EsophagealStricturesandCDanielSmithThetopicsofthisarticlecanbestbeun - PDF document

EsophagealStricturesandC.DanielSmith,Thetopicsofthisarticlecanbestbeunderstoodinthecontextofimpairmentofesophagealoutflowanditsconsequences.Conditionsthatleadtoimpairmentofesophagealoutflowcanbestbecategorizedinto2broadcategories:esophagealstrictureornarrowinganddisordersofesophagealmotilityandloweresophagealsphincter(LES)function.Theconsequenceofesophagealstricturemostoftenin- PiedmontClinic,2795PeachtreeRoad,Unit1808,Atlanta,GA30305,USA EsophagealstrictureEsophagealdiverticula toesophagealmotordysfunction,amidesophagealdiverticulumisalsodiscussedinthisarticle.Incontrastwiththefalsediverticulaoftheesophagus,amidesophagealdiverticulumisatruediverticulumandtheresultofmediastinalinflammatorypro-cessesandtheresultingfocaltractionontheesophagealwall,andisthereforenotrelatedtoesophagealoutflowobstruction.Manyconditionscancauseesophagealluminalnarrowingorstricture.Themostcommoncausesarepeptic,malignant,andcongenital;othercausesincludeautoim-mune,iatrogenic,medicationinduced,radiationinduced,infectious,caustic,andESOPHAGEALSTRICTURETheterm‘esophagealstricture’isreservedtypicallyforintrinsicdiseasesoftheesoph-aguscausingluminalnarrowingthroughinflammation,fibrosis,orneoplasia.Stricturesaregroupedtypicallyintobenignandmalignantcategories,withtreatmentvaryingdependingontheunderlyingcause.Othercausesofesophagealnarrowingsome-timesconsideredunderthecategoryofesophagealstrictureincludeextrinsiccompromiseoftheesophageallumenbydirectinvasion,lymphnodeenlargement,ordirectcompression.Thisarticlefocusesontheintrinsiccausesofesophagealnar-Regardlessofthenatureofastricture,theclinicalpresentationtypicallyinvolvesanyorallofthefollowing:dysphagia,foodimpaction,odynophagia,chestpain,andweightloss.Ofthese,progressivedysphagiatosolidsisthemostcommonpresentingsymptom,withbenignstricturesfo

llowingamoreslowandinsidiousprogression(eg,monthstoyears),whereasdysphagiaofamalignantstricturetendstoprogressmorerapidly(eg,inweekstomonths).Theclinicalhistorymayhelptodeterminethecauseofthedysphagia,although25%ofpatientpresentingwithpepticstrictureshavenopriorheartburnorothersymptomsofgastroesophagealrefluxdisease(GERD).Aknownhistoryofuseofmedicationsknowntocausepepticulcersorirritation,orcausticingestion,areotherexamplesofclinicalhistorythatmightsuggesttheunderlyingcause.Esophagogastroduodenoscopyandcontrastswallowarethemainstaysoftheinitialworkupanddiagnosisforesophagealstrictures.Althoughacontrastswallowisob-tainedmosteasily,esophagogastroduodenoscopycanprovidemoreoverallinforma-tionandestablishnotonlythediagnosisofastrictureoresophagealnarrowing,butalsoallowvisualizationoftheesophagealmucosa,includingbiopsytoestablishdefin-itivelytheunderlyingcauseofthestricture.Thisbecomesespeciallyimportantindeterminingwhetherastrictureisbenignormalignant.Contrastswallowmaybeparticularlyusefulindefiningtheoverallesophagealanatomyandidentifyingotherassociatedpathology,suchasanesophagealdiverticulum.EsophagealpHtesting,esophagealmotilitymaybeneededtoconfirmadiagnosisofGERDoranunderlyingesophagealmotorabnormality(seeEsophagealDiverticulasection).Finally,whenastrictureisdeterminedtobemalignant,orextrinsicpathologyisthoughttobethecauseofesophagealnarrowing,CTofthechestandabdomenisindicatedtoestablishthecauseofextrinsicnarrowingand/ortostageabiopsy-provenmalignantstricture.Endoscopicultrasonographyhasemergedasausefuldiagnostictooltocharacterizethenatureofastrictureandassessthestageandseverityofamalignantorinfiltrating process.ThishasbecomethemainstayofstagingmalignantdiseaseoftheBenignEsophagealStrictureBenignstricturesarebyfarthemostcommon,andpepticstricturesaccountfor70%to80%o

