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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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Qasim A, Lajara P, Jyala A, Patel H, Ghazanfar H. Understanding Esophageal Diverticular Bleeding: Causes, Symptoms, and Treatment. Cureus 2023; 15:e42991. [PMID: 37671216 PMCID: PMC10476628 DOI: 10.7759/cureus.42991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2023] [Indexed: 09/07/2023] Open
Abstract
Esophageal diverticulum refers to a sac or protrusion formed by the epithelial-lined tissue of the esophagus. It can exist as either a true diverticulum involving all layers of the esophagus or a false diverticulum. Most cases of esophageal diverticula are acquired conditions that primarily affect older individuals. Typically, patients with a known motility disorder experience dysphagia as a common symptom of esophageal diverticulum; other symptoms include recurrent pneumonia, hoarseness, and halitosis. Failure to diagnose this condition promptly or accurately can result in more severe complications, such as gastrointestinal bleeding, lung abscesses, aspiration pneumonia, and cancer development. In this report, we present the case of a 68-year-old female who arrived at the emergency department with symptoms of epigastric discomfort and hematemesis and was found to have diverticula in the middle portion of the esophagus.
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Affiliation(s)
- Abeer Qasim
- Internal Medicine, BronxCare Health System, Bronx, USA
| | | | | | - Harish Patel
- Medicine/Gastroenterology, BronxCare Health System, Bronx, USA
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Sato Y, Tanaka Y, Ohno S, Endo M, Okumura N, Takahashi T, Matsuhashi N. Optimal surgical approaches for esophageal epiphrenic diverticulum: literature review and our experience. Clin J Gastroenterol 2023; 16:317-324. [PMID: 36723767 DOI: 10.1007/s12328-023-01765-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 01/18/2023] [Indexed: 02/02/2023]
Abstract
Esophageal epiphrenic diverticulum is a rare condition usually secondary to a primary esophageal motility disorder. Although epiphrenic diverticulum may be treated by thoracoscopic and laparoscopic management, the optimal surgical approach have not been established. We successfully treated a left epiphrenic diverticulum along with achalasia and paraesophageal hernia by a planned combination of thoracoscopic and laparoscopic procedures aided by preoperative simulation using three-dimensional imaging. We reviewed a series of 17 reports on esophageal epiphrenic diverticulum that required either planned or unplanned unexpected transthoracic surgery. The main reasons for requiring a transthoracic approach were adhesions, site and size of the diverticulum, and length of the diverticulum neck. Unplanned procedure changes were required in 12 of the 114 cases for a conversion rate of 10.5%. Diverticulectomy, myotomy, and fundoplication were the most common surgical treatments administered at 42.6%. Based on literature review and our experience, we have developed a flowchart to identify the characteristics of epiphrenic diverticulum cases that require a transthoracic approach. This flowchart can help to determine therapeutic strategies and the optimal surgical approach to esophageal epiphrenic diverticulum treatment and may reduce unplanned changes in the surgery.
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Affiliation(s)
- Yuta Sato
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu Graduate School of Medicine, 1-1 Yanagido, Gifu City, Gifu Prefecture, 501-1194, Japan
| | - Yoshihiro Tanaka
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu Graduate School of Medicine, 1-1 Yanagido, Gifu City, Gifu Prefecture, 501-1194, Japan.
| | - Shinya Ohno
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu Graduate School of Medicine, 1-1 Yanagido, Gifu City, Gifu Prefecture, 501-1194, Japan
| | - Masahide Endo
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu Graduate School of Medicine, 1-1 Yanagido, Gifu City, Gifu Prefecture, 501-1194, Japan
| | - Naoki Okumura
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu Graduate School of Medicine, 1-1 Yanagido, Gifu City, Gifu Prefecture, 501-1194, Japan
| | - Takao Takahashi
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu Graduate School of Medicine, 1-1 Yanagido, Gifu City, Gifu Prefecture, 501-1194, Japan
| | - Nobuhisa Matsuhashi
- Department of Gastroenterological Surgery and Pediatric Surgery, Gifu Graduate School of Medicine, 1-1 Yanagido, Gifu City, Gifu Prefecture, 501-1194, Japan
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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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Nitsche U, Seitz M, Friess H, Feussner H, Hüser N, Jell A. Long-term outcome of patients with epiphrenic diverticula: A retrospective single-center analysis over 20 years. Surgery 2022; 172:1689-1696. [PMID: 36202656 DOI: 10.1016/j.surg.2022.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/30/2022] [Accepted: 08/24/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Epiphrenic diverticula are extremely rare. Evidence-based treatment recommendations are scarce. The primary study outcome was to examine whether surgical treatment in patients with epiphrenic diverticula leads to improved quality of life by outweighing the perioperative risks compared with conservative treatment. METHODS All patients with an epiphrenic diverticula at our institution between 2001 and 2021 were retrospectively reviewed and followed-up using a specific questionnaire, including the Eating Assessment Tool, and Gastrointestinal Quality of Life Index quality-of-life scores. RESULTS Of 51 patients with epiphrenic diverticula, 28 had surgery and 23 had conservative treatment. The most common symptom at presentation was dysphagia. Although 16 patients underwent open surgery, 12 had minimally invasive procedures. A prophylactic stent was applied intraoperatively in 6 patients. The morbidity rate in surgically treated patients was 50% (14/28), with a leakage in 43% (12/28; 33% for prophylactic stenting). Mortality was nil. At a median follow-up of 139 months, patients with surgery had better outcomes than those without (ie, less dysphagia [6/12 vs 11/12; P = .025]), a less likely pathologic Eating Assessment Tool score (4/12 vs 9/12; P = .041), and a nonsignificant better Gastrointestinal Quality of Life Index score (122 vs 112; P = .929). The rate of recurrence/progression of symptoms was significantly higher for conservatively treated patients (11/18 vs 6/27 for any surgery; P = .008), as well as for patients with minimally invasive procedure (5/12 vs 1/15 for open surgery; P = .030). CONCLUSION Despite the high perioperative morbidity, surgical treatment of epiphrenic diverticula leads to an improved long-term quality of life and lower recurrence rates than conservative treatment.
