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Boyanov N, Andonov V, Shtereva K, Madzharova K, Stoynov N, Dimitrova D, Yankov I. Initial experience in target peroral endoscopic submucosal myotomy combined with septotomy for epiphrenic diverticulum. Folia Med (Plovdiv) 2023; 65:490-494. [PMID: 38351827 DOI: 10.3897/folmed.65.e83893] [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: 03/16/2022] [Accepted: 04/18/2022] [Indexed: 02/16/2024] Open
Abstract
The epiphrenic esophageal diverticulum is a rare non-malignant condition that is commonly associated with motility disorders. It would normally be treated surgically, but with the advancement of endoscopy techniques, peroral endoscopic myotomy with septotomy (D-POEM) has shown its benefits in coping with the symptoms. We present a case of a 71-year-old woman with increasing symptoms of dysphagia, weight loss and imaging data showing a large epiphrenic diverticulum. We treated her using peroral endoscopic myotomy combined with septotomy of the diverticular septum. The procedure showed excellent results with reducing the amount of contrast materials retained in it, improving the quality of life of the patient, and increasing her weight. There were minimal adverse events and no perforations or severe adverse effects occurred. D-POEM is a new and rapidly evolving procedure that is proving to be a safe and effective method of treating epiphrenic esophageal diverticulum.
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Affiliation(s)
| | | | | | | | | | | | - Ivan Yankov
- Medical University of Plovdiv, Plovdiv, Bulgaria
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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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Sirasapalli SK, Senthamizhselvan K, Mohan P. Rare Association of Killian-Jamieson Diverticulum and Peptic Stricture of the Esophagus: Is It Causal or Casual? Euroasian J Hepatogastroenterol 2023; 13:32-35. [PMID: 37554977 PMCID: PMC10405809 DOI: 10.5005/jp-journals-10018-1388] [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: 05/03/2023] [Accepted: 06/23/2023] [Indexed: 08/10/2023] Open
Abstract
Killian-Jamieson diverticulum (KJD) is a rare esophageal diverticulum that arises from the anterolateral wall of the proximal cervical esophagus in the Killian-Jamieson space. Although rare presentations include dysphagia, globus sensation, or a suspected thyroid nodule, it is often asymptomatic. Treatment is indicated only in symptomatic cases. We report a 55-year-old female who had long-standing heartburn and presents now with dysphagia, weight loss, and anemia. Imaging and upper endoscopy revealed peptic stricture and an associated KJD. She underwent serial endoscopic dilatation of the peptic stricture and was symptomatically better afterwards. She is currently doing well on follow-up. How to cite this article Sirasapalli SK, Senthamizhselvan K, Mohan P. Rare Association of Killian-Jamieson Diverticulum and Peptic Stricture of the Esophagus: Is It Causal or Casual? Euroasian J Hepato-Gastroenterol 2023;13(1):32-35.
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Affiliation(s)
- Siva Krishna Sirasapalli
- Department of Medical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Kuppusamy Senthamizhselvan
- Department of Medical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - Pazhanivel Mohan
- Department of Medical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
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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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Andrási L, Ábrahám S, Simonka Z, Paszt A, Erdős M, Rovó L, Rosztóczy A, Ollé G, Lázár G. [Minimally invasive surgery for motility disorders of the oesophagus]. Magy Seb 2022; 75:121-132. [PMID: 35895537 DOI: 10.1556/1046.2022.20006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 04/04/2022] [Indexed: 01/06/2023]
Abstract
Introduction and aims. We present our experience with minimally invasive surgery for pharyngoesophageal (Zenker) diverticulums, epiphrenic diverticulums and achalasia cardiae focusing on the perioperative features and patients’ quality of life. Patients and methods. Between 1 January 2003 and 31 December 2020, patients were selected with a symptom-causing Zenker diverticulum, epiphrenic diverticulum and achalasia cardiae. In 17 cases, transoral stapler diverticulostomy, in 23 cases transcervical diverticulectomy and cricomyotomy were done because of Zenker diverticulum, in 14 cases, laparoscopic transhiatal surgery was performed because of epiphrenic diverticula, while in 63 cases, laparoscopic Heller–Dor operation were carried out because of achalasia cardiae. Perioperative results, the quality of life outcomes of various surgeries were evaluated in mid- and long-term. Results/conclusions. The surgeries were performed with minimal blood loss, zero mortality and low morbidity. According to our result, the two different surgical approaches in the therapy of Zenker’s diverticulum, the laparoscopic Heller–Dor procedure applied in the management of epiphrenic diverticulas and achalasia cardiae are safe and effective operations. In the long term, the symptom control in patients after minimally invasive surgeries is sufficient and only a small percentage of the patients may require additional medication therapy and/or reintervention due to persistent complaints.
