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Highlights • An esophageal diverticulum is a rare condition. • Laparoscopic diverticulectomy with myotomy and fundoplication for an esophageal diverticulum is the common approach. • Mediastinoscopic esophagectomy for the patient who need esophagectomy could be an effective and noninvasive candidate procedure., Introduction An esophageal diverticulum is a rare condition, and surgery is indicated if symptomatic. We successfully performed mediastinoscopic esophagectomy for a giant esophageal diverticulum with stenosis. Presentation of case A 63-year-old man visited our hospital because of dysphagia. He had been pointed out an esophageal diverticulum at a local hospital 13 years before visiting our hospital. Upper gastrointestinal endoscopy revealed an esophageal diverticulum at the lower thoracic esophagus and the structural stenosis in the anal side of the diverticulum. Computed tomography showed a 54 mm esophageal diverticulum at the lower thoracic esophagus. Esophagectomy was required because of the structural stenosis. His medical history included chronic obstructive pulmonary disorder. So, we chose the mediastinal approach to avoid a respiratory complication. We performed mediastinoscopic esophagectomy and esophagogastrostomy via the retrosternal route. The postoperative course was good. At 9 months postoperation, there were no symptoms. Discussion Recently, laparoscopic diverticulectomy with myotomy and fundoplication has been considered the best approach in most cases. In the case with the structural stenosis, esophagectomy may be required. Conclusion Mediastinoscopic esophagectomy for the patient with poor respiratory function and who need esophagectomy could be an effective and noninvasive candidate procedure.

Background. Terminal ileum diverticulitis is a rare clinical disease. It can frequently mimic other processes, such as acute appendicitis. Diagnosis and therapeutic decision making (surgical or conservative treatment) can be complex. We report four interesting cases of terminal ileum diverticulitis. Case Presentation. Case 1: a 55-year-old male presented to us with a 3-day history of severe right lower quadrant pain. Computed tomography (CT) showed penetration of terminal ileum diverticulitis. Following a 7-day conservative treatment, he underwent ileocecal resection. Pathology results revealed a false diverticulum and two in five points of perforated terminal ileum diverticulum. Case 2: a 77-year-old male presented to us with severe right lower quadrant pain and unconsciousness. CT showed penetration of terminal ileum diverticulitis and air in the mesentery. Ileocecal resection was performed 2 days postadmission. Pathology results revealed a false diverticulum and penetrated terminal ileum diverticulum. Case 3: a 61-year-old male presented to us with a right lower quadrant pain for 10 days and fever for 6 days. CT showed penetration of terminal ileum diverticulitis and abscess of the psoas muscle. Puncture and drainage of abscess were performed. Laparoscopic ileocecal resection was performed 30 days postadmission. Pathology results revealed a false diverticulum and penetrated terminal ileum diverticulum. Case 4: a 39-year-old female presented to us with right lower quadrant pain for 9 days, suspicious of appendicitis. CT showed abscess of pericecal area. Puncture and drainage were performed. A drainage tube was located into the cecum through the terminal ileum. Conservative therapy was effective, and she was discharged 23 days postadmission. Conclusions. All four cases had right lower quadrant pain. Three cases were diagnosed by CT, whereas one was diagnosed by abscess drainage. Two cases required surgical treatment within 3 days, one within about 1 month, and one case did not require surgery. The decision of whether to manage a patient surgically or conservatively is difficult. It is critical not to delay the decision of performing a surgical treatment until each patient reaches a stable general condition.

Endoscopic submucosal dissection (ESD) is a standard treatment for early gastric cancer (EGC) that does not have any risk of lymph node or distant metastases. Here, we report a case of EGC resembling a diverticulum. Diverticular formation makes it difficult for endoscopists to determine the depth of invasion and to subsequently perform ESD. Because the false diverticulum does not have a muscular layer, this lesion can be treated with ESD. Our case was successfully treated with ESD. After ESD, the EGC was confined to the submucosal layer without vertical and lateral margin involvement. This is the first case in which ESD was successfully performed for a case of EGC that coexisted with a false gastric diverticulum. An additional, larger study is needed to determine the efficacy of ESD in various types of EGC, such as a false gastric diverticulum.

The Zenker diverticulum (pharyngoesophageal diverticulum) arises from the triangle of mucosa located between the inferior pharyngeal constrictors and the cricopharyngeal muscle (Killian triangle). This type of diverticula is a false diverticulum and more common than true esophageal diverticula. The treatment options range from various endoscopic techniques to open surgical resection.

Zenker’s diverticulum is a false diverticulum or pseudodiverticulum of the esophageal mucosa and submucosa occurring at Killian’s dehiscence, which lies at the junction between the oblique fibers of the cricopharyngeus muscle and the transverse fibers of the inferior pharyngeal constrictor (Fig. 11.1). The Zenker’s diverticulum is a pulsion diverticulum thought to occur as a result of inadequate coordination between these muscle fibers, with a resultant increased pharyngoesophageal intraluminal pressure. The advent of endoscopic techniques has transformed the surgical treatment of Zenker’s diverticula. Although the treatment paradigm has shifted to minimally invasive approaches with repair assisted by endoscopic stapling or lasers, traditional transcervical procedures can still play a role in selected cases. This chapter illustrates our tailored approach to patients with Zenker’s diverticulum and demonstrates the open surgical and endoscopic techniques.

Pharyngoesophageal (Zenker’s) diverticulum is a false diverticulum of the cervical esophagus. This pulsion diverticulum is composed of mucosa, covered by thin areolar tissue, herniating at Killian’s triangle between the obliquely positioned inferior constrictor muscle and the transversely oriented cricopharyngeus muscle. Pharyngoesophageal diverticulum was first described by Abraham Ludlow in 1764 as a “bag formed in pharynx.” Friedrich Albert Zenker in 1867 described the clinicopathological characteristics of 23 previous cases and 5 of his own cases in Kraukenheiten Des Oesophagus. The pathophysiology of Zenker’s diverticulum has been attributed to functional abnormalities of the upper esophageal sphincter zone created by the cricopharyngeus muscle.

Gastroscopic examination can aid in differentiating gastric diverticula from diverticulum-like formations which develop secondary to perforating peptic ulcers and ulcerating carcinomas of the stomach. A case of true diverticulum and a case of false diverticulum of the stomach are presented. Both patients had symptoms which were thought to be due to the diverticula. These symptoms disappeared after surgical procedures which eliminated the diverticula.