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DOI: 10.1055/s-0043-125310
Successful treatment of giant esophageal diverticulum by per-oral endoscopic myotomy
Publication History
Publication Date:
16 February 2018 (online)
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A 79-year-old woman was referred to our department with a 20-year history of dysphagia, retrosternal pain, and several episodes of aspiration and pneumonia. Esophageal radiograph showed a giant diverticulum in the mid-esophagus containing a large amount of the barium ([Fig. 1]). Gastroscopy revealed food impaction in the giant esophageal diverticulum; the real opening of the esophagus was relatively narrow and compressed at the side ([Fig. 2]). Given the advanced age of the patient and the potential complications of a surgical procedure, the patient underwent per-oral endoscopic myotomy (POEM) ([Video 1]).
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Video 1 Gastroscopy showed a giant diverticulum in the mid esophagus and it was treated successfully by per-oral endoscopic myotomy.
Quality:
First, a 2-cm mucosal incision was made approximately 4 cm above and on the same side of the diverticulum using a DualKnife (Olympus, Tokyo, Japan). Then, a submucosal tunnel was created in the septum between the diverticulum and esophageal lumen ([Fig. 3]). Third, the muscle of the septum was completely dissected ([Fig. 4]). Finally, the entry of the tunnel was closed with hemostatic clips. The procedure was performed smoothly and there were no complications after the endoscopic treatment.
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After endoscopic treatment, the patient’s clinical symptoms gradually subsided and diet increased. Body weight had increased by 2 kg 3 months later. A repeat esophageal radiograph showed only a small amount of barium remaining in the diverticulum ([Fig. 5]), and repeat gastroscopy showed that the opening of the esophagus had increased and there was no food in the residual diverticulum ([Fig. 6]).
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Esophageal diverticula are congenital or acquired malformations of the gastrointestinal tract, and large ones often cause secondary dysmotility. For the symptomatic esophageal diverticulum, surgery is the traditional treatment [1]. But, surgery is more invasive, and poses a higher risk in older patients. POEM is now an effective and safe treatment technique for achalasia [2]. The septum between the diverticulum and the esophageal tract is the key focus of endoscopic treatment [3]. POEM is safer and less invasive than surgery for patients with esophageal diverticulum.
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* These authors contributed equally to this work.
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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 Swanstrom LL, Kurian A, Dunst CM. et al. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg 2012; 256: 659-667
- 3 Goelder SK, Brueckner J, Messmann H. Endoscopic treatment of Zenker’s diverticulum with the stag beetle knife (sb knife) – feasibility and follow-up. Scand J Gastroenterol 2016; 51: 1155-1158