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Affiliation(s)
- László Andrási
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Szabolcs Ábrahám
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Zsolt Simonka
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Attila Paszt
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Márton Erdős
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - László Rovó
- 2 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Fül-Orr-Gégészeti és Fej-Nyaksebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Rovó László)
| | - András Rosztóczy
- 3 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Belgyógyászati Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lengyel Csaba)
| | - Georgina Ollé
- 3 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Belgyógyászati Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lengyel Csaba)
| | - György Lázár
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
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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.
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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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Mandovra P, Kalikar V, Patel A, Patankar RV. The laparoscopic approach for epiphrenic diverticula with achalasia. Ann R Coll Surg Engl 2019; 101:256-260. [PMID: 30773891 DOI: 10.1308/rcsann.2019.0007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Epiphrenic diverticulum (ED) is an uncommon disease that is invariably associated with an underlying oesophageal motility disorder such as achalasia. Management of ED should always be accompanied by treatment of the underlying motility disorder to prevent recurrence of symptoms. Traditionally, ED were approached via a left thoracotomy but as laparoscopy offers better access to the distal oesophagus, its use is becoming more widespread. METHODS A total of 72 patients with oesophageal achalasia underwent laparoscopic surgery at our centre over a period of 7 years. Five (6.9%) of these had associated symptomatic ED. These patients were treated with a laparoscopic transhiatal epiphrenic diverticulectomy using intraoperative oesophagoscopy guidance, combined with a Heller myotomy and Dor fundoplication. Patients were followed up regularly and symptoms were assessed at 12 months. RESULTS The median age of the five patients with associated symptomatic ED was 56 years (range: 38-69 years). Three were male. The mean duration of surgery was 150 minutes (range: 120-180 minutes). One patient (20%) developed a postoperative oesophageal leak. The mean follow-up duration was 25 months (range: 12-36 months). At 12 months, the mean Eckardt score reduced from 6.8 to 1.6. Three patients (60%) reported an excellent outcome, one (20%) reported a good outcome and one (20%) reported a fair outcome. CONCLUSIONS Along with diverticulectomy, treating the underlying motility disorder with an adequate Heller myotomy and partial fundoplication is of prime importance for a good surgical outcome without symptom recurrence. Laparoscopy offers better access to the distal oesophagus than the conventional thoracic approach for ED.