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Affiliation(s)
- Ulrich Nitsche
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Marie Seitz
- School of Medicine, Technical University of Munich, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hubertus Feussner
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Norbert Hüser
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alissa Jell
- Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Ueno S, Ogawa R, Saito M, Ito S, Hayakawa S, Okubo T, Sagawa H, Tanaka T, Takahashi H, Matsuo Y, Mitsui A, Kimura M, Takiguchi S. Benefits of laparoscopic trans-hiatal approach with Heller-Dor surgery in a case of mid-esophageal diverticulum. Asian J Endosc Surg 2022; 16:289-292. [PMID: 36376259 DOI: 10.1111/ases.13140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/27/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022]
Abstract
Compared to the more common epiphrenic diverticula, those located at the central section of the esophagus are quite rare. Minimally invasive approaches for mid-esophageal diverticula have lacked standardization. Certain mid-esophageal diverticula, like epiphrenic diverticula, have been attributed to esophageal motility disorders. Thus, we believe that surgery for esophageal diverticula requires preoperative evaluation of esophageal function, with additional surgery being performed in case of abnormalities. The laparoscopic trans-hiatal approach has been a common technique for managing epiphrenic diverticula but can also be used for mid-esophageal diverticula located far from the esophagogastric junction provided that the port location is carefully considered. Laparoscopic surgery is also preferable given that it is a minimally invasive procedure and allows for diverticulum resection and Heller myotomy and Dor surgery to prevent reflux in the same field of view. Hence, laparoscopic surgery may be a beneficial alternative to the traditional thoracic or thoracoabdominal techniques.
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Affiliation(s)
- Shuhei Ueno
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Ryo Ogawa
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masaki Saito
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Sunao Ito
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shunsuke Hayakawa
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tomotaka Okubo
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiroyuki Sagawa
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tatsuya Tanaka
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiroki Takahashi
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yoichi Matsuo
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Akira Mitsui
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masahiro Kimura
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shuji Takiguchi
- Department of Gastroenterological Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Gergen AK, Pratap A. A robotic-assisted approach is safe and effective for repairing giant epiphrenic diverticulum. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2022. [DOI: 10.1016/j.lers.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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11
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Roh S. Foregut Diverticula. Korean J Fam Med 2021; 42:191-196. [PMID: 31658807 PMCID: PMC8164925 DOI: 10.4082/kjfm.18.0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/26/2018] [Accepted: 11/13/2018] [Indexed: 11/23/2022] Open
Abstract
Diverticular disease can present anywhere along the gastrointestinal (GI) tract. It can result from various pathologies such as abnormal contraction within the GI tract or inflammation causing scar tissue and the resulting forces surrounding the GI tract. Its clinical presentation can vary from asymptomatic to severe symptoms, with significant decrease in quality of life. The treatment for various diverticula along the GI tract can also vary, depending on the severity of symptoms. This article describes diverticular disease occurring within the foregut, with emphasis on pathophysiology, clinical presentation, and treatment.
