Squamous cell carcinoma in an esophageal diverticulum below the aortic arch

INTRODUCTIONEsophageal diverticula frequently arise from pharyngoesophageal transition area, tracheal bifurcation and epiphrenic region. Carcinoma arising from esophageal diverticulum is rarely seen. We report a patient with a squamous cell carcinoma arising within an esophageal diverticulum below the aortic arch.PRESENTATION OF CASEA 70-year-old man was diagnosed to have a squamous cell carcinoma of the vocal cord with enlarged lymph nodes in the neck, as well as a squamous cell carcinoma arising within an esophageal diverticulum below the aortic arch. There have been no reported cases of esophageal cancer arising from a diverticulum below the aortic arch. Preoperative radiotherapy for the esophageal cancer and pharyngeal cancer was given, followed by surgery. The excised specimen of the esophageal diverticulum and its external appearance revealed that it lacked muscle fibers, with a type 0-IIa lesion arising from the diverticulum. Microscopic examination showed three lymph nodes at the superior mediastinum were positive for malignancy. Bilateral pleural dissemination was detected 7 months after esophagectomy.DISCUSSIONCancer arising from an esophageal diverticulum is mainly found at an advanced stage because of delayed diagnosis. The absence of muscularis propia may lead to early invasion. Thus, cancers within an esophageal diverticulum are considered to be at a more advanced stage than similar cancers arising elsewhere.CONCLUSIONFor detecting of cancer arising from an esophageal diverticulum, a high index of awareness is important. Delay in diagnosis makes surgical management difficult.     

Transhiatale laparoskopische Divertikelresektion bei einem epiphrenischen Oesophagusdivertikel

Epiphrenic diverticula are rare. The exact prevalence of this condition is unknown because asymptomatic patients are usually not discovered. Symptoms are more often the result of an esophageal motility disorder than the diverticulum itself and no correlation exists between the size of the diverticulum and the severity of symptoms. We present a patient suffering from dysphagia, chest pain, food retention and regurgitation because of an epiphrenic diverticulum. The current treatment of choice for symptomatic epiphrenic diverticula is diverticulectomy via a left thoracic approach. We performed a successful abdominal laparoscopic approach.     

Esophageal diverticula: patient assessment.

Esophageal diverticula are best classified by their anatomic location: pharyngoesophageal (Zenker's diverticula), midthoracic, and epiphrenic. Most diverticula result from esophageal motility disorders. Although some patients are asymptomatic and diverticula are incidental findings, most patients are symptomatic. Dysphagia, regurgitation, and pain are common complaints, however, symptoms are often nonspecific and may be the result of an associated esophageal motility disorder. Contrast radiography is the prime diagnostic tool; evaluation of the diverticulum, associated esophageal abnormalities, and complications are assessed by a barium esophogram. Esophagoscopy adds little to the evaluation of the diverticulum but may be indicated in the assessment of other esophageal abnormalities. Motility studies, which may be difficult or hazardous to perform, are of little use in the diagnosis and treatment of Zenker's diverticula. Manometric evaluation of midthoracic or epiphrenic diverticula usually show an associated motility disorder and may influence treatment decisions.     

Therapeutic Strategies for Epiphrenic Diverticula: Systematic Review

Most patients with epiphrenic diverticula are asymptomatic. When dysphagia or regurgitation is limited and respiratory complaints are absent, these patients usually can live with the diverticulum left in place. Fewer than one-third of the diverticula produce symptoms severe enough to seek medical attention or to warrant surgery. The purpose of this systematic review was to analyze the therapeutic strategies for epiphrenic diverticula—from a nonsurgical alternative such as endoscopic dilatation for symptomatic patients unfit for surgery, to the traditional approach of surgical resection (left thoracotomy), and finally to the minimally invasive techniques (thoracoscopy, laparoscopy) used more recently. Whatever treatment and approach are used for the patient with epiphrenic diverticula, a tailored protocol always involves detailed study of the esophageal morphology and function.     