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Affiliation(s)
| | | | - A Patel
- Zen Hospital , Mumbai , India
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9
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Andrási L, Paszt A, Simonka Z, Ábrahám S, Rosztóczy A, Lázár G. Laparoscopic Surgery for Epiphrenic Esophageal Diverticulum. JSLS 2018; 22:JSLS.2017.00093. [PMID: 30022807 PMCID: PMC6035909 DOI: 10.4293/jsls.2017.00093] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Background and Objectives: We wanted to assess our surgical results focusing on the patients' quality of life. We present our experience with laparoscopic surgery for epiphrenic esophageal diverticulum. Short- and long-term results of surgical therapy were analyzed. Methods: Eight patients were examined with a symptom-causing epiphrenic diverticulum. Patients underwent complex gastroenterologic examinations before and after surgery. Laparoscopic transhiatal epiphrenic diverticulectomy, Heller cardiomyotomy, and Dor anterior partial fundoplication were performed on 7 patients. One patient underwent only diverticulectomy, where no motility disorder was present. Results from surgical treatments and changes in patients' pre- and postoperative complaints were evaluated. Results: In all cases except 1, the preoperative examination showed dysmotility of the esophagus. The average duration of the surgeries was 165 (130–195) minutes; blood loss was minimal. One patient developed bleeding in the early postoperative period, and a second laparoscopy was required. No other intraoperative complication was detected, and no mortality occurred. In one case, a staple line leak developed (1/8 [12.5%]), which was resolved with conservative therapy. Functional check-ups confirmed adequate esophageal function. The total symptom score for the patients was 6.3 points before surgery, and it decreased to 1.6 (P < .001) after surgery, an average of 74% subjective improvement. During the follow-up period (mean, 60 months; 10–138 months), proton pump inhibitor therapy was started in 4 patients to treat gastroesophageal reflux. In 3 cases, drug therapy was successful; in one case, Nissen antireflux surgery was performed. Conclusion: Laparoscopic transhiatal diverticulectomy and Heller–Dor surgery are effective interventions with low morbidity. Patient quality of life significantly improves in the long term, but gastroesophageal reflux disease may occur.
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Affiliation(s)
| | | | | | | | - András Rosztóczy
- 1st Department of Medicine, Albert Szent-Györgyi Health Center, University of Szeged, Szeged, Hungary
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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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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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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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13
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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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Surgical management of epiphrenic diverticulum: A single-center experience and brief review of literature. Am J Surg 2017; 216:280-285. [PMID: 28778314 DOI: 10.1016/j.amjsurg.2017.06.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/06/2017] [Accepted: 06/21/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND We present single-center experience of surgery for primary epiphrenic diverticulum (PED) over a 12-year period. METHODS Prospectively maintained database was queried to identify patients who underwent PED surgery. Preoperative and postoperative symptoms, operative data, perioperative complications, and follow-up were reviewed. RESULTS Twenty-seven patients (14 females; mean age-67-years) underwent PED surgery. The most common primary presenting symptoms were dysphagia and regurgitation (mean duration-3.6-years). 82% patients underwent laparoscopic procedures (one conversion), 11% operated via left thoracotomy and 7% via combined laparoscopy-right trans-thoracic approach. All patients received myotomy, all but one received diverticulectomy. Five-patients experienced intraoperative complications that were managed intraoperatively without sequelae. There was no perioperative mortality. Morbidity was seen in 3-patients, including one staple-line leak managed with endoscopic washes and stent placement. 90% patients with ≥1-year follow-up reported "excellent" satisfaction. CONCLUSIONS Minimally invasive surgery for PED is both feasible and safe. We observed low morbidity, short hospital stay, and excellent patient-reported outcomes.