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Affiliation(s)
- Simon Roh
- Division of Interventional Radiology, New York Presbyterian Hospital–Weill Cornell Medical Center, New York, NY, USA
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Yong Z, Dingding W, Kaiyun H, Yichao G, Yanan Z, Junmin L, Shen Y, Shuangshuang L, Peize W, Jinshi H. Thoracoscopy for Esophageal Diverticula After Esophageal Atresia With Tracheo-Esophageal Fistula. Front Pediatr 2021; 9:663705. [PMID: 34017810 PMCID: PMC8129005 DOI: 10.3389/fped.2021.663705] [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: 02/03/2021] [Accepted: 04/06/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Esophageal diverticulum (ED) is an extremely rare complication of congenital esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) surgery. We aimed to investigate feasible methods for the treatment of this rare complication. Methods: We retrospectively reviewed all patients with EA/TEF at Beijing Children's Hospital from January 2015 to September 2019. The clinicopathological features of patients with ED after EA/TEF surgery were recorded. Follow-up was routinely performed after surgery until December 2020. Results: Among 198 patients with EA/TEF, ED only occurred in four patients (2.02%; one male, three female). The four patients had varying complications after the initial operation, including anastomotic leakage (3/4), esophageal stenosis (3/4), and recurrence of TEF (1/4). The main clinical symptoms of ED included recurrent pneumonia (4/4), coughing (4/4), and dysphagia (3/4). All ED cases occurred near the esophageal anastomosis. Patients' age at the time of diverticulum repair was 6.6-16.8 months. All patients underwent thoracoscopic esophageal diverticulectomy (operation time: 1.5-3.5 h). Anastomotic leakage occurred in one patient and spontaneously healed after 2 weeks. The other three patients had no peri-operative complications. All patients were routinely followed up after surgery for 14-36 months. During the follow-up period, all patients could eat orally, had good growth and weight gain, and showed no ED recurrence or anastomotic leakage on esophagogram. Conclusions: ED is a rare complication after EA/TEF surgery and is a clear indication for diverticulectomy. During the midterm follow-up, thoracoscopic esophageal diverticulectomy was safe and effective for ED after EA/TEF surgery.
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Affiliation(s)
- Zhao Yong
- Department of Neonatal Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Wang Dingding
- Department of Neonatal Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Hua Kaiyun
- Department of Neonatal Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Gu Yichao
- Department of Neonatal Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Zhang Yanan
- Department of Neonatal Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Liao Junmin
- Department of Neonatal Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Yang Shen
- Department of Neonatal Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Li Shuangshuang
- Department of Neonatal Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Wang Peize
- Department of Neonatal Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Huang Jinshi
- Department of Neonatal Surgery, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
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13
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Gupta V, Darling G. Commentary: Measure Twice, Cut Once: Understanding the Anatomy and Physiology of Esophageal Epiphrenic Diverticula Guides Optimal Surgical Management. Semin Thorac Cardiovasc Surg 2020; 33:249-250. [PMID: 33171244 DOI: 10.1053/j.semtcvs.2020.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/14/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Vaibhav Gupta
- Department of Surgery and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto,Canada.
| | - Gail Darling
- Department of Surgery and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto,Canada; Toronto General Hospital, University Health Network, Toronto, Canada
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14
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Louie BE. Commentary: Toward Minimally Invasive Management of Epiphrenic Diverticula. Semin Thorac Cardiovasc Surg 2020; 33:247-248. [PMID: 33171237 DOI: 10.1053/j.semtcvs.2020.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 10/14/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Brian E Louie
- Thoracic Research Program, Minimally Invasive Thoracic Surgery Program, Swedish Digestive Health Institute, Seattle, Washington.
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15
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Sudarshan M, Fort MW, Barlow JM, Allen MS, Ravi K, Nichols F, Cassivi SD, Wigle DA, Shen RK, Blackmon SH. Management of Epiphrenic Diverticula and Short-term Outcomes. Semin Thorac Cardiovasc Surg 2020; 33:242-246. [PMID: 32853738 DOI: 10.1053/j.semtcvs.2020.08.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/20/2020] [Indexed: 12/31/2022]
Abstract
Epiphrenic diverticulum is a rare and benign condition with significant surgical morbidity and evolving surgical management. The objective of this study was to analyze short-term clinical outcomes after surgery for epiphrenic diverticula. We conducted a retrospective cohort study in a single tertiary care center of all patients who underwent treatment for epiphrenic esophageal diverticula from June 1990 to December 2016. Data collection included demographics, operative details and short-term outcomes (esophageal leak, other complications, 30-day mortality). In addition, all preoperative imaging was reviewed by an esophageal radiologist in order to describe epiphrenic diverticula characteristics in a uniform and blinded manner. Of the 94 patients in the study, 84 patients were managed with an open surgical approach and 10 with minimally invasive techniques. Median size of diverticula was 5.5 cm and mean height above gastroesophageal junction was 4 cm. A myotomy was completed in 95% of patients and a fundoplication in 58%. The MIS group had a shorter length of stay (4 vs 6 days). Overall complication rate was 27% with an esophageal leak rate of 7% with 60% grade I leaks that sealed with conservative management. Complete resection of the diverticulum, closure of the muscle over the resection, contralateral myotomy, and consideration for partial fundoplication are common strategies utilized to surgically treat patients with epiphrenic diverticulum. Minimally invasive approaches are increasingly utilized.