fallcausesofesophagealstricture.Pepticstricturesaretheresultofgastro-esophagealreflux–inducedesophagitisandscarring.Withthis,pepticstricturesusuallyoccurinthedistalesophaguswithin4cmofthesquamocolumnarjunction.Theassociatedmucosalinflammationandsubmucosalfibrosisgiveanappearanceofinflammationandsmoothnarrowingwithoutmasseffect(Fig.1AnothercommoncauseofbenignstrictureisaSchotski’sring,aringlikeconstric-tionofthedistalesophagus,oftendescribedasa“bandlike”ringofconstriction.TheetiologyofaSchotski’sringremainselusive.Theoriesincludethat(1)theringisapleatofredundantmucosathatformswhentheesophagusforunknownreasonsshortenstransientlyorpermanently,(2)theringiscongenital,(3)theringisashortpepticstric-turerelatedtoGERD,and(4)theringistheresultofpill-inducedesophagitis.Thetreatmentofbenignstrictureisdilation(seedetailselsewhereinthisarticle)andmanagementofanyunderlyinginflammatoryprocess.Thetreatmentoftheunder-lyingcausecannotbeoveremphasized.PatientsonmaximummedicaltherapyforGERDhavelowerredilationratesandbetterresolutionofdysphagiathanthosewhoarenotonmaximalmedicalGERDtherapy.Twicedailydosingofaprotonpumpin-hibitorismoreeffectivethanH2blockersaloneandforpatientswithbreakthrougheveningGERDsymptoms,addingasingleeveningdoseofanH2blockerisindicated.Thisregimeniscontinuedforatleast1month,atwhichtimearepeatesophagogas-troduodenoscopyisundertakentoreassess.Itmaybenecessarytorepeatthedilationatthattimeandcontinuemaximummedicaltherapyuntilthestrictureandinflamma-toryprocesshascompletelyresolved.Atthattime,medicationcanbetaperedtoalevelforsymptomcontrolandanendoscopyplannedfor12monthslater.moreseverestrictures,thisplanmaybecompressedtorepeatendoscopyand Fig.1.Endoscopicviewofseverepepticesophagitis.EsophagealStricturesandDiverticula dilationwithin1to2weeksofaninitialdilation,andmore

frequentreassessments.Ad-junctssuchassteroidinjectionsinandaroundthestricturehavebeenused,especiallyformorechronicfibroticstrictures.Stenting(seeelsewhereinthisarticle)haslittleroleinbenignstricturesunlesstheunderlyingissuewiththestrictureisanastomoticbreak-downandleakfromarecentesophagealprocedure(whichisbeyondthescopeofthisSurgeryisindicatedforpepticstricturethatrecursdespitemaximalmedicalther-apy,inwhichcaseanantirefluxprocedureisindicated,orfornondilatablefibroticstrictures,whichtypicallyrequiresresectionandreconstructiontoresolve.shouldbecautionedaboutusingasegmentalresectionofthedistalesophagusandesophagogastrostomytomanageabenignstricturebecausethemajorityofthesepa-tientswillhavesevereGERDaftersuchaprocedure,leavingthepatientwithongoingissueswithpepticinjurytotheesophagus.Ifaresectionisneeded,itisbesttouseanesophagojejunostomytoavoidsevereGERD.MalignantEsophagealStrictureThemostcommoncauseofmalignantesophagealstrictureisadenocarcinomaasso-ciatedwithBarrett’sesophagus.Thisisachangefromdecadesagowhenmostma-lignantdiseaseoftheesophaguswassquamouscancerassociatedwithalcoholandtobaccouse.Themanagementofmalignantstricturecentersontissuediagnosis,staging,anddefinitivetherapyversuspalliation.Incontrastwithbenignstrictures,dila-tionplaysonlyatemporizingrole,typicallytofacilitateplacementofastentorpreparefordefinitivetherapy(resection).Stenting(seeelsewhereinthisarticle)ismuchmorecommoninmalignantstricture,eitheraspermanentmanagementforadvanceddis-easeortemporarymanagementtoallowcompletionofneoadjuvanttherapybeforeundergoingresection.Esophagealdilationforstrictureinvolvesselectionoftechniqueofdilation,useofadjunctsandendpoint.TechniquesMercury-filledbougies(MaloneyorHurstdilators)arereasonableforuncomplicatedstrictureswithaninitialdiameterofgreaterthan10mm.Thesedilat