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15
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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] [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] [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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17
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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] [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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18
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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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19
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Crespin OM, Tatum RP, Yates RB, Sahin M, Coskun K, Martin AV, Wright A, Oelschlager BK, Pellegrini CA. Esophageal hypermotility: cause or effect? Dis Esophagus 2016; 29:497-502. [PMID: 25893778 DOI: 10.1111/dote.12367] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Nutcracker esophagus (NE), Jackhammer esophagus (JHE), distal esophageal spasm (DES), and hypertensive lower esophageal sphincter (HTLES) are defined by esophageal manometric findings. Some patients with these esophageal motility disorders also have abnormal gastroesophageal reflux. It is unclear to what extent these patients' symptoms are caused by the motility disorder, the acid reflux, or both. The aim of this study was to determine the effectiveness of laparoscopic Nissen fundoplication (LNF) on esophageal motility disorders, gastroesophageal reflux, and patient symptoms. Between 2007 and 2013, we performed high-resolution esophageal manometry on 3400 patients, and 221 patients were found to have a spastic esophageal motility disorder. The medical records of these patients were reviewed to determine the manometric abnormality, presence of gastroesophageal symptoms, and amount of esophageal acid exposure. In those patients that underwent LNF, we compared pre- and postoperative esophageal motility, gastroesophageal symptom severity, and esophageal acid exposure. Of the 221 patients with spastic motility disorders, 77 had NE, 2 had JHE, 30 had DES, and 112 had HTLES. The most frequently reported primary and secondary symptoms among all patients were: heartburn and/or regurgitation, 69.2%; respiratory, 39.8%; dysphagia, 35.7%; and chest pain, 22.6%. Of the 221 patients, 192 underwent 24-hour pH monitoring, and 103 demonstrated abnormal distal esophageal acid exposure. Abnormal 24-hour pH monitoring was detected in 62% of patients with heartburn and regurgitation, 49% of patients with respiratory symptoms, 36.8 % of patients with dysphagia, and 32.6% of patients with chest pain. Sixty-six of the 103 patients with abnormal 24-hour pH monitoring underwent LNF. Thirty-eight (13NE, 2JHE, 6 DES, and 17 HTLES) of these 66 patients had a minimum of 6-month postoperative follow-up that included clinical evaluation, esophageal manometry, and 24-hour pH monitoring. Postoperatively, all 38 patients had normal distal esophageal acid exposure. Of these 38 patients, symptoms resolved in 28 and improved in 10. Of six patients (one with NE, two JHE, and three with HTLES) that underwent postoperative esophageal manometry, five exhibited normal motility. Typical reflux symptoms are common among patients with esophageal hypermotility disorders. Abnormal 24-hour pH monitoring is present in the majority of patients with who report typical reflux symptoms and almost half of patients who report respiratory symptoms. Conversely, the majority of patients who report dysphagia or chest pain have normal distal esophageal acid exposure. Based on a small number of patients in this study, it also appears that motility disorders often improve after LNF. LNF is associated with resolution or improvement in reflux related symptoms and esophageal motility parameters in patients exhibiting abnormal esophageal acid exposure. This suggests that patient symptoms are due to abnormal acid exposure and not the motility disorder.
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Affiliation(s)
- O M Crespin
- University of Washington, Surgery, Seattle, WA, USA
| | - R P Tatum
- University of Washington, Surgery, Seattle, WA, USA
| | - R B Yates
- University of Washington, Surgery, Seattle, WA, USA
| | - M Sahin
- University of Washington, Surgery, Seattle, WA, USA
| | - K Coskun
- University of Washington, Surgery, Seattle, WA, USA
| | - A V Martin
- University of Washington, Surgery, Seattle, WA, USA
| | - A Wright
- University of Washington, Surgery, Seattle, WA, USA
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20
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Abstract
Esophageal epiphrenic diverticulum (EED) is a pseudodiverticulum of pulsion type located in the distal 10 cm of the esophagus and frequently associated to achalasia. The symptoms and the pathophysiology of achalasia and EED may overlap, leading to the speculation that achalasia may be responsible for the symptoms. Similarly to patients with achalasia without EED, a careful preoperative evaluation is essential in patients with EED. Endoscopy and an esophagram are mandatory in the workup of these patients, while esophageal manometry confirms the associated motility disorder. Treatment is indicated in all patients fit for an operation except those who are asymptomatic with a small EED and no prior history of aspiration. Laparoscopic Heller's myotomy and partial fundoplication is the most adequate therapy. Diverticulectomy must be added to the procedure in large diverticula. Experience with endoscopic therapy is very limited.