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Affiliation(s)
- Monisha Sudarshan
- Division of Cardiovascular and Thoracic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael W Fort
- Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - John M Barlow
- Division of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Mark S Allen
- Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Karthik Ravi
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Francis Nichols
- Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Dennis A Wigle
- Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert K Shen
- Division of Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
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16
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Fujinaga A, Shibata T, Etoh T, Tada K, Suzuki K, Nishiki K, Ogawa K, Kono Y, Hiratsuka T, Akagi T, Ueda Y, Toujigamori M, Shiroshita H, Shiraishi N, Inomata M. Laparoscopic transhiatal surgery for an epiphrenic esophageal diverticulum derived from a jackhammer esophagus: a case report. Surg Case Rep 2020; 6:151. [PMID: 32601779 PMCID: PMC7324458 DOI: 10.1186/s40792-020-00900-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/09/2020] [Indexed: 12/15/2022] Open
Abstract
Background An esophageal diverticulum is rare and is frequently associated with esophageal motility disorders. Jackhammer esophagus is also rare, is characterized by esophageal hypercontraction, and comprises 4.1% of esophageal motility disorders. Here, we report a case of a patient successfully treated by laparoscopic transhiatal surgery for an epiphrenic esophageal diverticulum derived from a jackhammer esophagus diagnosed with high-resolution manometry (HRM). Case presentation The patient was a 78-year-old man who presented to the hospital with dysphagia. A diverticulum was detected in the lower part of his esophagus by upper gastrointestinal endoscopy. HRM was performed to investigate esophageal motility disorders. His integrated relaxation pressure was normal at 25.9 (< 26) mmHg, but his distal contractile integral (DCI) was very high at 21,464 (1500–13,000) mmHg s cm. Esophageal peristalsis was preserved. Therefore, the patient was diagnosed as having an epiphrenic esophageal diverticulum derived from a jackhammer esophagus for which laparoscopic transhiatal diverticulectomy and Heller-Dor procedure were performed. The postoperative course was uneventful. His symptoms improved, and the level of DCI also returned to a normal level of 3867 mmHg s cm at 2 months after the operation. Conclusion Laparoscopic transhiatal diverticulectomy and esophagomyotomy can be useful procedures for an epiphrenic esophageal diverticulum derived from a jackhammer esophagus due to their lower invasiveness.
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Affiliation(s)
- Atsuro Fujinaga
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Idaigaoka 1-1, Hasama-machi, Oita, 879-5593, Japan.
| | - Tomotaka Shibata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Idaigaoka 1-1, Hasama-machi, Oita, 879-5593, Japan
| | - Tsuyoshi Etoh
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Idaigaoka 1-1, Hasama-machi, Oita, 879-5593, Japan
| | - Kazuhiro Tada
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Idaigaoka 1-1, Hasama-machi, Oita, 879-5593, Japan
| | - Kosuke Suzuki
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Idaigaoka 1-1, Hasama-machi, Oita, 879-5593, Japan
| | - Kohei Nishiki
- Department of Gastroenterological Surgery, Oita Nakamura Hospital, Oita, Japan
| | - Katsuhiro Ogawa
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Idaigaoka 1-1, Hasama-machi, Oita, 879-5593, Japan
| | - Yohei Kono
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Idaigaoka 1-1, Hasama-machi, Oita, 879-5593, Japan
| | - Takahiro Hiratsuka
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Idaigaoka 1-1, Hasama-machi, Oita, 879-5593, Japan
| | - Tomonori Akagi
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Idaigaoka 1-1, Hasama-machi, Oita, 879-5593, Japan
| | - Yoshitake Ueda
- Department of Comprehensive Surgery for Community Medicine, Oita University Faculty of Medicine, Oita, Japan
| | - Manabu Toujigamori
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Idaigaoka 1-1, Hasama-machi, Oita, 879-5593, Japan
| | - Hidefumi Shiroshita
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Idaigaoka 1-1, Hasama-machi, Oita, 879-5593, Japan
| | - Norio Shiraishi
- Department of Comprehensive Surgery for Community Medicine, Oita University Faculty of Medicine, Oita, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Idaigaoka 1-1, Hasama-machi, Oita, 879-5593, Japan
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17
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A Case of a Giant Epiphrenic Esophageal Diverticulum. ACTA MEDICA BULGARICA 2020. [DOI: 10.2478/amb-2020-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract
The esophageal diverticula are divided into pharyngoesophageal, parabronchial and epiphrenic. They could also be divided into congenital and acquired, true and false, pulsion and traction. Pulsion diverticula are usually formed in motor disorders of the esophagus, above the place of hypertension and uncoordinated peristalsis. They are pseudo-diverticula caused by increased intramural pressure, leading to herniation of the mucosa and submucosa through the focal areas of the esophageal wall. We present a 65-year-old woman who underwent left-sided transthoracic diverticulectomy, modified Heller esophagocardiomyotomy, and modified Belsey-Mark IV fundoplication due to a huge epiphrenic esophageal diverticulum.