High resolution manometry findings in patients with esophageal epiphrenic diverticula

The pathophysiology of esophageal epiphrenic diverticula is still uncertain even though a concomitant motility disorder is found in the majority of patients in different series. High resolution manometry may allow detection of motor abnormalities in a higher number of patients with esophageal epiphrenic diverticula compared with conventional manometry. This study aims to evaluate the high resolution manometry findings in patients with esophageal epiphrenic diverticula. Nine individuals (mean age 63 ± 10 years, 4 females) with esophageal epiphrenic diverticula underwent high resolution manometry. A single diverticulum was observed in eight patients and multiple diverticula in one. Visual analysis of conventional tracings and color pressure plots for identification of segmental abnormalities was performed by two researchers experienced in high resolution manometry. Upper esophageal sphincter was normal in all patients. Esophageal body was abnormal in eight patients; lower esophageal sphincter was abnormal in seven patients. Named esophageal motility disorders were found in seven patients: achalasia in six, diffuse esophageal spasm in one. In one patient, a segmental hypercontractile zone was noticed with pressure of 196 mm Hg. High resolution manometry demonstrated motor abnormalities in all patients with esophageal epiphrenic diverticula.     

Surgical treatment of pulsion diverticula of the esophagus

A retrospective study of 53 patients, operated upon for esophageal pulsion diverticula, is used to compare results with those in the literature in an attempt to improve operative indications with the hope of reducing the number of only fair short and long term results. Findings showed that results were rated as good in 81% of the 35 patients with pharyngo-esophageal diverticula and 65% of the 18 with epiphrenic diverticula. Indications for operation for pharyngo-esophageal diverticula can be based on clinical and radiological signs. Cricopharyngeal manometry indicates that myotomy is a logical procedure but results show that it is not necessary for choice of indications for surgery. Our preference is for a diverticulectomy, with or without associated myotomy, of debatable value. In contrast, for epiphrenic diverticula, functional esophageal explorations provide greater precision of the type of dyskinesia and allow better adaptation of surgery to type of dyskinesia associated with diverticulum.     

Laparoscopic Resection of an Esophageal Epiphrenic Diverticulum

Epiphrenic diverticulum of the esophagus is an uncommon disease. In the light of the benefits of minimally invasive treatment of such a functional disorder, we used the laparoscopic approach for resection of an epiphrenic diverticulum. We found that laparoscopic repair of symptomatic esophageal epiphrenic diverticula is a safe and effective technique with minimal postoperative pain and morbidity. It should be considered as an alternative to the traditional transthoracic approach, and may become the standard technique.     

Laparoscopic resection of an esophageal epiphrenic diverticulum

Epiphrenic diverticulum of the esophagus is an uncommon disease. In the light of the benefits of minimally invasive treatment of such a functional disorder, we used the laparoscopic approach for resection of an epiphrenic diverticulum. We found that laparoscopic repair of symptomatic esophageal epiphrenic diverticula is a safe and effective technique with minimal postoperative pain and morbidity. It should be considered as an alternative to the traditional transthoracic approach, and may become the standard technique.     

Robotic transhiatal excision of epiphrenic diverticula

An epiphrenic oesophageal diverticulum is most commonly a pulsion diverticulum which develops consequent to protrusion of mucosa through the muscular wall of the distal oesophagus. Most of them are associated with underlying oesophageal motility disorders. The predominant symptoms are dysphagia with regurgitation, and sometimes retrosternal pain, if accompanied by spasm of the oesophagus. Surgical management is recommended for symptomatic patients. Traditional procedures include thoracotomy or laparotomy with excision of the diverticula, but these are associated with high morbidity. Laparoscopic approach is a safe treatment option associated with lesser morbidity. Here, we present a case of epiphrenic diverticulum which was treated by the robotic approach without any complication. There was also no associated motility abnormality in our case so fundoplication was not done. Robotic surgery is a useful tool while operating near the hiatus and gastro-oesophageal junction. We consider transhiatal robotic approach as a safe and easy approach for surgery of epiphrenic diverticulum.     

