Endoscopic stapled diverticulotomy: treatment of choice for Zenker's diverticulum

OBJECTIVE: To evaluate the efficacy and safety of endoscopic stapled diverticulotomy in the treatment of patients with Zenker's diverticulum. STUDY DESIGN: Cohort study. METHODS: Fourteen elderly patients (11 men and 3 women) with Zenker's diverticulum were evaluated in a community hospital setting from July 1996 to November 1999. Before surgery patients had significant dysphagia, regurgitation, cough, or aspiration pneumonia. The common septum between the diverticulum and cervical esophagus was visualized with a Weerda diverticuloscope. While using videoendoscopic monitoring, the septum was divided and the edges simultaneously sealed with a linear endoscopic stapler. Average operative time was 31 minutes. RESULTS: The operation was successfully performed in 11 of 14 patients. In the three unsuccessful cases, one patient's pouch was too small to staple and the other two patients had a septum that was difficult to visualize with the diverticuloscope. There was no significant postoperative morbidity or mortality. Patients started a liquid diet on the first postoperative day and resumed a soft diet a week later. They were usually discharged on the first postoperative day. Most patients reported significant improvement with resolution of dysphagia and regurgitation. CONCLUSIONS: Compared with the traditional open technique, the endoscopic stapled diverticulotomy technique is safe, quick, and effective and requires a shorter length of stay in the hospital. Therefore it has become our treatment of choice for elderly, high-risk patients with a large (>2 cm) hypopharyngeal (Zenker's) diverticulum.     

Helicobacter pylori in Meckel's diverticulum with heterotopic gastric mucosa in a population with relatively high H. pylori prevalence rate

BACKGROUND: Helicobacter pylori (H. pylori) colonize only foveolar gastric-type mucosa and are associated with active chronic gastritis and peptic ulcer. The aim of this study was to investigate whether H. pylori can also be found in Meckel's diverticulum which contains heterotopic gastric mucosa. METHODS: Biopsy specimens of Meckel's diverticulum resected in Queen Mary Hospital, University of Hong Kong, during the 10 year period 1986-1995 were retrieved and reviewed. Those containing gastric heterotopia were examined for the presence of H. pylori, using Warthin-Starry silver stain. RESULTS: In the 59 cases of Meckel's diverticula studied, 16 were found to contain heterotopic gastric mucosa. Helicobacter pylori were not identified in any of these cases. In one of the 16 patients a concomitant gastric biopsy was performed. Although the gastric mucosa of this patient was heavily colonized by H. pylori, again no H. pylori was found in the heterotopic gastric mucosa in the Meckel's diverticulum. CONCLUSIONS: The absence of H. pylori in all the Meckel's diverticula examined, even when the stomach was heavily colonized by the organisms, suggests that colonization of Meckel's diverticulum by H. pylori is a rare event. This, together with the overall rarity of H. pylori in all reported series of Meckel's diverticulum, argues against its causative role in complications of Meckel's diverticulum.     

Catheter ablation in a patient with a congenital giant right atrial diverticulum presented as Wolff-Parkinson-White syndrome

A young woman symptomatic for tachycardia showed right ventricular preexcitation on the surface ECG with a pattern during induced atrial fibrillation suggestive of multiple APs. Noninvasive imaging techniques performed prior to catheter ablation demonstrated the presence of a giant right atrial diverticulum confirmed by hemodynamic procedure. This structure functioned as an enormous accessory AP. We performed catheter ablation of this pathway using a special 4-mm multipolar catheter inside the diverticulum. This is the first case of such as anomaly being successfully treated with catheter ablation.     

Left ventricular diverticulum A scintigraphic diagnosis

This report describes the scintigraphic features of a congenital left ventricular diverticulum in a child. The types of congenital diverticula of the heart and the possible diagnostic role of nuclear imaging is discussed.     

Spontaneous Haemoperitoneum Secondary to a Meckel’s Diverticulum

Meckel’s diverticulum is a relatively common gastrointestinal entity which occasionally causes complications. Meckel’s diverticulum is classically described to mimic acute appendicitis when inflamed as well as being a cause of unexplained luminal gastrointestinal bleeding. An unusual cause of spontaneous non traumatic haemoperitoneum found during surgery performed for a suspected acute appendicitis in a 22-year old female is described. The patient was found to have a significant haemoperitoneum due to a bleeding serosal vessel of a Meckel’s diverticulum. The diverti-culum was routinely excised. It was macroscopically and histologically devoid of inflammation. The bleeding vessel was not found to be abnormal or part of an arteriovenous malformation.     