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18
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Orlandini B, Barret M, Guillaumot MA, Léandri C, Leblanc S, Prat F, Chaussade S. Per-oral endoscopic myotomy for esophageal diverticula with or without esophageal motility disorders. Clin Res Hepatol Gastroenterol 2020; 44:82-89. [PMID: 31080116 DOI: 10.1016/j.clinre.2019.03.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Mid-esophageal and epiphrenic diverticula (MED) can be associated with esophageal motility disorders. Per-oral endoscopic myotomy (POEM) is an established treatment for esophageal motility disorders that has also been introduced for the treatment of MED. METHODS Data were prospectively collected from patients with MED treated with POEM at our institution. When esophageal motility disorders were present, myotomy was performed extending the myotomy to the lower esophageal sphincter (LES) to treat the motility dysfunction associated with the diverticulum. In the absence of esophageal motility disorder, POEM was performed without including the LES in the myotomy to achieve diverticulotomy. RESULTS Four patients were treated with POEM for MED between April 2017 and March 2018. The patients suffered from distal esophageal spasm, jackhammer esophagus or esophago-gastric junction outflow obstruction. One patient had no esophageal motility disorder. Diverticulum size was 3 cm in one case and 6 cm in the others. Preoperative Eckardt scores ranged from 6 to 8. No life-threatening complications were reported. Intraoperative pneumoperitoneum was described in two cases and one patient experienced aspiration pneumonia. The patients with motility disorders were asymptomatic at 6-8 months follow-up. The patient without documented underlying esophageal motility disorder had an Eckardt score of 3 at 9-months follow-up. Two cases of gastro-esophageal reflux were successfully managed with proton pump inhibitors. CONCLUSIONS In the case of MED and esophageal motility disorder, POEM permitted treatment of the underlying cause of the diverticulum, achieving favorable early clinical outcomes. In the absence of motility disorder, POEM was feasible with promising early outcomes, and could be a valid alternative to surgical diverticulectomy in selected patients.
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Affiliation(s)
- Beatrice Orlandini
- Department of gastroenterology, department of experimental and clinical biomedical sciences, Careggi hospital, University of Florence, Viale San Luca, 50134, Florence, Italy; Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
| | - Maximilien Barret
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France.
| | - Marie-Anne Guillaumot
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
| | - Chloé Léandri
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
| | - Sarah Leblanc
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
| | - Frédéric Prat
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
| | - Stanislas Chaussade
- Department of gastroenterology, Cochin hospital, assistance publique - Hôpitaux de Paris, Paris Descartes university, 27, rue du Faubourg St Jacques 75014, Paris, France
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Yatabe K, Oguma J, Ozawa S, Koyanagi K, Kazuno A, Yamamoto M, Ninomiya Y. A thoracoscopically resected case of the diverticulum in the middle esophagus. Surg Case Rep 2019; 5:109. [PMID: 31289952 PMCID: PMC6616558 DOI: 10.1186/s40792-019-0668-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 07/02/2019] [Indexed: 11/16/2022] Open
Abstract
Background Approximately 65% of esophageal diverticulum cases are asymptomatic and are found by endoscopic examination. Symptomatic middle esophageal diverticulum requiring surgery is rare. In recent years, endoscopic surgery for middle esophageal diverticulum has been reported, but cases remain few in number, and the surgical indication, surgical procedure, and postoperative results are unknown. Case presentation A 41-year-old man had been diagnosed as having a middle esophageal diverticulum based on an upper gastrointestinal contrast examination performed when he was 30 years old. He had not received treatment because he was asymptomatic. Eight months earlier, he experienced chest discomfort after eating and visited our hospital. The diameter of his middle esophageal diverticulum was 47 mm. A gastrointestinal endoscopy revealed a diverticulum in the right wall located 30 cm from the incisor row. The pathological findings of the endoscopic biopsy were atypical epithelium and no malignant findings. We confirmed the function of the lower esophageal sphincter, and the esophageal body peristaltic wave was observed to be normal using high-resolution manometry. We decided to perform a thoracoscopic diverticulectomy based on his symptoms and the possibility of malignancy suggested by the atypical epithelium. Surgery was performed with the patient in a prone position via 4 ports, and intraoperative endoscopy was performed during the surgery. To achieve a complete resection of the diverticulum, threads were placed on the oral and anal sides of the diverticulum, the threads were pulled, and the diverticulum was resected using an automatic suturing device. A postoperative upper gastrointestinal contrast examination revealed no abnormalities. He was discharged on postoperative day 12. Conclusions During thoracoscopic surgery for middle esophageal diverticulum, we think that pulling and separating the diverticulum and confirming the lumen using endoscopy are useful for reducing the risk of postoperative recurrence and stenosis. Few reports of long-term performance after surgery have been made for this procedure. Therefore, we believe that long-term follow-up is necessary.