orsareinexpensiveandfluoroscopyisnotneeded.Thisisthetechniqueusedforself,at-homedilations.Wire-guidedpolyvinylbougies(Savary-Gilliarddilators)arestiffdilatorsappropriateforstrictures5to20mmindiameterandarebestsuitedforlong,tightstrictures.Fluo-roscopyistypicallyneededtoassessguidewireplacementandtovisualizesafepas-sageofthedilator.Useusuallyrequiressedationandismoretraumaticonthelarynxthanothertechniquesofdilation.Through-the-scopeballoondilatorsallowvisualizedplacementanddilation.Althoughmoreexpensive,balloondilationseemstoresultinsafemanagementofmorecomplicatedandtighterstrictureswithfewersessionsandalowerrecurrenceIntralesionalsteroidinjectionandendoscopicstricturoplastyarethe2mostcommonlytalkedaboutadjunctstostricturedilation.Althoughfewdataexisttosupportamech-anismofaction,thefirstventurestodecreasetheinflammatoryreactiontothetraumaofdilationandtherebylimitthedegreeofrestenosisafterdilation.Severalstudieshaveachievedlargerfinalluminaldiameterandlowerstricturerecurrencewiththeuseof intralesionalsteroid.ItseemsreasonabletousethisinabenignstricturewheredysphagiapersistsdespitedilationsandmaximalmedicalmanagementofGERD.Four-quadrantstricturoplastyfollowedbydilationhasbeendescribedformorefibroticstrictureswithlimitedsuccess.Concernwithstricturoplastyrelatestoperfo-rationmakingthefibroticstricturesmostappealingforthisadjunct.EndpointofDilationHowmuchdilationcanbeachievedinasinglesessionofdilation,andwhatluminaldiametershouldbethegoalremaincontroversial.Mostwouldagreethatgaining1to2mmofluminaldiameterthrough3consecutivepassesofdilatorsofincreasingsizeduring1sessionisagoodgeneralrule.Useofballoondilatorsmayallowevenmoreincreaseinluminaldiameterduringasession.Obviously,perforationremainstheconcern,andballoondilationprovidesreal-time,directvisualizationoftheme-chanical

effectsofthedilationandmayallowmoreaggressive,safedilation.Mostpa-tientexperiencecompletereliefofdysphagiawhenaluminaldiameterof40to54FisStentingforesophagealstructureisusedmostcommonlyformalignantstrictures,eithertoprovidepermanentpalliationforadvanceddiseaseortemporarypalliationwhileapatientistreatedwithneoadjuvanttherapyinpreparationforcurativeresec-Permanentstentsareusuallyself-expandingmetalorplasticstents,andtemporarystentshavethestentitselfcoveredsoastolimittissueingrowth,allowingthestenttoberemovedmoreeasily.Thedetailsofstentdesignandplacementarebeyondthescopeofthisarticle.Finally,surgeryhasaprimaryroleforamalignantstricturewherestagingrevealsapotentiallycurablecancer.Inthiscase,esophagectomywitheitherhighthoracicorcervicalesophagealanastomosistotubularizedstomachorcoloninterpositionispreferred.DistalesophagealsegmentalresectionwithesophagogastrectomyshouldbeavoidedowingtothesevereGERDthatoftenresultswiththeLESgoneandanintrathoracicanastomosistostomach.Ifitisdesirabletopreserveasmuchesoph-agusaspossible,itisbettertousejejunumforreestablishingintestinalcontinuity.TheroleofsurgeryinbenignstrictureislargelylimitedtoantirefluxprocedurestomanagetheGERDthatisetiologicinmostbenignstrictures.Foranondilatablebenignstricture,segmentalresectionisreasonablesolongasanesophagojejunostomyisperformedratherthananesophagogastrostomy(seeelsewhereinthisarticle).ESOPHAGEALDIVERTICULAAnesophagealdiverticulumisanepithelial-linedmucosalpouchthatprotrudesfromtheesophageallumen.Esophagealdiverticulaareclassifiedaccordingtotheirloca-tion(pharyngoesophageal,midesophageal,orepiphrenic),thelayersoftheesoph-agusthataccompanythem(truediverticulum,whichcontainalllayers,orfalsediverticulum,containingonlymucosaandsubmucosa),ormechanismofformation(pulsionortraction;Table1).Mostesophagealdive

