ENDOSCOPIC STENTING IN THE TREATMENT OF RECURRENT EPIPHRENIC DIVERTICULUM AFTER LAPAROSCOPIC DIVERTICULECTOMY. CLINICAL CASE REPORT

Epiphrenic diverticulum, also known as a pulsion diverticulum, is a rare type of esophageal diverticulum occurring in the distal 10 centimeters of the esophagus. They are most commonly 4-10 cm above the gastric cardia representing 10% of all esophageal diverticula. Laparoscopic diverticulectomy has become the treatment of choice. This clinical case study is dedicated to minimally invasive treatment of recurrent epiphrenic diverticulum after laparoscopic diverticulectomy. A 74-year-old male patient was admitted to the hospital with complaints of dysphagia, regurgitation and halitosis. The examination revealed a 5 cm epiphrenic diverticulum with sings of inflammation. Laparoscopic transchiatal diverticulectomy, the Dor (anterior) fundoplication, cruroraphia and mediastinal drainage were performed. The patient was discharged on the 11-th postoperative day. The patient exhibited dysphagia relapse during a 3-month follow-up. Taking into account the previous surgical treatment and the habitus endoscopic esophageal stenting was chosen as the technique of choice for management. Under intravenous anesthesia a partially covered metal self-expandable stent 10 cm x 1.8 cm was inserted into the distal esophagus. Next day control fluoroscopy showed stable stent position and no evidence of leakage. The water-soluble contrast agent reached stomach freely. The patient was discharged on the 2nd post-operative day. Within 4 months after having a stent placed, the patient feels well and oral feeding is satisfactory. In terms of literature search we have not come across any reference to the post-epiphrenic diverticulectomy recurrence treatment, so the management was chosen individually based on the comorbid status of the patient. The installation of a partially covered metal self-expandable stent allowed to promptly eliminate dysphagia and design features enabled to achieve stent stable position. A partially covered metal self-expandable stent can be considered effective in the post-epiphrenic diverticulectomy recurrence treatment.

Surgical treatment of a distal oesophageal stricture by mucosal radial incision and dilation in a kitten with secondary megaoesophagus

Case summary A 7-month-old intact female Maine Coon cat was presented with a 2-month history of regurgitations. Contrast radiographic and endoscopic examinations revealed a diffuse megaoesophagus secondary to a severe lower oesophageal stricture. An epiphrenic diverticulum was noted. Endoscopic balloon dilation was unsuccessful. Gastrotomy was thus performed in order to incise the oesophageal wall radially along the stricture site, and then to dilate the stricture. A diameter of 20 mm was reached. With the aim of preventing stricture recurrence, submucosal injections of triamcinolone acetonide were performed. An 18 Fr oesophagogastric feeding tube was placed and a left gastropexy was performed in order to exert some traction on the gastroesophageal junction, with the aim of reducing the oesophageal diverticulum. Twelve months postoperatively, clinical signs had completely resolved and follow-up radiographs revealed marked improvement of the oesophageal dilatation. Relevance and novel information Lower oesophageal strictures should be considered when evaluating regurgitations or megaoesophagus in a kitten. Surgical mucosal radial incision is a therapeutic option in cases of lower oesophageal stricture refractory to balloon dilation, and can lead to a marked improvement of clinical signs and of the oesophagus diameter leading to clinical success.

453 LAPAROSCOPIC RESECTION OF A GIANT EPIPHRENIC DIVERTICULUM

Epiphrenic diverticula are acquired mucosal out-pouchings of the distal third of the oesophagus; vastly undiagnosed due to their usual asymptomatic status, with limited number in all published series, and a still ongoing debate both in their surgical indication and technique. This video shows all steps we think that are necessary when operating an epiphrenic diverticulum, in order to illustrate them all and to show the feasibility of performing such operation with minimally invasive procedures. Methods A 52-year-old male was diagnosed of a symptomatic giant epiphrenic diverticulum after previous complaints of dysphagia and regurgitation of undigested food. Preoperative barium-swallow and upper endoscopy confirmed the diagnosis, excluding any other secondary aetiology, and conventional oesophageal manometry did not show any relevant findings. Results Surgery was indicated for symptomatic disease, and a laparoscopic procedure was performed, with pneumoperitoneum created through a Veress needle and trocars placed similar to those used for a hiatal hernia repair. After opening the hiatus, access was granted to the mediastinum and the diverticulum was identified and dissected, and when its neck was completely exposed, diverticulectomy was performed using endostapler loads reinforced with Peri-strips Dry®. Aferwards, both an oesphageal myotomy (from the oesophago-gastric junction to the distal point of the diveticulum’s neck) and a partial Dor fundoplication (despite the absence of relevant findings in the conventional manometry) were performed. Conclusion Surgical management of epiphrenic diverticula should entail both resection of the pouch (diverticulectomy, to avoid postoperative persistent symptoms) and treatment of the underlying motility disorder that has been demonstrated in other studies in nearly 100% of the patients using high-resolution manometry (myotomy and fundoplication, both to avoid recurrences and leakages of the staple line). The laparoscopic approach is feasible without video-assisted thoracoscopy in diverticula with their neck up to 10 cm from the oesophagogastric junction. Video https://www.dropbox.com/s/hugbemgi6wl55kp/EpiphrenicDiverticulumx2.mp4?dl=0