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Affiliation(s)
- Kentaro Yatabe
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Junya Oguma
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.,Department of Esophageal Surgery, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan
| | - Soji Ozawa
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Akihito Kazuno
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Miho Yamamoto
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Yamato Ninomiya
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
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20
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Aiolfi A, Micheletto G, Tringali D, Jonghi-Lavarini E, Bonitta G, Campanelli G, Bona D. Semi-prone video-assisted thoracoscopy for the treatment of large infracarinal traction diverticula. Langenbecks Arch Surg 2019; 404:771-777. [PMID: 31278489 DOI: 10.1007/s00423-019-01801-1] [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] [Received: 03/18/2019] [Accepted: 06/25/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Large middle-third esophageal diverticula are rare. Thoracotomy has been proposed as mainstay of treatment; however, minimally invasive resection through lateral or prone position thoracoscopy has been described. METHODS The technical aspects of the novel semi-prone minimally invasive thoracoscopy (spVATS) in the management of large (> 5 cm) infracarinal traction diverticula are described. Operative outcomes, pre- and postoperative symptoms (Eckardt score) and quality of life (Short-Form 36) are analyzed. RESULTS Four symptomatic patients underwent spVATS for traction midesophageal diverticula. The median age was 59 years and 75% were males. The median diverticulum size was 7.0 cm (range 5.5-8). The median preoperative Eckardt score was 8.4 (range 5-10), and the overall incidence of respiratory symptoms was 50%. Esophageal manometry was performed in three patients with no evidence of underlying motility disorders. The median operative time was 149 min (range 125-175). No intraoperative complications or open conversions occurred. Postoperative morbidity and mortality were 25% and 0%, respectively. The median hospital length of stay was 7.5 days (range 6-10). The median postoperative follow-up was 22 months (range 5-35). At the last follow-up, there was a significant improvement of patients' symptoms (p = 0.024) and quality of life (p < 0.05) with complete resolution of respiratory symptoms. CONCLUSION In summary, spVATS seems a valuable approach to treat large midesophageal traction diverticula in centers experienced with minimally invasive esophageal surgery. Further studies are needed to validate the advantages and promising outcomes of the spVATS providing more robust evidence on the treatment of this rare clinical entity.
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Affiliation(s)
- Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery, Istitituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy.
| | - Giancarlo Micheletto
- Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Domenico Tringali
- Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Eugenio Jonghi-Lavarini
- Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery, Istitituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
| | - Giampiero Campanelli
- Department of Surgery, Istituto Clinico Sant'Ambrogio, University of Insubria, Milan, Italy
| | - Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery, Istitituto Clinico Sant'Ambrogio, University of Milan, Via Luigi Giuseppe Faravelli, 16, 20149, Milan, Italy
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Caso R, Chang H, Marshall MB. Evolving Options in Management of Minimally Invasive Diverticular Disease: A Single Surgeon's Experience and Review of the Literature. J Laparoendosc Adv Surg Tech A 2019; 29:780-784. [DOI: 10.1089/lap.2018.0711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Affiliation(s)
- Raul Caso
- Division of Thoracic Surgery, Department of Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Hoon Chang
- Georgetown University School of Medicine, Washington, District of Columbia
| | - M. Blair Marshall
- Division of Thoracic Surgery, Department of Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
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22
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Onodera Y, Nakano T, Fukutomi T, Naitoh T, Unno M, Shibata C, Kamei T. Thoracoscopic Esophagectomy for a Patient With Perforated Esophageal Epiphrenic Diverticulum After Kidney Transplantation: A Case Report. Transplant Proc 2018; 50:3964-3967. [PMID: 30577297 DOI: 10.1016/j.transproceed.2018.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/29/2018] [Indexed: 10/28/2022]
Abstract
A 58-year-old man who underwent cadaveric kidney transplantation twice presented to hospital with a perforated epiphrenic diverticulum. Computed tomography revealed epiphrenic diverticulitis and right pleural effusion. Upper gastrointestinal fibroscopy showed an epiphrenic diverticulum full of food residue. He was transferred to our hospital, where we performed percutaneous endoscopic gastrostomy under general anesthesia in the supine position before thoracoscopy. Thoracoscopic esophagectomy was performed in the semi-prone position under 6-10 mmHg artificial pneumothorax via the right thoracic cavity. We performed subtotal esophagectomy to remove sources of infection because the esophageal wall surrounding the diverticulum was too thick to close or to perform diverticulectomy. A cervical esophagostomy was constructed after the thoracic procedure. The patient was managed with continuous hemodiafiltration and administered immunosuppressants and steroids to preserve the transplanted kidney. Continuous hemodiafiltration was stopped on postoperative day (POD) 4. The patient was discharged from the intensive care unit on POD 10 and transferred to the original hospital on POD 24 for rehabilitation. The second operative stage was performed on POD 157 at our hospital. We performed gastric tube reconstruction via the ante-sternal route and anastomosed the tube to the cervical esophagus. The postoperative course was uneventful; the patient was transferred to the original hospital on POD 15 after the second operation. Minimally invasive surgery was sufficient to treat perforated epiphrenic diverticulum while preserving the transplanted kidney. We recommend completely removing the source of infection and reducing surgical invasiveness to preserve the transplanted kidney in cases of esophageal perforation following kidney transplantation.
