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Albéniz E, Marra-López Valenciano C, Estremera-Arévalo F, Sánchez-Yagüe A, Montori S, Rodríguez de Santiago E. POEM from A to Z: current perspectives. Rev Esp Enferm Dig 2023. [PMID: 37073708 DOI: 10.17235/reed.2023.9602/2023] [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] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
The "third space endoscopy" or also called "submucosal endoscopy" is a reality we can transfer to our patients since 2010. Various modifications of the submucosal tunneling technique allow access to the submucosa or deeper layers of the gastrointestinal tract. In addition to peroral endoscopic myotomy for the treatment of achalasia, also called esophageal POEM, other variants have emerged that make it possible to treat different esophageal motility disorders, esophageal diverticula, subepithelial tumors of various locations, gastroparesis, reconnection of complete esophageal strictures or even thanks to exceptional endoscopists, pediatric disorders such as Hirschsprung's disease. Although some technical aspects are yet to be standardized, these procedures are becoming widespread worldwide and will likely become the standard treatment of these pathologies soon.
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Affiliation(s)
- Eduardo Albéniz
- Endoscopy Unit. Gastroenterology, Hospital Universitario de Navarra (HUN). Navarrabiomed. UPNA, IdiSNA, España
| | | | | | | | - Sheyla Montori
- Gastrointestinal Endoscopy Research Unit, Hospital Universitario de Navarra (HUN). Navarrabiomed. UPNA, IdiSNA, Spain
| | - Enrique Rodríguez de Santiago
- Gastroenterology and Hepatology , Hospital Universitario Ramón y Cajal. Universidad de Alcalá. IRYCIS. CIBERehd. ISCIII, Spain
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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] [What about the content of this article? (0)] [Affiliation(s)] [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] [What about the content of this article? (0)] [Affiliation(s)] [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] [What about the content of this article? (0)] [Affiliation(s)] [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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Nadaleto BF, Herbella FAM, Patti MG. Treatment of Achalasia and Epiphrenic Diverticulum. World J Surg 2022. [PMID: 35142875 DOI: 10.1007/s00268-022-06476-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [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.
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Miutescu BP, Khan S, Mony S, Khashab MA. Role of Peroral Endoscopic Myotomy (POEM) in the Management of Esophageal Diverticula. Clin Endosc 2020; 53:646-651. [PMID: 33238358 PMCID: PMC7719426 DOI: 10.5946/ce.2020.262] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/05/2020] [Indexed: 01/10/2023] Open
Abstract
Esophageal diverticula are uncommon; however, when present, they can cause symptoms of dysphagia, regurgitation, and chest pain. Based on location and pathophysiological characteristics, they are classified as pulsion- and traction-type diverticula. In the past, the open surgical approach was the only treatment available; however, in the past few decades, transoral incisionless approaches in the form of rigid and flexible endoscopy have gained popularity. Diverticular peroral endoscopic myotomy has emerged as an alternative treatment option. In this paper, we reviewed the role of peroral endoscopic myotomy as a treatment option for different types of esophageal diverticula. Although a safe and effective procedure, this novel submucosal tunneling technique for the treatment of esophageal diverticula requires further validation, and head-to-head comparisons between the different approaches for the treatment of esophageal diverticula are warranted.