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Affiliation(s)
- Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003l, Brazil,
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21
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Macke RA, Luketich JD, Pennathur A, Bianco V, Awais O, Gooding WE, Christie NA, Schuchert MJ, Nason KS, Levy RM. Thoracic Esophageal Diverticula: A 15-Year Experience of Minimally Invasive Surgical Management. Ann Thorac Surg 2015; 100:1795-802. [DOI: 10.1016/j.athoracsur.2015.04.122] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 03/27/2015] [Accepted: 04/01/2015] [Indexed: 12/15/2022]
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22
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Abstract
Esophageal disease and dysfunction of the lower esophageal sphincter (LES) manifesting as gastroesophageal reflux disease (GERD) particularly, is the most common of all gastrointestinal conditions impacting patients on a day-to-day basis. LES dysfunction can lead to anatomic changes to the distal esophagus, with GERD-mediated changes being benign stricture or progression of GERD to Barrett's esophagus and even esophageal cancer, and LES hypertension impairing esophageal emptying with subsequent development of pulsion esophageal diverticulum. This article details the causes, clinical presentation, workup, and treatment of esophageal stricture and epiphrenic esophageal diverticulum. Other types of esophageal diverticula (Zenker's and midesophageal) are also covered.
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Rossetti G, Fei L, del Genio G, Maffettone V, Brusciano L, Tolone S, Cimmino M, Moccia F, Terrone A, Romano G, Guerriero L, del Genio A. Epiphrenic diverticula mini-invasive surgery: a challenge for expert surgeons--personal experience and review of the literature. Scand J Surg 2014; 102:129-35. [PMID: 23820690 DOI: 10.1177/1457496913482242] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS While in the past, thoracotomy represented the traditional surgical approach for the treatment of epiphrenic diverticula, actually mini-invasive approach seems to be the preferred treatment as many series have been published in the recent years. This article describes the authors' experience with the laparoscopic approach for performing diverticulectomy, myotomy, and Nissen-Rossetti fundoplication. MATERIAL AND METHODS From 1994 to 2010, 21 patients (10 men and 11 women), mean age 58.5 years (range 45-74 years), with symptomatic epiphrenic diverticulum underwent laparoscopic diverticulectomy, myotomy and Nissen-Rossetti fundoplication. RESULTS The mean operative time was 135 min (range = 105-190 min). Mean hospital stay was 14.2 days (range = 7-25 days). In 5 patients (23.8%), a partial suture staple line leak was observed. Conservative treatment achieved leak resolution in all the cases. One patient (4.8%) died of a myocardial infarction in the postoperative period. After a mean clinical follow-up period of 78 months (range = 6-192 months), excellent or good outcome was referred with no dysphagia in 16 patients (80%) and only mild occasional dysphagia in 4 patients (20%). CONCLUSIONS Surgical treatment of epiphrenic diverticula remains a challenging procedure also by mini-invasive approach, with major morbidity and mortality rates. For this reason, indications must be restricted only to selected and symptomatic patients in specialized centers.
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Affiliation(s)
- G Rossetti
- I Division of General and Gastrointestinal Surgery, Second University of Naples, Naples, Italy
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24
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Gonzalez-Calatayud M, Targarona EM, Balague C, Rodriguez-Luppi C, Martin AB, Trias M. Minimally invasive therapy for epiphrenic diverticula: Systematic review of literature and report of six cases. J Minim Access Surg 2014; 10:169-74. [PMID: 25336815 PMCID: PMC4204258 DOI: 10.4103/0972-9941.141498] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 10/29/2013] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION: Epiphrenic diverticula (ED) are infrequent and conventional surgical treatment entails aggressive open or transthoracic surgery. Minimally invasive treatment has changed the surgical approach but some surgical controversies are not resolved. OBJECTIVE: The objective of this study is to describe our experience in minimally invasive treatment of the ED and to perform a systematic review of the current literature in this subject. MATERIALS AND METHODS: We reviewed all data from the Hospital de Sant Pau, focusing on patients that underwent minimally invasive treatment for an ED since 1998 to date. Furthermore, we performed a systematic literature review focused on the minimally invasive approach for ED. RESULTS: A total of 6 patients have been treated (5 transhiatal and 1 with abdominal and thoracic approach). We found a predominance of males with a median age of 63. The diagnosis was made with an endoscopy, barium swallow and manometry. Half of the manometry results were pathologic. The surgical technique involved a diverticulectomy, myotomy and a Dor partial founduplication. Two patients that presented suture line leakage (SLL) were treated conservatively. No mortality was reported. The systematic review was carried out under the Preferred Reporting Items for Systematic Reviews and Meta-analyses scheme, with a total of 20 studies where 189 patients were found. No comparative or prospective randomised trials were found. Overall morbidity was 24%, with a SLL rate of 12%, hospital stay of 5 days and mortality of 1.5%. After a median follow-up of 42 months, 81.5% of the patients were asymptomatic. CONCLUSION: The minimally invasive approach for ED is a safe and feasible procedure.
