diverticula or a recurrence of previous symptoms. Conclusions Surgery for diverticular disease of the esophagus has been associated with high rates of morbidity and mortality. Despite the lethal non-surgical complication we encountered, with regard to recent publications minimally invasive apporaches to treat patients with symptomatic esophageal diverticula entail lower rates of complications with better long term results in comparison to open surgery.
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Affiliation(s)
- Tilman Laubert
- Department of Surgery, University of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23552 Lübeck, Germany.
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Epiphrenic diverticulum of the esophagus. From pathophysiology to treatment. J Gastrointest Surg 2010; 14:2009-15. [PMID: 20437107 DOI: 10.1007/s11605-010-1216-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2010] [Accepted: 04/20/2010] [Indexed: 01/31/2023]
Abstract
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.
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Abstract
For the most part, the management of benign esophageal disease in all patients is in evolution. Advances in laparoscopic, thoracoscopic, and endoscopic techniques have lessened the morbidity and mortality associated with the traditional approaches to this pathology. Our understanding of the pathophysiology of primary motor disorders remains incomplete but is certainly more advanced than our understanding just a decade ago. As research continues in this area, our knowledge will increase. Persistent development efforts with industry will continue to provide less invasive options for the management of these patients, and, eventually, the results associated with these techniques will improve as well. For the management of these pathologies in the elderly, the critical issues are the associated comorbidities, the current quality of life, the life expectancy, and the desired quality of life. The optimal treatment strategy may be determined by consideration of all of these factors along with the relative effectiveness and durability of each treatment strategy for the individual elderly patient.
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Affiliation(s)
- M Blair Marshall
- Division of Thoracic Surgery, Georgetown University Medical Center, Georgetown University School of Medicine, 4 PHC, 3800 Reservoir Road, NW, Washington, DC 20007, USA.
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Epiphrenic Diverticulum: Robotic-Assisted Transhiatal Approach. Surg Laparosc Endosc Percutan Tech 2009; 19:e184-8. [DOI: 10.1097/sle.0b013e3181bb83b8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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D'Journo XB, Ferraro P, Martin J, Chen LQ, Duranceau A. Lower oesophageal sphincter dysfunction is part of the functional abnormality in epiphrenic diverticulum. Br J Surg 2009; 96:892-900. [PMID: 19591165 DOI: 10.1002/bjs.6652] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- X B D'Journo
- Department of Surgery, Division of Thoracic Surgery, Université de Montréal, Montreal, Quebec, Canada
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41
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Squamous cell carcinoma in a large epiphrenic esophageal diverticulum. Dig Dis Sci 2009; 54:1365-8. [PMID: 19184423 DOI: 10.1007/s10620-009-0727-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2006] [Accepted: 01/18/2007] [Indexed: 12/09/2022]
Abstract
Carcinoma is rare in an esophageal diverticulum. The case of a 53-year-old man with a large mass in a long-standing symptomatic epiphrenic esophageal diverticulum is presented in this study. Squamous cell carcinoma in the diverticulum with pleural invasion was diagnosed after surgical diverticulectomy. The patient underwent subtotal esophagectomy with locoregional lymph node dissection and reconstruction with gastric tube because of micro-invasion at the surgical margin. The patient developed malignant pleural effusion at 6 months after surgery, and he eventually expired 3 months later. Carcinoma can develop in esophageal diverticula and is usually diagnosed at an advanced stage with poor prognosis.
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Ruiz De Angulo Martín D, Ortiz Escandell MÁ, Martínez De Haro LF, Munítiz Ruiz V, Parrilla Paricio P. Divertículos epifrénicos: ¿cuándo y cómo operar? Cir Esp 2009; 85:196-204. [DOI: 10.1016/j.ciresp.2008.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Accepted: 10/07/2008] [Indexed: 10/21/2022]
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Videothoracoscopic management of middle esophageal diverticulum with secondary bronchoesophageal fistula: Report of a case. Surg Today 2008; 38:1124-8. [DOI: 10.1007/s00595-008-3797-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2007] [Accepted: 02/14/2008] [Indexed: 10/21/2022]
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Esophageal manometric characteristics and outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication for epiphrenic diverticula. Surg Endosc 2008; 23:1337-41. [PMID: 18813978 DOI: 10.1007/s00464-008-0165-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2008] [Revised: 07/21/2008] [Accepted: 08/13/2008] [Indexed: 12/21/2022]
Abstract
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.
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Zaninotto G, Portale G, Costantini M, Merigliano S, Guirroli E, Rizzetto C, Rampado S, Ancona E. Long-term outcome of operated and unoperated epiphrenic diverticula. J Gastrointest Surg 2008; 12:1485-90. [PMID: 18622660 DOI: 10.1007/s11605-008-0570-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Accepted: 06/04/2008] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Giovanni Zaninotto
- General Surgery, Venice Hospital, ULSS12, University of Padova School of Medicine, Via Giustiniani 2, 35128, Padova, Italy.
