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      Large Epiphrenic Diverticula: A Rare Case Presentation

      case-report

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          Abstract

          A 70-year old female was admitted to hospital with heartburn and chronic halitosis since 5 years. She was on proton pump inhibitors for the same. Her complaints worsened during the last one-year. Workup comprising of esophago-gastro-duodenoscopy, esophageal manometry, 3D computed tomography scan showed right-sided epiphrenic diverticula measuring 10x10 cm with wide mouth about 5 cm with hypertensive lower esophageal sphincter. Patient underwent a video assisted thoracoscopic surgery for esophageal diverticulectomy using two 45 mm staplers. On day 5, the patient developed leak, which was managed by a covered esophageal stent placement. Patient started on oral feeds from day 3 and the esophageal leak healed completely within 2 weeks. Literature suggests that esophageal leaks treated conservatively took approximately 30-40 days on an average for healing. Literature search did not reveal esophageal leak managed by stent with faster recovery (2 weeks). This is one of the largest epiphrenic diverticuli reported in literature.

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          Epiphrenic diverticulum: results of surgical treatment.

          V F Trastek, Keith R. Daly, C Deschamps … (1993)
          From 1975 to 1991, 112 patients (64 men and 48 women) were found to have an epiphrenic diverticulum. Symptoms were absent or minimal in 71 patients and incapacitating in 41. All patients with minimal symptoms were managed conservatively; 35 were available for follow-up, which ranged from 1 to 25 years (median, 9 years). None of these 35 patients had clinically significant progression of symptoms. Surgical repair was done in 33 patients with incapacitating symptoms. Achalasia was present in 8 of the surgical patients (24.2%), diffuse esophageal spasm in 3 (9.1%), hypertensive lower esophageal sphincter alone in 1 (3.0%), and nonspecific motor abnormalities of the esophageal body in 7 (21.2%). Diverticulectomy and esophagomyotomy were performed in 22 patients, diverticulectomy alone in 7, esophageal resection in 3, and esophagomyotomy alone in 1. Concomitant hiatal hernia repair was done in 6 patients. Complications occurred in 11 patients; 6 had esophageal leaks. There were three operative deaths (9.1%), all occurring in patients with abnormal manometry. Follow-up was complete in 29 patients and ranged from 4 months to 15 years (median, 6.9 years). Long-term results were excellent in 14 patients (48.2%), good in 8 (27.6%), fair in 5 (17.2%), and poor in 2 (6.9%). We conclude that operation has significant risks and is not warranted in patients with minimal symptoms because progression is unlikely. Surgical treatment, however, is advisable in patients with incapacitating symptoms because most operative survivors will have long-term symptomatic palliation.
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            Laparoscopic approach in the treatment of epiphrenic diverticula: long-term results.

            L Brusciano, P Limongelli, Sebastian Russo … (2004)
            Thoracotomy represents the traditional surgical approach for the treatment of epiphrenic diverticula. A mini-invasive procedure has been reported in only few series. This article describes the authors experience with the laparoscopic approach for performing diverticulectomy, myotomy and Nissen-Rossetti fundoplication. From 1994 to 2002, 13 patients (6 men and 7 women), mean age 57 years (range 45-71 years), with symptomatic epiphrenic diverticulum underwent laparoscopic diverticulectomy, myotomy, and Nissen-Rossetti fundoplication. The mean operative time was 145 min (range 110-180 min). No operative mortality was observed. The mean hospital stay was 13.9 days (range 7-25 years). The first three patients (23.1%) who underwent surgery experienced a partial disruption of the suture staple line. One patient (7.7%) died of a myocardial infarction. After a mean clinical follow-up period of 58 months (range 3-96 months), all the patients were symptom free. Laparoscopic management of epiphrenic diverticula seems to be as safe and effective as the traditional approach, although a longer follow-up period is necessary to confirm the study results.
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              Oesophageal diverticula.

              Christian Rizzetto, S Narne, Mario Costantini … (2004)
              Oesophageal diverticula are rare. They are most commonly seen at the pharyngo-oesophageal junction (Zenker's diverticula) or at the distal oesophagus (epiphrenic diverticula). In both cases they are caused by altered motility which results in abnormal intraluminal pressure and the pushing of the oesophageal mucosa through focal weaknesses of the muscular wall (pulsion diverticula). The established surgical treatment for these diverticula therefore consists of eliminating the functional obstruction causing the disease (myotomy), associated with resection of the diverticulum (diverticulectomy) or its suspension (diverticulopexy). Recently, the spread of minimally invasive surgery has also led the application of such techniques to the treatment of oesophageal diverticula. Endoscopic diverticulostomy with stapler, laser or coagulation, through a rigid or flexible endoscope, has been demonstrated to be a valid treatment for Zenker's diverticula-as an alternative to surgery-especially in high-risk patients. On the other hand, laparoscopic treatment of epiphrenic diverticula has recently been introduced with encouraging results. However, because the disease is rare, more experience is required in order to allow definitive conclusions.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Clin Pract
                Journal ID (iso-abbrev): Clin Pract
                Journal ID (publisher-id): CP
                Title: Clinics and Practice
                Publisher: PAGEPress Publications, Pavia, Italy
                ISSN (Print): 2039-7275
                ISSN (Electronic): 2039-7283
                Publication date (Electronic): 20 November 2015
                Publication date Collection: 05 November 2015
                Volume: 5
                Issue: 4
                Electronic Location Identifier: 784
                Affiliations
                Department of General Surgery, Grant Medical College & Sir JJ Group of Hospitals , Byculla, Mumbai, India
                Author notes
                702, Vibhavari, Opposite CCI, Dinsha Waccha Road, Churchgate, Mumbai-400020, Maharashtra, India. +91.09869039609. abhandarwar@ 123456yahoo.com

                Conflict of interest: the authors declare no potential conflict of interest.

                Article
                DOI: 10.4081/cp.2015.784
                PMC ID: 4745591
                PubMed ID: 26918097
                SO-VID: 2bc1c0d6-d88b-49a3-9b74-2a029e7dca63
                Copyright © ©Copyright A.H. Bhandarwar et al.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 06 May 2015
                Date revision received : 21 August 2015
                Date accepted : 28 September 2015
                Page count
                Figures: 4, Tables: 0, Equations: 0, References: 9, Pages: 3
                Categories
                Subject: Case Report

                Keywords: epiphrenic diverticulum,achalasia,stent,leak
                Data availability:
                Keywords: epiphrenic diverticulum, achalasia, stent, leak

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