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Affiliation(s)
| | - Eduardo M Targarona
- Deparment of General Surgery, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
| | - Carmen Balague
- Deparment of General Surgery, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
| | - Carlos Rodriguez-Luppi
- Deparment of General Surgery, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
| | - Ana B Martin
- Deparment of General Surgery, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
| | - Manuel Trias
- Deparment of General Surgery, Hospital de la Santa Creu i Sant Pau, UAB, Barcelona, Spain
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25
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Felix VN, DeVault K, Penagini R, Elvevi A, Swanstrom L, Wassenaar E, Crespin OM, Pellegrini CA, Wong R. Causes and treatments of achalasia, and primary disorders of the esophageal body. Ann N Y Acad Sci 2013; 1300:236-249. [PMID: 24117646 DOI: 10.1111/nyas.12254] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The following on achalasia and disorders of the esophageal body includes commentaries on controversies regarding whether patients with complete lower esophageal sphincter (LES) relaxation can be considered to exhibit early achalasia; the roles of different mucle components of the LES in achalasia; sensory neural pathways impaired in achalasia; indications for peroral endoscopic myotomy and advantages of the technique over laparoscopic and thorascopic myotomy; factors contributing to the success of surgical therapy for achalasia; modifications to the classification of esophageal body primary motility disorders in the advent of high-resolution manometry (HRM); analysis of the LES in differentiating between achalasia and diffuse esophageal spasm (DES); and appropriate treatment for DES, nutcracker esophagus (NE), and hypertensive LES (HTLES).
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Affiliation(s)
| | - Kenneth DeVault
- Department of Medicine, Mayo Clinic Florida, Jacksonville, Florida
| | - Roberto Penagini
- Università degli Studi di Milano and Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandra Elvevi
- Università degli Studi di Milano and Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Eelco Wassenaar
- Department of Surgery, University of Washington, Seattle, Washington
| | - Oscar M Crespin
- Department of Surgery, University of Washington, Seattle, Washington
| | | | - Roy Wong
- Department of Gastroenterology, Walter Reed National Military Medical Center, Bethesda, Maryland
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26
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Fumagalli Romario U, Ceolin M, Porta M, Rosati R. Laparoscopic repair of epiphrenic diverticulum. Semin Thorac Cardiovasc Surg 2013. [PMID: 23200078 DOI: 10.1053/j.semtcvs.2012.10.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Epiphrenic diverticulum of the esophagus is an uncommon disease, and its pathogenesis remains unclear. Surgical repair of this disease is warranted only for symptomatic patients because treatment carries high risk of morbidity. Over the past decade, the laparoscopic approach to epiphrenic diverticulectomy has been shown to be safe and effective. The aim of the study was to describe our specific approach to the procedure and results. From 1994 to 2012, 30 patients with symptomatic epiphrenic diverticulum underwent laparoscopic surgery. There were no conversions to open surgery. The postoperative course was uneventful in 28 patients (93.3%). One patient had a suture line leak, which required repair through right thoracotomy, and 1 patient had a hemoperitoneum, which needed an open splenectomy. The median follow-up was 52 months (2-144). To date, no patient has presented with a recurrence. Laparoscopic transhiatal surgery is in our opinion the preferred approach to treatment of epiphrenic diverticulum of the esophagus. The procedure has proven to be feasible and safe in experienced hands. Long-term results, both clinical and with an objective evaluation, are satisfactory.
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