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Affiliation(s)
- Bogdan P Miutescu
- Department of Gastroenterology and Hepatology, Victor Babeș University of Medicine and Pharmacy, Timișoara, Romania
| | - Sarah Khan
- Department of Medicine, Saint Agnes Hospital, Baltimore, MD, USA
| | - Shruti Mony
- Department of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mouen A Khashab
- Department of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
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Barbieri LA, Parise P, Cossu A, Puccetti F, Elmore U, Talavera Urquijo E, Rosati R. Treatment of Epiphrenic Diverticulum: How I Do It. J Laparoendosc Adv Surg Tech A 2020; 30:653-658. [DOI: 10.1089/lap.2020.0165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Paolo Parise
- Department of Surgery, San Raffaele Hospital, Milan, Italy
| | - Andrea Cossu
- Department of Surgery, San Raffaele Hospital, Milan, Italy
| | | | - Ugo Elmore
- Department of Surgery, San Raffaele Hospital, Milan, Italy
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Kim S, Cho JH. The Abdominal Approach for Epiphrenic Esophageal Diverticulum as an Alternative to the Thoracic Approach. Korean J Thorac Cardiovasc Surg 2019; 52:227-231. [PMID: 31404329 PMCID: PMC6687040 DOI: 10.5090/kjtcs.2019.52.4.227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 04/02/2019] [Accepted: 04/08/2019] [Indexed: 12/25/2022]
Abstract
Background There is no established surgical procedure for the treatment of epiphrenic esophageal diverticulum. The aim of this study was to compare the clinical outcomes of esophageal diverticulectomy using abdominal and thoracic approaches. Methods We retrospectively reviewed 30 patients who underwent esophageal diverticulectomy through the thoracic or abdominal approach for an epiphrenic diverticulum at a single center between 1996 and 2018. We compared clinical outcomes, including the postoperative length of stay, time from the operation to oral feeding, leakage rate, and reoperation rate between the 2 groups. Results The median age was 56 years. Of the 30 patients, 18 (60%) underwent diverticulectomy via the thoracic approach and 12 (40%) underwent the abdominal approach. The median hospital stay was 10 days (range, 5-211 days) in the thoracic approach group and 9.5 days (range, 5-18 days) in the abdominal approach group. The median time from the operation until oral feeding was 6.5 days (range, 3-299 days) when the thoracic approach was used and 5 days (range, 1-11 days) when the abdominal approach was used. In the thoracic approach group, the leakage rate was 16.67% and the reoperation rate was 27.78%. However, there were no cases of leakage or reoperation in the abdominal approach group. Conclusion The abdominal approach for esophageal diverticulectomy is a feasible and appropriate alternative to the thoracic approach.
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Affiliation(s)
- Shin Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Westcott CJ, O'Connor S, Preiss JE, Patti MG, Farrell TM. Myotomy-First Approach to Epiphrenic Esophageal Diverticula. J Laparoendosc Adv Surg Tech A 2019; 29:726-729. [PMID: 31034339 DOI: 10.1089/lap.2019.0239] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Introduction: Epiphrenic esophageal diverticula are typically treated with concurrent cardiomyotomy and diverticulectomy. However, resection of these diverticula can be technically difficult and associated with significant morbidity with a staple line leak rate ranging up to 27%. For this reason, and because the diverticulum is secondary to a primary esophageal motility disorder such as achalasia, we decided to adopt a laparoscopic myotomy-first strategy, reserving the diverticulectomy for patients with persistent or recurrent symptoms. Methods: From 2004 to 2018, 22 patients with epiphrenic diverticula were treated by laparoscopic Heller myotomy and partial fundoplication alone, with the plan to add the diverticulectomy as a second stage if needed. There were 13 women and 9 women, with a mean age of 68 years. Results: Patients had been symptomatic for an average of 36 months. The most common presenting symptom was dysphagia (91%), followed by regurgitation (77%). More than half of the diverticula were solitary and on the right side. Esogphagoscopy ruled out cancer. Esophageal manometry (18 patients) showed achalasia in 14 patients, nutcracker esophagus in 3 patients, and nonspecific motility disorder in 1 patient. There were no perioperative complications, and average length of stay was 2.5 days. At a mean follow-up of 68 months, dysphagia resolved in 77% and regurgitation in 86% of patients. Three patients had persistent symptoms: 2 patients underwent a transthoracic diverticulectomy (1 patient with resolution of symptoms and 1 patient with no improvement). Another patient had per oral endoscopic myotomy, but his dysphagia persisted. Conclusions: The laparoscopic myotomy-first approach reduces risk and unnecessary surgery. A laparoscopic Heller myotomy and partial fundoplication provide excellent resolution of symptoms for most, whereasonly a few will need a staged resection of the diverticulum.
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Affiliation(s)
- Carl J Westcott
- 1 Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina.,2 Department of Surgery, The W.G. Hefner Veterans Medical Center, Salisbury, North Carolina
| | - Sean O'Connor
- 1 Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Joshua E Preiss
- 3 Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Marco G Patti
- 3 Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Timothy M Farrell
- 3 Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Khitaryan А, Golovina A, Mezhunts A, Veliev K, Zavgorodnyaya R, Orekhov А. Laparoscopic-thoracoscopic esophageal resection in the treatment of giant epiphrenic esophageal diverticulum (Ivor Lewis operation): Case report. Int J Surg Case Rep 2018; 52:89-94. [PMID: 30336387 PMCID: PMC6197753 DOI: 10.1016/j.ijscr.2018.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 10/03/2018] [Indexed: 12/03/2022] Open
Abstract
Complicated epiphrenic diverticula are extremely rare. A 57-year-old woman had giant diverticulum with spread esophageal wall necrosis. One-step laparoscopic-thoracoscopic esophageal resection with gastric tube plasty. Treatment of giant diverticulum with necrotic diverticulitis and sepsis on the background of dilatation of the esophagus. The patient had an uneventful recovery and was discharged 11 days after the surgery.