Laparoscopic resection of an epiphrenic diverticulum of the esophagus

Diverticulectomy of epiphrenic diverticula of the esophagus is conventionally performed via left thoracotomy. We report the case of a 57-year-old man who presented with an epiphrenic diverticulum that was resected using a transperitoneal laparoscopic technique.     

Management of epiphrenic diverticula

Epiphrenic diverticula are very rarely seen and are often associated with achalasia, esophageal body dysmotility, and a high resting lower esophageal sphincter pressure. The aim of this study was to evaluate the different treatment options for patients with epiphrenic diverticula. Patients with an epiphrenic diverticulum were divided into two treatment groups: surgical and nonsurgical. Retrospective chart review was performed, and a symptom questionnaire was created. There were six patients in the nonsurgical group and 11 patients in the surgical group. The mean follow-up was 26.4 months. Ten patients had a laparoscopic operation performed. One patient was operated on thoracoscopically and had to be converted to a thoracotomy. Two diverticula were inverted with good results. There was one postoperative esophageal leak where no myotomy was added. An empyema developed in another patient at 4 weeks after surgery. One patient, in whom no antireflux procedure was performed, reported postoperative heartburn. Patients in the nonsurgical group had smaller diverticula, were not good candidates for surgery, or were asymptomatic. Esophageal diverticula are very rarely seen. Asymptomatic patients may not require therapy. If surgery is performed and the diverticulum is large, it should be removed. The laparoscopic approach is the surgical treatment of choice. A long myotomy and an antireflux procedure should be added to avoid esophageal leakage at the line of repair and gastroesophageal reflux.     

Cause and treatment of epiphrenic diverticula

BACKGROUND: Epiphrenic diverticula of the esophagus are often associated with a concomitant esophageal motor disorder, which is thought to be the cause of the diverticulum and some of the patient's symptoms. At one time diverticula were best removed via a left thoracotomy, but now the operation can be performed laparoscopically in most cases. We hypothesized that: (1) a motor disorder is the underlying cause of the diverticulum; and (2) optimal treatment consists of laparoscopic resection of the diverticulum, a Heller myotomy, and Dor fundoplication. METHODS: We performed a retrospective review of a prospectively collected database from a university hospital tertiary care center. Between June 1994 and December 2002, we evaluated 21 patients with epiphrenic diverticula. An associated motility disorder of the esophagus was found in 81% of patients (achalasia, 9%; diffuse esophageal spasm, 24%; nonspecific esophageal motility disorder, 24%; nutcracker esophagus, 24%). Seven (33%) of these patients, all with esophageal dysmotility, were referred for treatment. The laparoscopic operation entailed resection of the diverticulum (using an endoscopic stapler), a Heller myotomy, and a Dor fundoplication. RESULTS: All operations were completed laparoscopically. The postoperative course of 6 patients was uneventful and they left the hospital after 72 +/- 21 hours. In 1 patient an acute paraesophageal hernia developed, which was repaired on the second postoperative day. Late follow-up (median 57 months) showed that all 7 patients were asymptomatic. CONCLUSIONS: These data support the conclusions that: (1) a primary esophageal motility disorder is the underlying cause of most epiphrenic diverticula; and (2) laparoscopic treatment is successful and should be the method of choice. The diverticular neck can be exposed satisfactorily from the abdomen; a stapler inserted from this angle is better orientated to transect the neck than one inserted through a thoracoscopic approach. Furthermore, the myotomy and fundoplication are much more easily performed from the abdomen than from alternative approaches.     