成人及儿童心脏憩室临床分析

目的 :探讨成人与儿童心脏憩室的临床特点。方法 :将经心脏造影或手术证实为心脏憩室的 9例患者临床资料进行回顾性分析。结果 :14例成人患者 (成人组 )皆因并发冠心病在冠状动脉及左室造影检查时被偶然发现。 5例儿童患者 (儿童组 )中 4例因并存其他严重先天性心脏畸形而施行外科矫治手术时被确诊 ,另 1例经左室造影证实。2成人组平均憩室瘤体径为 2 0～ 48(36 .3± 11.8) mm,憩室颈径为 10～ 17(14.0± 2 .9) mm;儿童组平均憩室瘤体径 2 5～ 80 (42 .0± 2 2 .0 ) m m,憩室颈径为 4～ 12 (8.6± 3.9) mm。 3成人组均为孤立性左室肌型憩室 ,无与憩室有关的并发症 ,未行手术治疗 ;儿童组中仅 1例为孤立性左室肌型憩室 ,其余 4例均根据其并存的心脏畸形类型分别接受了憩室缝合术和房、室间隔修补术、三尖瓣成形术、二尖瓣置换术或动脉导管结扎术等治疗。结论 :成人与儿童心脏憩室的临床特点有许多不同之处     

Laparoscopic transhiatal treatment of large epiphrenic esophageal diverticulum

BACKGROUND: Epiphrenic diverticulum is an uncommon disorder of the distal third of the esophagus. We report the case of a 73-year-old woman with a large symptomatic esophageal epiphrenic diverticulum, diffuse nonspecific esophageal dysmotility, and a hiatal hernia. METHODS: Surgery was indicated by the patient's symptoms, the size of the diverticulum (maximum diameter 10 cm), and the associated esophageal motor disorder. Preoperative study included barium swallow, upper gastrointestinal endoscopy, and esophageal manometry. A laparoscopic transhiatal diverticulectomy associated with a Heller myotomy, hiatoplasty, and a Dor's fundoplication was carried out. The overall operative time was 230 minutes. RESULTS: No intraoperative complications occurred. Gastrografin swallow performed on postoperative day 4 did not show any signs of leakage from the staple line. The postoperative hospital stay was 5 days. The patient was readmitted 10 days after discharge complaining of fever and chest pain. A new Gastrografin swallow demonstrated a small leak from the staple line successfully treated with 3 weeks of total enteral nutrition. CONCLUSION: The laparoscopic approach to epiphrenic diverticulum is feasible. Postoperative Gastrografin swallow is not 100% sensitive in detecting small suture-line leaks if a preexisting esophageal motility disorder is present. In case of late postoperative fever and pleural effusion, a suture-line leak should be suspected. Conservative management of the small suture-line leak should be considered as an effective therapeutic option.     

Ultrasound detection of pneumoperitoneum due to colonic diverticulum perforation

Pneumoperitoneum may be shown by abdominal ultrasonography. This case report illustrates the potential value of ultrasound in detecting free intraperitoneal free air in a patient with acute abdominal pain. We outline the ultrasonographic features of pneumoperitoneum and discuss the role of both conventional and cross-sectional imaging modalities in making this diagnosis.     

Zenker’s Diverticula: Feasibility of a Tailored Approach Based on Diverticulum Size

Background  Zenker’s diverticula (ZD) can be treated by transoral diverticulostomy or open surgery (upper esophageal sphincter myotomy and diverticulectomy or diverticulopexy). The aim of this study was to compare the effectiveness of a minimally invasive (group A) versus a traditional open surgical approach (group B) in the treatment of ZD. Material and Methods  Between 1993 and September 2007, 128 ZD patients underwent transoral diverticulostomy (n = 51) or cricopharyngeal myotomy and diverticulectomy or diverticulopexy (n = 77). All patients were evaluated for symptoms using a detailed questionnaire. Manometry recorded upper esophageal sphincter (UES) pressure, relaxations, and intrabolus pharyngeal pressure. The size of the pouch was measured on the barium swallow. The choice of treatment was based on the size of the diverticulum and the patients’ preference. Long-term follow-up data were available for 121/128 (94.5%) patients with a median follow-up of 40 months (interquartile range, 17–83). Results  Mortality was nil. Three patients in group A (5.8%) and ten in group B (13%) had postoperative complications (p = n.s.). Hospital stays were markedly shorter for patients after diverticulostomy (p < 0.01). Postoperative manometry showed a reduction in UES pressure, improved UES relaxation, and lower intrabolus pressure in both groups (p < 0.05). Four patients in the open surgery group (5.2%) complained of severe dysphagia after surgery (three of them required endoscopic dilations). In the transoral diverticulostomy group, 11 patients (21.5%) required additional septal reduction (n = 8) or a surgical myotomy (n = 3) for persistent symptoms (p < 0.01); nine of these 11 patients had a ZD ≤ 3 cm in size. After primary and complementary treatments, symptoms disappeared or improved significantly at long-term follow-up in 93.5% of patients in group A and 96% of those in group B. Conclusion  Diverticulostomy is safe, quick, and effective for most patients with medium-sized ZD, but open surgery offers better long-term results as a primary treatment and should be recommended for younger, healthy patients, especially those with small diverticula. Small ZD may represent a formal contraindication to the transoral approach because an excessively short septum prevents a complete division of the sphincter fibers.