Introduction Complicated esophageal diverticulum is an extremely rare disease. The most widespread surgical tactic in such cases is drainage of the mediastinum and the position of a feeding gastrostomy or enterostomy. Our objective was to demonstrate the possibility of performing a one-step operation in case of giant esophageal diverticulum with necrotic diverticulitis and sepsis on the background of dilatation of the esophagus. Presentation of case A 57-year-old woman complained of persistent nagging epigastric pain, heartburn, belching, daily vomiting of eaten food and liquid, impaired swallowing, fever up to 39° C. EGD revealed large pouch of the right esophageal wall in middle and lower third of the esophagus with signs of inflammation, ulceration and necrosis and retained food in the pouch. Barium esophagogram demonstrated 50 × 100 mm epiphrenic diverticulum on the right side and in the lower third of the esophagus which contained food. CBC revealed leukocytosis along with “left upper shift” and ESR. Discussion The laparoscopic-thoracoscopic esophageal resection with gastric tube plasty (Ivor Lewis operation) might be the method of choice in cases of giant epiphrenic esophageal diverticula, when esophageal resection is connected with the high risk of anastomotic dehiscence due to esophageal wall necrosis. Conclusion We have established that in case of necrobiotic changes in the esophageal wall in the area of the diverticulum, this tactic is completely justified because of the greater patient safety and the less risk of the stapler suture line dehiscence.
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Affiliation(s)
- Аlexander Khitaryan
- NGHCI Railway Clinical Hospital at the "Rostov-Glavnyy" Station, OAO Russian Railways, Varfolomeeva Street 92, Rostov-on-Don, Russian Federation(1); FSBEI HE Rostov State Medical University of the Ministry of Health of the Russian Federation, Nakhichevansky Lane 19, Rostov-on-Don, Russian Federation(2)
| | - Anastasiya Golovina
- FSBEI HE Rostov State Medical University of the Ministry of Health of the Russian Federation, Nakhichevansky Lane 19, Rostov-on-Don, Russian Federation(2).
| | - Arut Mezhunts
- FSBEI HE Rostov State Medical University of the Ministry of Health of the Russian Federation, Nakhichevansky Lane 19, Rostov-on-Don, Russian Federation(2)
| | - Kamil Veliev
- NGHCI Railway Clinical Hospital at the "Rostov-Glavnyy" Station, OAO Russian Railways, Varfolomeeva Street 92, Rostov-on-Don, Russian Federation(1)
| | - Raisa Zavgorodnyaya
- NGHCI Railway Clinical Hospital at the "Rostov-Glavnyy" Station, OAO Russian Railways, Varfolomeeva Street 92, Rostov-on-Don, Russian Federation(1)
| | - Аlexey Orekhov
- NGHCI Railway Clinical Hospital at the "Rostov-Glavnyy" Station, OAO Russian Railways, Varfolomeeva Street 92, Rostov-on-Don, Russian Federation(1); FSBEI HE Rostov State Medical University of the Ministry of Health of the Russian Federation, Nakhichevansky Lane 19, Rostov-on-Don, Russian Federation(2)
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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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Stašek M, Aujeský R, Vrba R, Loveček M, Chudáček J, Janda P, Gregořík M, Vomáčková K, Neoral Č, Klos D. Indications and benefits of intraoperative esophagogastroduodenoscopy. Wideochir Inne Tech Maloinwazyjne 2018; 13:164-75. [PMID: 30002748 DOI: 10.5114/wiitm.2018.72740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 10/16/2017] [Indexed: 11/29/2022] Open
Abstract
Introduction Intraoperative esophagogastroduodenoscopy (IOG) is a diagnostic and therapeutic method for a variety of special conditions in upper gastrointestinal (UGI) pathology. The indication remains individual due to insufficient evidence and limited training of surgeons in digestive endoscopy. Aim To evaluate the indications, benefits and risks of IOG. Material and methods A single-center retrospective study of 110 consecutive IOGs in 104 patients was performed. The preoperative plan, the timing of IOG, preoperative evaluation, intraoperative finding, localization of the pathology, type of the procedure, change of expected therapy and complications were assessed. Results The cohort comprised 29 esophageal tumors, 5 tumors of the cardia, 36 gastric tumors, gastrointestinal bleeding (8), esophageal diverticula (3), perforations (3), GERD (5), mediastinal pathology (3), fistula (4), assessment of nutrition (10), duodenal adenoma (2), ulcer disease, esophageal stenosis and gastric volvulus. The indication for IOG was established preoperatively in 79% and intraoperatively in 21%. The lesion was localized in 96.4%. The therapy was altered to a wider resection (11), smaller resection (5), localization and surgical therapy of bleeding (8) or allowed minimally invasive surgery (25). A total of 3 postoperative complications included gastric perforation and positivity of resection line (following EMR/ESD) and recurrent bleeding. The 30-day mortality reached 3.6% without a specific cause in IOG. Conclusions The IOG is a complementary method in the diagnosis and treatment of UGI pathology. It enables minimally invasive finalization of the procedures and individualization of the therapy.
