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Wessels EM, Schuitenmaker JM, Bastiaansen BAJ, Fockens P, Masclee GMC, Bredenoord AJ. Efficacy and safety of peroral endoscopic myotomy for esophageal diverticula. Endosc Int Open 2023; 11:E546-E552. [PMID: 37251790 PMCID: PMC10219786 DOI: 10.1055/a-2071-6744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/03/2023] [Indexed: 05/31/2023] Open
Abstract
Background and study aims Epiphrenic diverticula are rare and mainly occur in patients with underlying esophageal motility disorders. The current standard treatment is surgical diverticulectomy often combined by myotomy and is associated with significant adverse event (AE) rates. The aim of this study was to examine the efficacy and safety of peroral endoscopic myotomy in reducing esophageal symptoms in patients with esophageal diverticula. Patients and methods We performed a retrospective cohort study including patients with an esophageal diverticulum who underwent POEM between October 2014 and December 2022. After informed consent, data were extracted from medical records and patients completed a survey by telephone. The primary outcome was treatment success, defined as Eckardt score below 4 with a minimal reduction of 2 points. Results Seventeen patients (mean age 71 years, 41.2 % female) were included. Achalasia was confirmed in 13 patients (13 /17, 76.5 %), Jackhammer esophagus in two patients (2 /17, 11.8 %), diffuse esophageal spasm in one patient (1 /17, 5.9 %) and in one patient no esophageal motility disorder was found (1 /17, 5.9 %). Treatment success was 68.8 % and only one patient (6.3 %) underwent retreatment (pneumatic dilatation). Median Eckardt scores decreased from 7 to 1 after POEM (p < 0.001). Mean size of the diverticula decreased from 3.6 cm to 2.9 cm after POEM (p < 0.001). Clinical admission was one night for all patients. AEs occurred in two patients (11.8 %) which were classified as grade II and IIIa (AGREE classification). Conclusions POEM is effective and safe to treat patients with esophageal diverticula and an underlying esophageal motility disorder.
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Affiliation(s)
- Elise M Wessels
- Amsterdam University Medical Centres, Gastroenterology & Hepatology, Amsterdam, Netherlands
| | - Jeroen M Schuitenmaker
- Amsterdam University Medical Centres, Gastroenterology & Hepatology, Amsterdam, Netherlands
| | | | - Paul Fockens
- Amsterdam University Medical Centres, Gastroenterology & Hepatology, Amsterdam, Netherlands
| | - Gwen M C Masclee
- Amsterdam University Medical Centres, Gastroenterology & Hepatology, Amsterdam, Netherlands
| | - Albert J Bredenoord
- Amsterdam University Medical Centres, Gastroenterology & Hepatology, Duivendrecht, Netherlands
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Zeng X, Bai S, Zhang Y, Ye L, Yuan X, Hu B. Peroral endoscopic myotomy for the treatment of esophageal diverticulum: an experience in China. Surg Endosc 2021; 35:1990-1996. [PMID: 32347387 DOI: 10.1007/s00464-020-07593-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 04/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND With the development of minimally invasive endoscopic approaches for the esophagus in recent years, peroral endoscopic myotomy (POEM) in the treatment of esophageal diverticulum has been described recently in some reports due to its successful outcomes. The aim of this study is to report our experience with the use of diverticular POEM (D-POEM) technique in the management of esophageal diverticulum. METHODS This retrospective study included consecutive patients with symptomatic esophageal diverticulum who visited our endoscopy center between April 2014 and January 2019. D-POEM was performed based on the principles of submucosal endoscopy. A new symptomatic scoring system was introduced to evaluate the severity of diverticular symptoms. RESULTS A total of 10 patients with esophageal diverticulum (Zenker's 2, mid-esophagus 5, and epiphrenic 3) were included. The overall technical success rate of D-POEM was 100%, with a mean procedure time of 38.9 ± 20.5 (range 16-70) min. No serious complications occurred. Clinical improvement was achieved in 90% (9/10) of patients. The symptomatic score was significantly decreased from 2.5 (IQR 2.00-3.25) to 1.0 (IQR 0-1.25) (P = 0.007) during a median follow-up period of 11.0 (IQR 10.25-17.25) months. CONCLUSION These findings suggested complete septotomy by D-POEM. Our preliminary data and experience put forwarded D-POEM as a safe and effective technique for esophageal diverticulum.
