Peroral endoscopic myotomy for the treatment of epiphrenic diverticulum.(Case series)

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OBJECTIVE

This study aimed to assess the efficacy of peroral endoscopic myotomy (POEM) in managing epiphrenic diverticula of the esophagus.

MATERIAL AND METHODS

Our study involved four patients (two females), aged 62 to 67, with a 3—10-year history of the disease. One patient had a recurrence of the disease after laparoscopic diverticulectomy. Patients’ upper GI fluoroscopy and endoscopy revealed diverticulum sized from 4 to 7 cm on a narrow base, containing food and liquid, situated in the lower third of the esophagus. All patients exhibited non-productive contractions in the middle and lower thirds of the esophagus.

RESULTS

Undergoing POEM, patients had diverticula septum dissected. No complications were noted during or after the procedure. POEM duration spanning 110 to 195 minutes (mean of 133.5 minutes) and myotomy length varying from 15 to 30 cm (mean of 16.4 cm). Six and twelve-month follow-ups showed no ingestion issues, positive patient feedback. Post-operative assessments using upper GI fluoroscopy showed normal contrast flow into the stomach. Endoscopy confirmed a reduction in diverticulum size. All patients exhibited a decline in the Eckardt score from 10 to 0 points (average 0.25). One patient was diagnosed with grade B erosive esophagitis, which was effectively managed with proton pump inhibitors.

CONCLUSION

POEM has proven to be highly effective and safe for treating epiphrenic diverticula, significantly enhancing patients’ oral food intake. It stands as a viable alternative to conventional surgical approaches. However, long-term monitoring is recommended to address the potential development of gastroesophageal reflux post-operation.

Keywords:

peroral endoscopic myotomy

epiphrenic diverticula

esophageal diverticulum

esophageal dysmotility

endoscopy

Authors:

Drobayzgin E.A.

Novosibirsk State Medical University;
Novosibirsk State Regional Clinical Hospital;
Meshalkin National Medical Research Center

ORCID: 0000-0002-3690-1316

Chikinev Yu.V.

Novosibirsk State Medical University;
Novosibirsk State Regional Clinical Hospital

ORCID: 0000-0002-6795-6678

Kutepov A.V.

Novosibirsk State Medical University;
Novosibirsk State Regional Clinical Hospital

ORCID: 0009-0001-2293-9524

Received:

27.12.2023

Accepted:

12.04.2024

List of references:

