1
|
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.
Collapse
Affiliation(s)
- James Tankel
- Division of Thoracic and Upper Gastrointestinal Surgery, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | | | | | | | | | | | | | | |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
Treatment of Achalasia and Epiphrenic Diverticulum. World J Surg 2022; 46:1547-1553. [PMID: 35142875 DOI: 10.1007/s00268-022-06476-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2022] [Indexed: 10/19/2022]
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.
Collapse
|
5
|
Sommer R, Machado Grossi JV, Grossi Harada GR, Seabra MK, Cavazzola LT, Seabra AP. Treatment of Giant Esophageal Epiphrenic Diverticulum Using Robotic-Assisted Surgery. CRSLS : MIS CASE REPORTS FROM SLS 2021; 9:CRSLS.2021.00068. [PMID: 36016814 PMCID: PMC9387394 DOI: 10.4293/crsls.2021.00068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Epiphrenic diverticulum is a rare condition associated with esophageal motor disorder, and it is often asymptomatic, with a well-established surgical indication. The present study aims to report a case of a giant epiphrenic diverticulum in a 68-year-old male patient who, due to the symptoms, opted for surgical treatment using the daVinci® system. Robotic surgery consisting of esophageal diverticulectomy with cardiomyotomy was performed. The patient had an excellent recovery with an abbreviated hospitalization, return to food, and satisfactory routine activity.
Collapse
Affiliation(s)
- Renato Sommer
- Department of Surgery, Moinhos de Vento Hospital, Porto Alegre, Brazil
| | | | | | | | | | | |
Collapse
|
6
|
Maertens V, Lagarde S, Wijnhoven B. Surgical resection of voluminous epiphrenic diverticula. Acta Chir Belg 2021; 121:274-277. [PMID: 31718462 DOI: 10.1080/00015458.2019.1693153] [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: 10/25/2022]
Abstract
A 52-year-old male and 55-year-old female underwent surgical resection of a voluminous symptomatic epiphrenic diverticulum via a right thoracotomy. A formal myotomy of the distal esophagus was not performed. The first patient had an uncomplicated recovery whilst the other patient still suffers from an esophageal-cutaneous fistula and repetitive abscesses, treated by intravenous antibiotics and percutaneous drainage. The authors discuss the indication for resection, surgical techniques and complications.
Collapse
Affiliation(s)
- Vicky Maertens
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Sjoerd Lagarde
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Bas Wijnhoven
- Department of Surgery, Erasmus MC, Rotterdam, The Netherlands
| |
Collapse
|