rticulaarepulsiondiverticulaandaretheconsequenceofadysfunctionalesophagealsphincterthatfailstoopenappropriately,resultinginpressurizationoftheesophageallumenforcingthemucosaandsubmucosatoherniatethroughtheesophagealmusculature(falsediverticulum).Pharyngoesophagealandepiphrenicdiverticulaarepulsiondiverticula.LessEsophagealStricturesandDiverticula commonly,aperiesophagealinflammatoryprocessadherestotheesophagusandsubsequentlypullstheesophagealwallfocally,resultinginalllayersoftheesophaguscomprisingthediverticulum(truediverticulum).Midesophagealdiverticulaareusuallytractiondiverticularesultingfrominflammatorychangesinmediastinallymphnodes.PharyngoesophagealDiverticulum(Zenker’s)In1878,Zenkerdescribed27casesofpharyngoesophagealdiverticulum,andthushisnameisassociatedwiththiscondition.Thisisthemostcommonoftheesophagealdiverticula.Pharyngoesophagealdiverticulaconsistentlyarisewithintheinferiorpharyngealconstrictor,betweentheobliquefibersofthethyropharyngeusmuscleandthroughorabovethemorehorizontalfibersofthecricopharyngeusmuscle(theupperesophagealsphincter;Fig.2).Killian’striangleistheareaofweaknessthroughwhichmostpharyngoesophagealdiverticulaprotrude.Thesediverticulaseemtobeacquiredowingtosomedegreeofincoordinationintheswallowingmechanismwith Table1ClassificationofesophagealdiverticulaDiverticulumLocationMechanismTypePharyngoesophagealUESPulsionFalseMidesophagealTrachealbifurcationTractionTrueEpiphrenicDistalesophagusPulsionFalseAbbreviation:UES,upperesophagealsphincter. Fig.2.Anatomyoflocationofpharyngoesophagealdiverticula. anabnormallyhighintrapharyngealpressureleadingtoprotrusionofesophagealmu-cosaandsubmucosathroughtheesophagealwallwithsubsequentdiverticulumThepresentingsymptomsofpharyngoesophagealdiverticulumareusuallycharacter-istic,andconsistofcervicalesophageal

dysphagia,regurgitationofblandundigestedfood,frequentaspiration,noisydeglutition(gurgling),halitosis,andvoicechanges.Dysphagiaispresentin98%ofpatients,andpulmonaryaspirationoccursinuptoone-thirdofpatients.Thediagnosisofpharyngoesophagealdiverticulumismadeeasilywithabariumesophagram(Fig.3).Endoscopy,24-hourpHmonitoring,andesophagealmanometryarenotindicatedunlesssomefeaturesofthesymptomsortheesophagramraisesus-picionofotherconditions(malignancyorGERD).Althoughthesediverticulacanreachimpressivesizes,itisthedegreeofupperesophagealsphincterdysfunctionthatde-terminestheseverityofsymptoms,nottheabsolutesizeofthediverticulum.Inmostsymptomaticcases,treatmentisindicatedregardlessofthesizeofthediverticulum.TreatmentAsisthecasewithallpulsiondiverticula,propertreatmentmustbedirectedatrelievingtheunderlyingneuromotorabnormalityresponsiblefortheincreasedintralu-minalpressureandthenmanagingthediverticulum.Mosttechniquesdescribedhaveuseddivisionofthecricopharyngeusmusclefollowedbyresection,imbrication,obliteration,orfenestrationofthediverticulum(Table2).Mostapproachestoman-agementagreethatreliefoftherelativeobstructiondistaltothepouchthroughcrico-pharyngealmyotomyisthemostimportantaspectoftreatment.Earlysurgical Fig.3.Bariumesophagramshowingpharyngoesophagealdiverticulum.EsophagealStricturesandDiverticula strategiesusingdiverticulectomyonly,withoutmyotomy,hadhighfailureratesbecauseofesophagealleaksfromthesutureline,orrecurrence.Morerecently,endo-scopicmanagementhasemergedasthepreferredmethodofmanagingthesediver-ticula(ref).Dividingtheseptumbetweentheesophagusanddiverticulumandthecricopharyngeusmuscleusingeitheranenergydevice(eg,cautery,laser;Fig.4)orastaplingdevice(Fig.5)allowsaminimallyinvasiveapproachthatbothaddressesthecricopharyngeusmuscleandthetrappingofcontentinthediverticul