Esophageal diverticula

Esophageal diverticula are classified by location-phrenoesophageal (Zenker's diverticulum-70%), thoracic and mediastinal (10%), and epiphrenic (20%). Almost all esophageal diverticula are acquired pulsion diverticula. The most common symptoms are dysphagia, regurgitation, thoracic pain, and pulmonary manifestations related to aspiration. Barium swallow and upper endoscopy will help to establish the diagnosis while esophageal manometry may reveal underlying dysmotility. Diverticula should not be treated unless they are symptomatic. The treatment of Zenker's diverticulum is surgical and consists of either diverticulectomy or diverticular suspension with a myotomy of the cricopharyngeus muscle via cervical approach. Transoral endoscopic stapled diverticulostomy is a new and simple approach which may become the treatment of choice, particularly in elderly and high-risk patients. Treatment of diverticula of the mid and low esophagus must take into account any motor anomalies or associated lesions. Diverticulectomy with esophageal myotomy and an anti-reflux procedure through a left thoracotomy is the standard approach, but endoscopic approaches seem feasible, particularly for epiphrenic diverticula, and may become the norm in years to come.     

Esophageal diverticula

Esophageal diverticula are considered to be rare but this has not deterred interest in the condition, either historically or in the present era. Most parabronchial esophageal diverticula are traction diverticula, and resection is thought to be unnecessary. The majority of pharyngoesophageal diverticula and epiphrenic diverticula are pulsion diverticula. It is now well accepted that they correlate with underlying motor disturbance and that surgery is indicated. If there is motor disturbance is preoperative manometry, it is necessary to add myotomy. However, if there is no motor disturbance, the surgical management remains controversial. Recently, minimal access surgery with laparoscopy or thoracoscopy has been successful in the treatment of epiphrenic diverticulum.     

Surgical indication and technique in diverticulosis of the esophagus]

Diverticula of the oesophagus are a rare disease with an interesting patho-physiology which is the basis for a correct indication and surgical procedure. Our experience bases on 72 operated cases with a long follow-up. The pharyngo-oesophageal or Zenker's diverticulum and the epiphrenic diverticulum are pulsion diverticula above an achalasic sphincter: the upper cervical and the LES. A surgical treatment is necessary in the most cases of Zenker's, in the epiphrenic form depending on symptoms and risk. The treatment of Zenker's is a cervicotomy with diverticulectomy (we use a stapler) and accurate myotomy of the cricopharyngeus. A beginning little D or a cervical achalasia without D are often the cause of serious and lasting symptoms. Here the alone cricomyotomy is the procedure of choice. Reflux disease is frequently associated with Zenker's, sometimes a surgical problem too. The operation of the epiphrenic D is a left thoracotomy with diverticulectomy and the very important abolition of the causal achalasia with myotomy and antireflux (by us a fundoplication). The traction diverticula of the thoracic oesophagus are frequently asymptomatic. Operation with right thoracotomy is exceptionally necessary on painful segmental dyskinesia of bezoar. It is essential on oesophago-respiratory fistula.     

经腹腔镜微创治疗膈上食管憩室

目的探讨经腹腔镜微创治疗膈上食管憩室的可行性与有效性。 方法回顾性分析2015年1月至2020年6月于上海市胸科医院治疗的31例食管憩室患者,分析其中13例膈上食管憩室。术前辅助诊断检查包括钡餐造影、上消化道内镜检查、24 h食管pH监测以及食道Manometry测压。手术方式包括病例1~2经左胸开放,病例3经右胸腔镜,病例4~13经腹腔镜裂孔完成。术后观察指标包括手术相关并发症以及症状缓解情况。 结果13例膈上食管憩室中男7名（53.8%）,年龄（64.08±5.9）岁,10例（76.9%）憩室朝向食管左侧壁,憩室颈上缘距门齿距离（35.8±2.0）cm,憩室体直径（4.5±1.7）cm。13例患者接受手术治疗,手术时间（122.1±45.7）min,手术失血量（115.4±60.5）mL,住院时间（10.0±3.4） d。术后发生食管瘘3例,左胸（50%）、右胸（100%）、经腹（10%）路径各1例,其中2例经胸瘘患者均需二次手术。无院内死亡。远期随访可见左胸路径术后有1例患者出现食管狭窄,右胸路径术后1例患者出现反流,腹腔镜术后有2例患者出现食管狭窄。 结论腹腔镜经裂孔治疗膈上食管憩室,可以极大地提高手术安全性,通过解除远端梗阻,极大地降低术后瘘和憩室复发的发生率。     

Automatic stapling devices in the surgical treatment of esophageal diverticula.