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Affiliation(s)
- Y Onodera
- Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai Miyagi, Japan
| | - T Nakano
- Division of Gastroenterological and Hepatobiliarypancreatic Surgery, Tohoku Medical and Pharmaceutical University, Miyagino-ku, Sendai Miyagi, Japan.
| | - T Fukutomi
- Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai Miyagi, Japan
| | - T Naitoh
- Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai Miyagi, Japan
| | - M Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai Miyagi, Japan
| | - C Shibata
- Division of Gastroenterological and Hepatobiliarypancreatic Surgery, Tohoku Medical and Pharmaceutical University, Miyagino-ku, Sendai Miyagi, Japan
| | - T Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai Miyagi, Japan
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Abstract
Introduction Esophageal diverticulum is a rare entity with symptoms that include dysphagia, halitosis, chest pain, and regurgitation. Indications for surgery include the presence of any of these symptoms and a diverticulum larger than 3 cm because of the increased risk of malignancy and aspiration. Treatment is open or minimally invasive surgery performed from the transhiatal or transthoracic approach. Case Description Three patients were investigated by esophagogastroduodenoscopy, esophageal manometry, and computed tomography and were given the diagnosis of epiphrenic diverticulum of the esophagus. Management and Outcome The patients underwent robot-assisted surgery by a transthoracic approach for esophageal diverticulectomy. The mean operative time was 211 min, with no significant blood loss or intraoperative complications. Discussion This report of robot-assisted surgery for esophageal diverticulectomy from a transthoracic approach adds to the literature regarding surgical treatment of epiphrenic esophageal diverticulum. It is a feasible method that can be used in selected patients with esophageal diverticulum.
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Affiliation(s)
- Bengi Balci
- Department of General Surgery, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Gizem Kilinc
- Department of General Surgery, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Bülent Calik
- Department of General Surgery, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Gökhan Akbulut
- Department of General Surgery, Tepecik Education and Research Hospital, Izmir, Turkey
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24
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Chandeze MM, Gayet B, Cowan J, Ferraz JM, Fuks D. Resection of an Esophageal Diverticulum by Thoracoscopy in Prone Position. Ann Thorac Surg 2018; 107:e153-e155. [PMID: 30315798 DOI: 10.1016/j.athoracsur.2018.08.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/02/2018] [Accepted: 08/12/2018] [Indexed: 10/28/2022]
Abstract
Diverticula of the middle one third of the esophagus are rare clinical entities, by comparison with the more common epiphrenic diverticula. For midesophageal diverticula, a minimally invasive approach has not been standardized. This report presents the case of a 60-year-old man with a large midesophageal diverticulum who was treated successfully by four-port video-assisted thoracic surgery while he was in the prone position. Thoracoscopy is a good approach for direct visualization of the diverticulum, and the prone position has several advantages to help clear the view. Routine myotomy for middle one-third diverticula is not advised, given the risk of poor functional results and diverticulization of the myotomy itself.
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Affiliation(s)
| | - Brice Gayet
- Institut Mutualiste Montsouris, Paris, France
| | - Jane Cowan
- Institut Mutualiste Montsouris, Paris, France
| | | | - David Fuks
- Institut Mutualiste Montsouris, Paris, France
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25
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26
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Kao AM, Arnold MR, Schlosser KA, Siddiqui SL, Prasad T, Colavita PD, Heniford BT. Epiphrenic Diverticulum: 20-Year Single-Institution Experience. Am Surg 2018. [DOI: 10.1177/000313481808400730] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Epiphrenic diverticula are pulsion-type outpouchings of the distal esophagus associated with motility disorders. They can present with chronic symptoms of dysphagia, regurgitation, reflux, and aspiration. A prospectively collected surgical outcomes database was queried for patients who underwent surgical treatment of epiphrenic diverticula at a single institution between August 1997 and August 2018. Patient demographics, presenting symptoms, operative intervention, and perioperative data were retrospectively reviewed. Twenty-seven patients with a symptomatic epiphrenic diverticulum were identified. Abnormal esophageal motility was diagnosed in 16 patients (59.2%), most commonly achalasia (29.6%). All patients had a minimally invasive (26 laparoscopic, one thoracoscopic) diverticulectomy with no conversions to open required. Concurrent myotomy was performed in 88.9 per cent patients and anti-reflux procedure in 85.2 per cent patients. There was minimal morbidity with no esophageal leaks, mortalities, or recurrent diverticula noted after 35.8 months of follow-up. Dysphagia was the most common persistent symptom and occurred in 11.1 per cent; overall resolution of symptoms was achieved with surgery in 89.9 per cent of patients. As minimally invasive techniques have advanced, laparoscopic diverticulectomy seems to be an excellent surgical approach for symptomatic epiphrenic diverticula. Long-term resolution of symptoms was achieved in most patients, with a very low complication rate.