um.Thetypicaladvancedageofmanywhosufferwiththisconditionalsomakestheendo-scopicapproachappealing.Successisachievedinmorethan90%ofpatientsunder-goingendoscopicmanagementwithalowmorbidityandmortality.Twentypercentofpatientsmayrequire2treatmentstoachievetheseresults.18–21MidesophagealDiverticulumMidesophagealdiverticulaarerareandmostcommonlyassociatedwithmediastinalgranulomatousdisease(histoplasmosisortuberculosis).Theyarethoughttoarisebecauseofadhesionsbetweeninflamedmediastinallymphnodesandtheesophagus.Bycontraction,theadhesionsexert“traction”ontheesophaguswitheventuallocal-izeddiverticulumdevelopment.Thesearetruediverticulawithalllayersoftheesoph-aguspresentinthediverticulum. Table2TreatmentoptionsforpharyngoesophagealdiverticulaTreatmentDescriptionEndoscopicdiverticulotomyEndoscopicdivisionofcricopharyngeusandcommonwallbetweendiverticulumandesophagus(electrocautery,stapler,laser,etc)OperativemyotomyandCricopharyngealmyotomyandexcisionofdiverticulumOperativemyotomyandCricopharyngealmyotomyandmobilizationofsacwithsuturefixationofthesacabovetheneckofthediverticulumOperativemyotomyaloneCricopharyngealmyotomyonly Fig.4.Endoscopicmanagementofpharyngoesophagealdiverticulum.Yellowdashesindi-catelateraledgeofdiverticulum.()Endoscopicviewbeforediverticulotomy.NG,nasogas-trictubeinesophagus;ZD,lumenofZenker’sdiverticulum.()Completeddiverticulotomy. Amidesophagealdiverticulumistypicallyasymptomaticanddiagnosedincidentallyonabariumesophagramundertakenforotherreasons.Whensuchanasymptomaticdiverticulumisfound,notreatmentisnecessary.Inpatientswithsymptoms,esopha-gealmanometryisindicatedtoensurethattheLESfunctionisnormalandthatthereisnotapulsiondiverticulum.Symptomaticdiverticularequiretreatment.Largerdiver-ticulausuallyrequireanaccompanyingresectionordiverticulopexy.Intheabsence

ofamotorabnormality,diverticulectomyalonemaybeadequate.Manysurgeonswilladdanesophagogastricmyotomy(Hellermyotomy)foranyesophagealdivertic-ulectomytominimizetheriskofstaplelineleakthatmayaccompanyanyearlypost-operativeesophageallumenpressurization.Dataintheliteraturearemixedrelatedtotherequirementofesophagogastricmyotomyfortruetractiondiverticula.Itisthisauthor’spreferencetoaddanesophagogastricmyotomy(Hellermyotomy)myotomytoallcaseswhereesophagealdiverticulectomyisindicated(ofcourse,notincludingpharyngoesophagealdiverticula).Epiphrenic(Pulsion)DiverticulumAnepiphrenicdiverticulumtypicallyoccurswithinthedistal10cmoftheesophagusandisapulsiontype.Itismostcommonlyassociatedwithesophagealmotorabnor-malities(achalasia,hypertensiveLES,diffuseesophagealspasm,nonspecificmotordisorders),butmaybetheresultofothercausesofincreasedesophagealpressure(eg,afterfundoplicationwithesophagealoutflowobstruction).Ihavemanagedseveralepiphrenicdiverticulainpatientswhohaveundergoneendoluminalfundoplication,inparticulartransoralincisionlessfundoplication,wheretheesophagealwallhasbeenweakenedbythetransmuralfixationandoutflowobstructionhasallowedpressuriza-tionoftheesophagusaboveandatthefundoplicationwithsubsequentdiverticulumMostepiphrenicdiverticulaaresymptomaticbecauseoftheunderlyingesophagealmotordisorder.DiagnosisofthediverticulumismadeduringbariumesophagramFig.6).Manometry,esophagoscopy,and24-hourpHtestingmaybenecessarytodi-agnoseassociatedconditionsanddirectspecifictreatments.Mostepiphrenicdiver-ticularequireesophagealmyotomyextendingfromtheneckofthediverticulum Fig.5.Stapledendoscopicmanagementofpharyngoesophagealdiverticulum.EsophagealStricturesandDiverticula ontothegastriccardiaforadistanceof1.5to3.0cm(seeMyotomyforAchalasia).Diverticulectomy,fundoplication,orrepairofhiatalherniamaya