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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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Feußner H, Hüser N, Wilhelm D, Fingerle A, Jell A, Friess H, Bajbouj M. [Surgical treatment of esophageal diverticula : Endoscopic or open approach?]. Chirurg 2017; 88:196-203. [PMID: 28054111 DOI: 10.1007/s00104-016-0344-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 10/20/2022]
Abstract
Esophageal diverticula are comparatively rare. The majority are Zenker's diverticula but parabronchial and epiphrenic diverticula can also occur. Parabronchial diverticula are of low clinical relevance, whereas Zenker's and epiphrenic diverticula both belong to the group of pulsion diverticula and can become clinically apparent by dysphagia and regurgitation. Approximately 100 years after the first surgical treatment, peroral approaches (e.g. stapler dissection and flexible endoscopic diverticulotomy) have now achieved a certain level of importance. Both approaches are less invasive than the open approach but are evidently more prone to recurrences. Accordingly, traditional open diverticulectomy with cervical myotomy should be recommended to patients with a reasonable life expectancy and an acceptable operative risk. This holds particularly true for Brombart stages I-III of the disease, as complete myotomy cannot be achieved via the peroral access. The classical surgical treatment of epiphrenic diverticula is open or laparoscopic/thoracoscopic diverticulectomy with distal myotomy, mostly combined with an anterior partial fundoplication; however, the leakage rate is high and several alternative options are currently being evaluated.
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Affiliation(s)
- H Feußner
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland.
| | - N Hüser
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - D Wilhelm
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - A Fingerle
- Institut für Diagnostische und Interventionelle Radiologie, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland
| | - A Jell
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - H Friess
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - M Bajbouj
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Andolfi C, Wiesel O, Fisichella PM. Surgical Treatment of Epiphrenic Diverticulum: Technique and Controversies. J Laparoendosc Adv Surg Tech A 2016; 26:905-910. [DOI: 10.1089/lap.2016.0365] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Ciro Andolfi
- Department of Surgery, University of Chicago, Chicago, Illinois
| | - Ory Wiesel
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - P. Marco Fisichella
- Department of Surgery, Brigham and Women's Hospital and Boston VA, Boston, Massachusetts
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Beiša V, Kvietkauskas M, Beiša A, Strupas K. Laparoscopic approach in the treatment of large epiphrenic esophageal diverticulum. Wideochir Inne Tech Maloinwazyjne 2016; 10:584-8. [PMID: 26865897 DOI: 10.5114/wiitm.2015.56407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 11/17/2015] [Indexed: 01/05/2023] Open
Abstract
Epiphrenic diverticulum of the lower third of the esophagus is a relatively rare disorder. We present the case of a large, 7.5 cm diameter esophageal epiphrenic diverticulum treated by the laparoscopic approach. Surgery was indicated by the severity of the patient‘s symptoms and size of the diverticulum. A laparoscopic transhiatal diverticulectomy with a myotomy and Dor fundoplication was carried out. The overall operative time was 180 min. The patient tolerated the surgery well and was discharged from hospital 4 days after the surgery. From the 10th postoperative day the patient resumed a regular diet. Four weeks after the operation the patient had no complaints, symptoms of dysphagia or vomiting. The laparoscopic approach in the treatment of a large, 7.5 cm epiphrenic diverticulum of the esophagus is feasible, safe and well tolerated by the patient.
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