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Affiliation(s)
- Xianhui Zeng
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Wuhou District, Chengdu, China
| | - Shuai Bai
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Wuhou District, Chengdu, China
| | - Yuhang Zhang
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Wuhou District, Chengdu, China
| | - Liansong Ye
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Wuhou District, Chengdu, China
| | - Xianglei Yuan
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Wuhou District, Chengdu, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guo Xue Alley, Wuhou District, Chengdu, China.
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Samanta J, Mandavdhare HS, Kumar N, Kumar-M P, Jafra A, Chauhan R, Gupta P, Kumar KH, Singh H, Dutta U, Kochhar R. Per Oral Endoscopic Myotomy for the Management of Large Esophageal Diverticula (D-POEM): Safe and Effective Modality for Complete Septotomy. Dysphagia 2021; 37:84-92. [PMID: 33533970 DOI: 10.1007/s00455-021-10252-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 01/13/2021] [Indexed: 01/26/2023]
Abstract
With the advent of the technique of sub-mucosal tunnelling, peroral endoscopic myotomy (POEM) has been used for the treatment of esophageal diverticulum, which otherwise is a recurring problem with conventional flexible endoscopic treatment due to incompleteness of septotomy. This study reports our experience of the use of diverticular POEM (D-POEM) technique in the management of large esophageal diverticulum. This is a retrospective study of prospectively maintained database including all consecutive patients with symptomatic esophageal diverticulum presenting at a tertiary care academic center. D-POEM was performed using the technique of submucosal tunnelling and septotomy. Besides baseline parameters, technical success, clinical success, size of diverticula, procedure time, complications and symptom recurrence on follow up were noted. A total of five patients (4 males; median age 72) were included with an average Charlson comorbidity index of 3.2 ± 0.8. Of them, three had Zenker's while two had epiphrenic diverticulum. The median symptom duration was 12 months with a mean diverticulum size of 68.8 ± 1.9 mm. The mean procedure time was 64.80 ± 12.6 min. with a mean septotomy/myotomy length of 79.44 ± 12.2 mm. Minor adverse events were noted intra-procedure in two cases. Clinical success achieved in all cases with a significant mean dysphagia score reduction from 2.20 to 0.20 post procedure (p = 0.011). On a median follow up of 280 days (range 98-330), none had recurrence of symptoms. Our data highlighted that complete septotomy by D-POEM technique can be achieved for the management of large esophageal diverticulum and is safe and effective.
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Affiliation(s)
- Jayanta Samanta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India.
| | - Harshal S Mandavdhare
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India
| | - Naveen Kumar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India
| | | | - Anudeep Jafra
- Department of Anaesthesiology, PGIMER, Chandigarh, India
| | - Rajeev Chauhan
- Department of Anaesthesiology, PGIMER, Chandigarh, India
| | - Pankaj Gupta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India
| | | | | | - Usha Dutta
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Sato H, Takeuchi M, Hashimoto S, Mizuno KI, Furukawa K, Sato A, Yokoyama J, Terai S. Esophageal diverticulum: New perspectives in the era of minimally invasive endoscopic treatment. World J Gastroenterol 2019; 25:1457-1464. [PMID: 30948909 PMCID: PMC6441918 DOI: 10.3748/wjg.v25.i12.1457] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 02/28/2019] [Accepted: 03/12/2019] [Indexed: 02/06/2023] Open
Abstract
Esophageal diverticula are rare conditions that cause esophageal symptoms, such as dysphagia, regurgitation, and chest pain. They are classified according to their location and characteristic pathophysiology into three types: epiphrenic diverticulum, Zenker’s diverticulum, and Rokitansky diverticulum. The former two disorders take the form of protrusions, and symptomatic cases require interventional treatment. However, the esophageal anatomy presents distinct challenges to surgical resection of the diverticulum, particularly when it is located closer to the oral orifice. Since the condition itself is not malignant, minimally invasive endoscopic approaches have been developed with a focus on alleviation of symptoms. Several types of endoscopic devices and techniques are currently employed, including peroral endoscopic myotomy (POEM). However, the use of minimally invasive endoscopic approaches, like POEM, has allowed the development of new disorder called iatrogenic esophageal diverticula. In this paper, we review the pathophysiology of each type of diverticulum and the current state-of-the-art treatment based on our experience.
