Esophageal diverticulum: New perspectives in the era of minimally invasive endoscopic treatment

Abstract

Esophageal diverticula are rare conditions that cause esophageal symptoms, such as dysphagia, regurgitation, and chest pain. They are classified according to their location and characteristic pathophysiology into three types: epiphrenic diverticulum, Zenker's diverticulum, and Rokitansky diverticulum. The former two disorders take the form of protrusions, and symptomatic cases require interventional treatment. However, the esophageal anatomy presents distinct challenges to surgical resection of the diverticulum, particularly when it is located closer to the oral orifice. Since the condition itself is not malignant, minimally invasive endoscopic approaches have been developed with a focus on alleviation of symptoms. Several types of endoscopic devices and techniques are currently employed, including peroral endoscopic myotomy (POEM). However, the use of minimally invasive endoscopic approaches, like POEM, has allowed the development of new disorder called iatrogenic esophageal diverticula. In this paper, we review the pathophysiology of each type of diverticulum and the current state-of-the-art treatment based on our experience.

Keywords: Diverticulectomy; Diverticulum; Epiphrenic diverticulum; Esophageal achalasia; Esophagus; Iatrogenic disease; Peroral endoscopic myotomy; Rokitansky diverticulum; Zenker’s diverticulum.

Figure 1

Epiphrenic diverticulum with achalasia treated using salvage peroral endoscopic myotomy. A: A giant epiphrenic diverticulum (yellow triangle) is visible in the right anterior wall through gastrointestinal endoscopy. The true lumen is compressed and never opens (black arrow); B: On high resolution manometry (HRM), the mean lower esophageal sphincter (LES) pressure is elevated (black triangle) and no normal peristalsis is observed. The patient is diagnosed with type I achalasia. The right lower insert shows the HRM findings after salvage peroral endoscopic myotomy (s-POEM), showing decreased LES pressure; C: s-POEM: Posterior wall myotomy (of the side opposite to the diverticulum, black arrow) is performed longitudinally from the oral terminus of the diverticulum to the gastric terminus, through the LES; D: Preoperative esophagography (left) showing barium inflow into the diverticulum. Some stagnant barium is observed in the mid to lower esophagus. After s-POEM (right), barium flow through the true lumen shows significant improvement and pathologic muscle contraction in the LES area is relieved (white arrow). ED: Epiphrenic diverticulum.

Figure 2

A case of iatrogenic diverticulum after peroral endoscopic myotomy. A: An iatrogenic diverticulum (yellow triangle) is visible on the anterior right wall in the lower esophagus on barium swallow; B: Hypercontractions on high resolution manometry persisted after peroral endoscopic myotomy, causing pulsion of the esophageal wall; C: Endoscopic view of the iatrogenic diverticulum of the esophagus that developed on the side where peroral endoscopic myotomy was performed, which lacks a muscle layer.

Figure 3

Zenker’s diverticulum treated using endoscopic diverticulectomy. A: Zenker’s diverticulum (ZD, yellow triangle) visible on a barium swallow; B: On endoscopy, the ZD (yellow triangle) is easily visible and is bigger than the true esophageal lumen (black arrow); C: Endoscopic diverticulectomy is performed with a diverticuloscope (insert) straddled across the septum, with one flap inserted into the bottom of the ZD and the other in the esophageal lumen (black arrow) for a clear visualization of the septum and safe diverticulectomy[34]. ZD: Zenker’s diverticulum.