Clin Endosc.  2021 Mar;54(2):275-279. 10.5946/ce.2020.093.

Parapneumonic Effusion and Tension Pneumothorax after Diverticular Peroral Endoscopic Myotomy in a Woman with Large Epiphrenic Diverticulum: A Case Report and Literature Review

• Shiu SI

• KMID: 2514184
• DOI: http://doi.org/10.5946/ce.2020.093

Abstract

Esophageal diverticula (ED) represents a group of rare conditions that warrant intervention when they are symptomatic or coexisting with pulmonary disorders. Few literature reviews have described this patient entity or discussed the postoperative outcome. Therefore, I present the case of a 59-year-old woman with symptoms of dysphagia who was significantly underweight, which was conducive to the diagnosis of symptomatic ED. Because she was a poor candidate for surgery, she received a diverticular peroral endoscopic myotomy. She subsequently developed parapneumonic effusion and tension pneumothorax after the procedure. She was finally discharged on postoperative day 23. I also performed the first known comprehensive literature review of 34 published cases (including my patient) from PubMed and have addressed the demography, intervention, and prognosis for symptomatic ED after the procedure. Prompt treatment as well as prognostic measurement are crucial to successful outcomes.

Keyword

Epiphrenic diverticulum; Parapneumonic effusion; Peroral endoscopic myotomy; Tension pneumothorax

Figure

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  Fig. 1. An esophageal diverticulum. (A) Chest radiograph shows an esophageal diverticulum (asterisk) measuring 80×60 mm. (B) Computed tomography of the chest shows an outpouching sac with air-fluid levels in the distal 10 cm of the esophagus.

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  Fig. 2. (A) Upper endoscopy showed a large epiphrenic esophageal diverticulum and narrowed lumen at the distal esophagus. A diverticular peroral endoscopic myotomy was performed stepwise as follows: (B) mucosotomy was created 3 cm from the diverticular septum, (C) submucosal tunneling was followed, (D) a diverticuloseptotomy was performed to the bottom of diverticulum, (E) further myotomy was performed by dividing the circular muscle layer of the distal esophagus 3 cm beyond, and (F) endoclips were applied for final closure.

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  Fig. 3. (A) Subcutaneous emphysema (EPS) was noted on the neck and chest of the right side after the procedure. (B) On postoperative day 3, a computed tomography of the chest showed massive pleural effusion and pulmonary atelectasis of the left side. (C) A follow-up esophagoscopy showed a spontaneous mucosal defect within the esophageal diverticulum on postoperative day 5. (D) On postoperative day 11, esophagoscopy showed an enlarged esophageal ulcer with suspicious communication to the pleural space. (E) Mucosal closure with an endoloop and endoclips was applied. (F) On postoperative day 16, esophagoscopy revelaed a healing ulcer. (G) A barium esophagography showed smooth passage of barium to the gastric lumen without any additional leakage on postoperative day 22. Asterisk indicates an esophageal diverticulum.

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