Endoscopy 2015; 47(S 01): E14-E15
DOI: 10.1055/s-0034-1390735
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Salvage peroral endoscopic myotomy for esophageal diverticulum

Hiroki Sato
1   Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan
,
Yuichi Sato
1   Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan
,
Manabu Takeuchi
1   Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan
,
Kazuya Takahashi
1   Division of Gastroenterology, Niigata University Medical and Dental Hospital, Niigata, Japan
,
Shin-ryu Takeda
2   Division of Endoscopy, Niigata University Medical and Dental Hospital, Niigata, Japan
,
Haruhiro Inoue
3   Digestive Disease Center, Showa University Koto-Toyosu Hospital, Tokyo, Japan
,
Masaaki Kobayashi
2   Division of Endoscopy, Niigata University Medical and Dental Hospital, Niigata, Japan
› Author Affiliations
Further Information

Corresponding author

Hiroki Sato, MD, PhD
Division of Gastroenterology
Niigata University Medical and Dental Hospital
757-1, Asahimachidori, Chuo-ku, Niigata City
Niigata 951-8510
Japan   
Fax: +81-25-223-6161   

Publication History

Publication Date:
20 January 2015 (online)

 

Esophageal diverticulum often causes secondary dysmotility. If a diverticulum associated with a functional disorder is growing and exacerbating symptoms, surgical treatment is usually indicated [1] [2]. Peroral endoscopic myotomy (POEM) was introduced by Inoue et al. in 2010 as a novel treatment technique for achalasia [3]. Here, we report our clinical experience of salvage POEM for esophageal diverticulum.

An 84-year-old woman was referred to our hospital with a 30-year history of dysphagia. Endoscopy and esophagography revealed a giant diverticulum in the mid esophagus, into which most of the barium flowed ([Fig. 1], [Fig. 2 a]). The diverticulum compressed the true esophageal lumen, although high resolution manometry (Star Medical Co., Tokyo, Japan) showed no findings of a primary motility disorder ([Fig. 3]). The patient was not suitable for curative surgery, and salvage POEM was undertaken as a less invasive treatment. A posterior wall myotomy (side opposite the diverticulum) was performed longitudinally, from the oral side of the diverticulum to the gastric side, and a pathologic thick layer of muscle was completely resected ([Fig. 4 a, b]). The patient’s subjective dysphagia was markedly decreased, and the smooth passage of barium flow was observed during esophagography ([Fig. 2 b]).

Zoom Image
Fig. 1 A diverticulum is seen in the mid esophagus.
Zoom Image
Fig. 2 a Preoperative esophagography showing barium inflow into the diverticulum and an empty true lumen. b After the peroral endoscopic myotomy procedure, barium flow through the true lumen is significantly improved, and pathologic muscle contraction is relieved.
Zoom Image
Fig. 3 There are no findings of a primary motility disorder by high resolution manometry.
Zoom Image
Fig. 4 a, b A posterior wall myotomy is performed longitudinally from the oral side of the diverticulum, and a pathologic thick muscle layer is completely resected.

The most common treatment for esophageal diverticulum is surgical resection. However, the surgical procedure is invasive and often difficult because of factors such as mediastinal adhesion. It also carries a high risk for complications, related mainly to suture leakage. POEM may be an appropriate salvage therapy for esophageal diverticulum in patients who cannot undergo an invasive operation.

Endoscopy_UCTN_Code_TTT_1AO_2AN


#

Competing interests: None

  • References

  • 1 Onwugbufor MT, Obirieze AC, Ortega G et al. Surgical management of esophageal diverticulum: a review of the Nationwide Inpatient Sample database. J Surg Res 2013; 184: 120-125
  • 2 Hirano Y, Takeuchi H, Oyama T et al. Minimally invasive surgery for esophageal epiphrenic diverticulum: the results of 133 patients in 25 published series and our experience. Surg Today 2013; 43: 1-7
  • 3 Inoue H, Minami H, Kobayashi Y et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271

Corresponding author

Hiroki Sato, MD, PhD
Division of Gastroenterology
Niigata University Medical and Dental Hospital
757-1, Asahimachidori, Chuo-ku, Niigata City
Niigata 951-8510
Japan   
Fax: +81-25-223-6161   

  • References

  • 1 Onwugbufor MT, Obirieze AC, Ortega G et al. Surgical management of esophageal diverticulum: a review of the Nationwide Inpatient Sample database. J Surg Res 2013; 184: 120-125
  • 2 Hirano Y, Takeuchi H, Oyama T et al. Minimally invasive surgery for esophageal epiphrenic diverticulum: the results of 133 patients in 25 published series and our experience. Surg Today 2013; 43: 1-7
  • 3 Inoue H, Minami H, Kobayashi Y et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271

Zoom Image
Fig. 1 A diverticulum is seen in the mid esophagus.
Zoom Image
Fig. 2 a Preoperative esophagography showing barium inflow into the diverticulum and an empty true lumen. b After the peroral endoscopic myotomy procedure, barium flow through the true lumen is significantly improved, and pathologic muscle contraction is relieved.
Zoom Image
Fig. 3 There are no findings of a primary motility disorder by high resolution manometry.
Zoom Image
Fig. 4 a, b A posterior wall myotomy is performed longitudinally from the oral side of the diverticulum, and a pathologic thick muscle layer is completely resected.