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Long-term Botulinum Toxin Treatment for Dysphagia Due to Large Epiphrenic Diverticulum in Elderly Patients: A Report of Two Cases. Dysphagia 2008; 24:109-13. [DOI: 10.1007/s00455-008-9159-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2007] [Accepted: 02/01/2008] [Indexed: 11/29/2022]
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Varghese TK, Marshall B, Chang AC, Pickens A, Lau CL, Orringer MB. Surgical treatment of epiphrenic diverticula: a 30-year experience. Ann Thorac Surg 2007; 84:1801-9; discussion 1801-9. [PMID: 18036889 DOI: 10.1016/j.athoracsur.2007.06.057] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2006] [Revised: 06/10/2007] [Accepted: 06/13/2007] [Indexed: 12/22/2022]
Abstract
BACKGROUND Epiphrenic diverticula are rare and associated with esophageal motility abnormalities. Their optimal surgical treatment is debated, mortality being 9% in the largest reported surgical series of 33 patients. Our experience with a traditional thoracic approach was reviewed to provide benchmark data against which newer surgical techniques can be measured. METHODS A retrospective review of 35 patients operated on for epiphrenic diverticula from 1976 to 2005 was conducted. All underwent open transthoracic operations: resection of the diverticulum, long esophagomyotomy, and antireflux operations (modified Belsey, 29 patients; Nissen, 4 patients) in 33 patients; resection and long myotomy alone in 1 patient; and plication, long myotomy, and Collis-Nissen in 1 patient. Preoperative assessment included barium esophagogram, flexible esophagoscopy, manometry, and standard acid reflux test. Operative complications and functional results were assessed. RESULTS Median age was 71 years (range, 36 to 87 years). Diverticulum size averaged 6.4 cm (range, 3 to 14 cm). Sixty-eight percent presented to the right of the esophagus. The median duration of symptoms was 3 years. Presenting complaints included dysphagia (83%), regurgitation (69%), and chest pain (26%). Eighteen had a mean weight loss of 19 pounds. There was 1 perioperative death (2.8%) from a plicated diverticulum leak and one nonfatal suture line leak. Median hospital stay was 7 days. Mean follow-up was 45.3 months. Twenty-six patients (74%) had an excellent result (no residual symptoms). Seven required a periodic esophageal dilatation for intermittent mild dysphagia. CONCLUSIONS Traditional transthoracic resection, long esophagomyotomy, and an antireflux procedure provide excellent long-term functional results with relatively low postoperative morbidity in patients with epiphrenic diverticula.
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Affiliation(s)
- Thomas K Varghese
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI 48109-0344,USA
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del Genio G, Rossetti G, Brusciano L, Limongelli P, Pizza F, Tolone S, Fei L, Maffettone V, Napolitano V, del Genio A. Laparoscopic Nissen-Rossetti fundoplication with routine use of intraoperative endoscopy and manometry: technical aspects of a standardized technique. World J Surg 2007; 31:1099-106. [PMID: 17426906 DOI: 10.1007/s00268-006-0495-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Several different ways of fashioning a total fundoplication lead to different outcomes. This article addresses the technical details of the antireflux technique we adopted without modifications for all patients with GERD beginning in 1972. In particular it aims to discuss the relation between the mechanism of function of the wrap and the physiology of the esophagus. METHODS The study population consisted of 380 patients affected by GERD with a 1-year minimum of follow-up who underwent laparoscopic Nissen-Rossetti fundoplication by a single surgeon. RESULTS No conversion to open surgery and no mortality occurred. Major complications occurred in 4 patients (1.1%). Follow-up (median 83 months; range: 1-13 years) was achieved in 96% of the patients. Ninety-two percent of the patients were satisfied with the results of the procedure and would undergo the same operation again. Postoperative dysphagia occurred in 3.5% of the patients, and recurrent heartburn was observed in 3.8%. CONCLUSIONS Laparoscopic Nissen-Rossetti fundoplication with the routine use of intraoperative manometry and endoscopy achieved good outcomes and long-term patient satisfaction with few complications and side-effects. Appropriate preoperative investigation and a correct surgical technique are important in securing these results.
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Affiliation(s)
- Gianmattia del Genio
- First Division of General and Gastrointestinal Surgery, Second University of Naples, via Pansini, 5 I-80131, Naples, Italy.
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Reznik SI, Rice TW, Murthy SC, Mason DP, Apperson-Hansen C, Blackstone EH. Assessment of a pathophysiology-directed treatment for symptomatic epiphrenic diverticulum. Dis Esophagus 2007; 20:320-7. [PMID: 17617881 DOI: 10.1111/j.1442-2050.2007.00716.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- S I Reznik
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Abstract
Epiphrenic diverticula are rare. Their true incidence is unknown. Thoracotomy or thoracoscopy with resection and myotomy is the most common reported approach for the surgical treatment of epiphrenic esophageal diverticula. In patients with large epiphrenic diverticula, the laparoscopic approach is an uncommon procedure. In this case, the laparoscopic transhiatal approach was shown to be safe and effective over with short-term follow-up. However, long-term follow-up of this procedure is needed.
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Affiliation(s)
- F A Granderath
- Division of Surgical Endoscopy, Department of General, Visceral and Transplant Surgery, University Hospital of Tuebingen, Hoppe-Seyler-Strasse 3, D-72076 Tuebingen, Germany.
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