Experience is presented of 18 patients in whom surgical treatment of esophageal diverticulum included use of an automatic stapling device. Ten diverticula were pharyngoesophageal, three mid-esophageal and five epiphrenic. One-stage diverticulectomy with myotomy was performed in all cases. Postoperative follow-up was 6-66 months. The results were excellent, without early or late complications or recurrence.     

Epiphrenic diverticulum composed of airway components attributed to a bronchopulmonary-foregut malformation: Report of a case

Bronchopulmonary-foregut malformation (BPFM), defined originally as pulmonary sequestration with or without communication to the esophagus, has been acknowledged to include congenital foregut diverticula. We present herein the case of a 43-year-old woman with a 9-year history of dysphagia, in whom a barium meal examination demonstrated a 2.5-cm epiphrenic diverticulum and several fistulae. A laparotomy was performed and the lower esophagus without communication to the lung was pulled down and resected, followed by an esophagogastrostomy carried out with fundopexy. Since her operation, the patient has been free of symptoms. Histologically, the diverticulum was observed to be lined by stratified squamous cells, but its shape was formed by mural cartilage, smooth muscle cells, and three ciliated-cell cysts. The dysphagia was considered to have been derived from the kinked esophagus created by the rigid diverticulum, being the possible developmental arrest of a supernumerary lung bud. These findings indicate that this case may involve BPFM in the broad sense. Although several cases of bronchogenic cysts located beneath or across the diaphragm have been reported as a subgroup of BPFM, congenital epiphrenic diverticula has rarely been described.     

Long-term survival following diverticulectomy for cancer in pharyngoesophageal (Zenker's) diverticulum

The incidence of cancer in a pharyngoesophageal (Zenker's) diverticulum was 0.4% among 1,249 patients treated for such diverticula at the Mayo Clinic in a 53-year period. Twenty-four patients with squamous cell carcinoma arising in a pharyngoesophageal diverticulum have been reported by others. However, most of the patients died of the malignancy within 2 years of treatment, and there were no long-term survivors. We describe 2 long-term survivors who were without evidence of tumor or diverticulum recurrence 4 1/4 and 8 years after one-stage pharyngoesophageal diverticulectomy. Review of the literature revealed that most patients with cancer in pharyngoesophageal diverticulum should be managed in a manner similar to that for patients with ordinary cervical esophageal malignancy. However, our data suggest that when the tumor is well localized without full-thickness penetration, nodal metastasis, or extension to the line of resection (as in the 2 patients discussed), diverticulectomy alone can provide satisfactory control of cancer with minimal therapeutic risk.     

Laparoscopic approach for esophageal achalasia with epiphrenic diverticulum

We report the case of a 65-year-old woman with a 10-year history of dysphagia, regurgitation, cough, and 10-kg weight loss caused by an epiphrenic diverticulum associated with esophageal achalasia managed with a laparoscopic approach. A preoperative barium swallow showed a dilated sigmoid esophagus with a 6-cm epiphrenic diverticulum. Esophageal manometry confirmed the absence of peristalsis in the esophageal body. We performed a laparoscopic diverticulectomy and a 7-cm distal esophageal myotomy with a Dor fundoplication. The postoperative course was uneventful. On the third postoperative day a barium swallow showed no leak, and the patient started oral intake. She was discharged home 5 days after the operation free of symptoms and tolerating a soft diet. Sixteen months after surgery, she was asymptomatic and had gained 8 kg. A barium swallow showed a normal-size esophagus with regular emptying. We reaffirm the feasibility, safety, and efficacy of the laparoscopic diverticulectomy and distal myotomy with Dor fundoplication to manage epiphrenic diverticula resulting from esophageal achalasia.