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Affiliation(s)
- Angela M. Kao
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Michael R. Arnold
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Kathryn A. Schlosser
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Sania L. Siddiqui
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Tanushree Prasad
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Paul D. Colavita
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - B. Todd Heniford
- From the Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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27
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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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28
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Surgical Management of Esophageal Epiphrenic Diverticula: A Transthoracic Approach Over Four Decades. Ann Thorac Surg 2017; 104:1123-1130. [DOI: 10.1016/j.athoracsur.2017.06.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 05/31/2017] [Accepted: 06/05/2017] [Indexed: 12/13/2022]
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29
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Khullar OV, Shroff SR, Sakaria SS, Force SD. Midesophageal Pulsion Diverticulum Resulting From Hypercontractile (Jackhammer) Esophagus. Ann Thorac Surg 2017; 103:e127-e129. [PMID: 28109370 DOI: 10.1016/j.athoracsur.2016.07.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/05/2016] [Accepted: 07/13/2016] [Indexed: 10/20/2022]
Abstract
We report a patient with significant dysphagia from hypercontractile "jackhammer" esophagus and a midesophageal pulsion diverticulum. This was treated with a thoracoscopic diverticulectomy and a long esophageal myotomy sparing the lower esophageal sphincter (LES). We describe the clinical diagnosis and surgical treatment of this uncommon esophageal motility disorder. To our knowledge, this is the first report in the literature of a midesophageal diverticulum caused by jackhammer esophagus. We propose that in the setting of normal LES function, successful treatment should include diverticulectomy with an LES-sparing myotomy.
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Affiliation(s)
- Onkar V Khullar
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
| | - Sagar R Shroff
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Sonali S Sakaria
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Seth D Force
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
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30
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Kang DK. Single-port video-assisted thoracoscopic surgery for a huge epiphrenic esophageal diverticulum. J Thorac Dis 2017; 9:E10-E13. [PMID: 28203430 DOI: 10.21037/jtd.2017.01.29] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Epiphrenic esophageal diverticulum is uncommon disease, which is defined as the herniation of the mucosa and submucosa through the muscle layers of the esophageal wall in distal third of the esophagus. Traditionally, thoracotomy has been the preferred surgical approach. Recently, many surgeons have attempted minimally invasive surgeries for epiphrenic esophageal diverticula. They reported that minimally invasive surgery (MIS) for epiphrenic esophageal diverticula was a safe and feasible approach which had many advantages. There are various options of surgical approaches for MIS of epiphrenic diverticula. However, the best surgical approach remains uncertain. We report the case of a huge epiphrenic esophageal diverticulum, which was successfully treated by single-port video-assisted thoracoscopic surgery (VATS).
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Affiliation(s)
- Do Kyun Kang
- Department of Thoracic and Cardiovascular Surgery, Haeundae Paik Hospital, College of Medicine, Inje University, Busan, Korea
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31
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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: 3.6] [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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32
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Macke RA, Luketich JD, Pennathur A, Levy RM. Reply. Ann Thorac Surg 2016; 102:1027-1028. [PMID: 27549525 DOI: 10.1016/j.athoracsur.2016.03.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 03/25/2016] [Accepted: 03/30/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Ryan A Macke
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Ste C-800, Pittsburgh, PA15213
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Ste C-800, Pittsburgh, PA15213
| | - Arjun Pennathur
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Ste C-800, Pittsburgh, PA15213.
| | - Ryan M Levy
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Ste C-800, Pittsburgh, PA15213
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33
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Eroglu A, Aydin Y, Altuntas B. A Minimally Invasive Surgery for Thoracic Esophageal Diverticula. Ann Thorac Surg 2016; 102:1027. [PMID: 27549526 DOI: 10.1016/j.athoracsur.2015.12.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 12/08/2015] [Accepted: 12/16/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Atilla Eroglu
- Department of Thoracic Surgery, Medical Faculty, Ataturk University, Erzurum, Turkey, GSM: 0532 3203638.
| | - Yener Aydin
- Department of Thoracic Surgery, Medical Faculty, Ataturk University, Erzurum, Turkey, GSM: 0532 3203638
| | - Bayram Altuntas
- Department of Thoracic Surgery, Medical Faculty, Ataturk University, Erzurum, Turkey, GSM: 0532 3203638
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34
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Achim V, Aye RW, Farivar AS, Vallières E, Louie BE. A combined thoracoscopic and laparoscopic approach for high epiphrenic diverticula and the importance of complete myotomy. Surg Endosc 2016; 31:788-794. [DOI: 10.1007/s00464-016-5033-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Accepted: 06/11/2016] [Indexed: 12/17/2022]
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35
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Invited Commentary. Ann Thorac Surg 2015; 100:1802-3. [PMID: 26522526 DOI: 10.1016/j.athoracsur.2015.04.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 04/07/2015] [Accepted: 04/09/2015] [Indexed: 11/20/2022]
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