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Affiliation(s)
- Hiroki Sato
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata 951-8510, Japan
| | - Manabu Takeuchi
- Division of Gastroenterology, Nagaoka Red Cross Hospital, Nagaoka 940-2085, Japan
| | - Satoru Hashimoto
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata 951-8510, Japan
| | - Ken-ichi Mizuno
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata 951-8510, Japan
| | - Koichi Furukawa
- Division of Gastroenterology, Niigata City General Hospital, Niigata 950-1197, Japan
| | - Akito Sato
- Division of Gastroenterology, Nagaoka Chuo General Hospital, Nagaoka 940-8653, Japan
| | - Junji Yokoyama
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata 951-8510, Japan
| | - Shuji Terai
- Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata 951-8510, Japan
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Nakajima N, Sato H, Takahashi K, Hasegawa G, Mizuno K, Hashimoto S, Sato Y, Terai S. Muscle layer histopathology and manometry pattern of primary esophageal motility disorders including achalasia. Neurogastroenterol Motil 2017; 29. [PMID: 27699951 DOI: 10.1111/nmo.12968] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 09/08/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Histopathology of muscularis externa in primary esophageal motility disorders has been characterized previously. We aimed to correlate the results of high-resolution manometry with those of histopathology. METHODS During peroral endoscopic myotomy, peroral esophageal muscle biopsy was performed in patients with primary esophageal motility disorders. Immunohistochemical staining for c-kit was performed to assess the interstitial cells of Cajal (ICCs). Hematoxylin Eosin and Azan-Mallory staining were used to detect muscle atrophy, inflammation, and fibrosis, respectively. KEY RESULTS Slides from 30 patients with the following motility disorders were analyzed: achalasia (type I: 14, type II: 5, type III: 3), one diffuse esophageal spasm (DES), two outflow obstruction (OO), four jackhammer esophagus (JE), and one nutcracker esophagus (NE). ICCs were preserved in high numbers in type III achalasia (n=9.4±1.2 cells/high power field [HPF]), compared to types I (n=3.7±0.3 cells/HPF) and II (n=3.5±1.0 cells/HPF). Moreover, severe fibrosis was only observed in type I achalasia and not in other types of achalasia, OO, or DES. Four of five patients with JE and NE had severe inflammation with eosinophilic infiltration of the esophageal muscle layer (73.8±50.3 eosinophils/HPF) with no epithelial eosinophils. One patient with JE showed a visceral myopathy pattern. CONCLUSIONS & INFERENCES Compared to types I and II, type III achalasia showed preserved ICCs, with variable data regarding DES and OO. In disorders considered as primary esophageal motility disorders, a disease category exists, which shows eosinophilic infiltration in the esophageal muscle layer with no eosinophils in the epithelium.
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Affiliation(s)
- N Nakajima
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - H Sato
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan.,Division of Gastroenterology and Hepatology, Saiseikai Niigata Daini Hospital, Niigata, Japan
| | - K Takahashi
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - G Hasegawa
- Division of Cellular and Molecular Pathology, Department of Cellular Function, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - K Mizuno
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - S Hashimoto
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Y Sato
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - S Terai
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
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