Wessels EM, Schuitenmaker JM, Bastiaansen BAJ, Fockens P, Masclee GMC, Bredenoord AJ. Efficacy and safety of peroral endoscopic myotomy for esophageal diverticula. Endoscopy International Open. 2023;11(5):E546-E552. https://doi.org/10.1055/a-2071-6744
Facciorusso A, Ramai D, Ichkhanian Y, Yadlapati R, Annese V, Wani S, Khashab MA. Peroral Endoscopic Myotomy for the Treatment of Esophageal Diverticula: A Systematic Review and Meta-analysis. Journal of Clinical Gastroenterology. 2022;56(10):853-862. https://doi.org/10.1097/MCG.0000000000001622
Nabi Z, Chavan R, Asif S, Ramchandani M, Basha J, Darisetty S, Goud R, Kotla R, Reddy DN. Per-oral Endoscopic Myotomy with Division of Septum (D-POEM) in Epiphrenic Esophageal Diverticula: Outcomes at a Median Follow-Up of Two Years. Dysphagia. 2022;37(4):839-847. https://doi.org/10.1007/s00455-021-10339-8
Melman L, Quinlan J, Robertson B, Brunt LM, Halpin VJ, Eagon JC, Frisella MM, Matthews BD. Esophageal manometric characteristics and outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication for epiphrenic diverticula. Surgical Endoscopy. 2009;23(6):1337-1341. https://doi.org/10.1007/s00464-008-0165-9
Demeter M, Bánovčin P Jr, Ďuriček M, Kunda R, Hyrdel R. Peroral endoscopic myotomy in achalasia and large epiphrenic diverticulum. Digestive Endoscopy. 2018;30(2):260-262. https://doi.org/10.1111/den.12961
Sommer R, Machado Grossi JV, Grossi Harada GR, Seabra MK, Cavazzola LT, Seabra AP. Treatment of Giant Esophageal Epiphrenic Diverticulum Using Robotic-Assisted Surgery. CRSLS: MIS Case Reports from SLS. 2021;9(1):e2021.00068. https://doi.org/10.4293/CRSLS.2021.00068
Boutron C, Rebibo L, Duboc H, Antonopulos C, Calabrese D, Coffin B, Msika S. Thoracoscopic approach as surgical management of esophageal epiphrenic diverticulum. Journal of Visceral Surgery. 2023:1878-7886(23)00005-X. https://doi.org/10.1016/j.jviscsurg.2023.01.003
Kinoshita M, Tanaka S, Kawara F, Sakaguchi H, Abe H, Ariyoshi R, Toyonaga T, Kodama Y. Peroral endoscopic myotomy alone is effective for esophageal motility disorders and esophageal epiphrenic diverticulum: a retrospective single-center study. Surgical Endoscopy. 2020;34(12):5447-5454. https://doi.org/10.1007/s00464-019-07340-6
Bechara R, Onimaru M, Ikeda H, Inoue H. Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations. Gastrointestinal Endoscopy. 2016;84(2):330-338. https://doi.org/10.1016/j.gie.2016.03.1469
Orlandini B, Barret M, Guillaumot MA, Léandri C, Leblanc S, Prat F, Chaussade S. Per-oral endoscopic myotomy for esophageal diverticula with or without esophageal motility disorders. Clinics and Research in Hepatology and Gastroenterology. 2020;44(1):82-89. https://doi.org/10.1016/j.clinre.2019.03.013
Yang J, Zeng X, Yuan X, Chang K, Sanaei O, Fayad L, Kumbhari V, Singh V, AN, Hu B, Khashab MA. An international study on the use of peroral endoscopic myotomy (POEM) in the management of esophageal diverticula: the first multicenter D-POEM experience. Endoscopy. 2019;51(4):346-349. https://doi.org/10.1055/a-0759-1428
Leopold AR, Kim RE. Successful D-POEM after failed surgical myotomy and diverticulectomy. VideoGIE. 2022;7(6):211-215. https://doi.org/10.1016/j.vgie.2022.02.008
Pizzicannella M, Spota A, Dallemagne B, Swanström L, Marescaux J, Perretta S. Peroral endoscopic myotomy in a case of recurrent epiphrenic diverticulum after surgery. Endoscopy. 2021;53(3): E92-E93. https://doi.org/10.1055/a-1201-2725
Beyna T, Kandler J, Neuhaus H. Per-oral endoscopic myotomy and simultaneous diverticuloseptotomy in coincident epiphrenic diverticulum and achalasia. VideoGIE. 2018;4(2):62-65. https://doi.org/10.1016/j.vgie.2018.09.019
Mou Y, Zeng H, Wang O, Yi H, Liu W, Wen D, Tang C, Hu B Giant mid-esophageal diverticula successfully treated by per-oral endoscopic myotomy. Surgical Endoscopy. 2016;30(1):335-338. https://doi.org/10.1007/s00464-015-4181-2
Nabi Z, Reddy DN, Ramchandani M. Per-oral endoscopic myotomy in achalasia with large esophageal diverticulum: the “owl eyes” sign. Gastrointestinal Endoscopy. 2018;87(4):1151-1152. https://doi.org/10.1016/j.gie.2017.09.035
Oh SJ, Runge TM, Khashab MA, Sloan JA. Cut and Tied: Esophageal Dysmotility and Epiphrenic Diverticulum Treated with Peroral Endoscopic Myotomy (POEM) and Septotomy. Digestive Diseases and Sciences. 2022;67(2):446-451. https://doi.org/10.1007/s10620-021-06914-6
Basile P, Gonzalez JM, Le Mouel JP, Irarrazaval R, Caillo L, Barthet M. Per-oral endoscopic myotomy with septotomy for the treatment of distal esophageal diverticula (D-POEM). Surgical Endoscopy. 2020;34(5):2321-2325. https://doi.org/10.1007/s00464-019-07354-0
Nabi Z, Ramchandani M, Reddy DN. Per-oral endoscopic myotomy and gastroesophageal reflux: Where do we stand after a decade of “POETRY”? Indian Journal of Gastroenterology. 2019;38(4):287-294. https://doi.org/10.1007/s12664-019-00980-5

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