lsobenecessary,dependingonthesizeofthediverticulumorassociatedconditions.TechniqueofmidesophagealandepiphrenicdiverticulectomyInthepast,anopenthoracicapproachhasbeenthepreferredapproachtothesediverticula.Today,alaparoscopicorcombinedlaparoscopic/thoracoscopicapproachallowsaminimallyinvasiveapproachtothesediverticula,significantlydecreasingthemorbidityandmortalityofmanagementofthesediverticula(ref).Iftheneckofthediverticulumisabovetheesophagealhiatusand/orthediverticulumitselfisverylargeandextendsupintothechest,theoperationcommenceswithathoracoscopicapproach.Pronethoracoscopysignificantlyfacilitatesmobilizationofthedivertic-ulum(Figs.7)andstapledtransectionoftheneck(Figs.9).Oncethediverticulumisresected,thepatientisflippedintothesupinepositionforlaparoscopicesophagogastricmyotomyandpartialfundoplication.Iftheneckofthediverticulumisattheleveloftheesophagealhiatusandthediverticulumdoesnotextendfarintothechest,anentirelylaparoscopicapproachmaybeadequate.Aswehavegainedexpe-riencewithpronethoracoscopy,wenowapproachmostepiphrenicdiverticulawiththecombinedthoracoscopic/laparoscopicapproach.Severalserieshavedocumentedthefeasibilityofthisapproach.25,26Wehaveexpe-rienceinthemanagementofmorethan40casesusinglaparoscopic/thoracoscopicapproach.Asstated,weprefertoaddanesophagogastricmyotomytoallcasestominimizetheriskofstaplelineleakpostoperatively. Fig.6.Bariumesophagramshowingalargeepiphrenicdiverticulum. Fig.7.Illustrationofpronethoracoscopyusedtoapproachmid-andlargeepiphrenicdiverticula. Fig.8.Pronethoracoscopicviewofepiphrenicdiverticulum. Fig.9.Pronethoracoscopicviewofdiverticulumneckbeingtransectedwithstapler.(A)Sta-pleracrossdiverticulumneck.(B)Grasperholdingdiverticulum.EsophagealStricturesandDiverticula PregunI,HritzI,TulassayZ,etal.Pepticesophagealstricture:medicaltreat

ment.DigDis2009;27:31–7PaceF,AntinoriS,RepiciA.Whatisnewinesophagealinjury(infection,drug-induced,caustic,stricture,perforation)?CurrOpinGastroenterol2009;25:372–9GudaNM,VakilN.Protonpumpinhibitorsandthetimetrendsforesophagealdilation.AmJGastroenterol2004;99:797–800MarksRD,RichterJE,RizzoJ,etal.OmeprazoleversusH2-receptorantagonistsintreatingpatientswithpepticstrictureandesophagitis.Gastroenterology1994;DakkakM,HoareRC,MaslinSC,etal.Oesophagitisisasimportantasoesopha-gealstricturediameterindeterminingdysphagia.Gut1993;34:152–5PattersonDJ,GrahamDY,SmithJL,etal.Naturalhistoryofbenignesophagealstricturetreatedbydilatation.Gastroenterology1983;85:346–50SmithCD.Antirefluxsurgery.SurgClinNorthAm2008;88:943–58SmithCD.Surgicaltherapyforgastroesophagealrefluxdisease:indications,evaluation,andprocedures.GastrointestEndoscClinNAm2009;19:35–48,v–videWijkersloothLR,VleggaarFP,SiersemaPD.Endoscopicmanagementofdiffi-cultorrecurrentesophagealstrictures.AmJGastroenterol2011;106:2080–91[quiz:2092]FanY,SongHY,KimJH,etal.Fluoroscopicallyguidedballoondilationofbenignesophagealstrictures:incidenceofesophagealruptureanditsmanagementin589patients.AJRAmJRoentgenol2011;197:1481–6SaeedZA,WinchesterCB,FerroPS,etal.Prospectiverandomizedcomparisonofpolyvinylbougiesandthrough-the-scopeballoonsfordilationofpepticstric-turesoftheesophagus.GastrointestEndosc1995;41:189–95RamageJIJr,RumallaA,BaronTH,etal.Aprospective,randomized,double-blind,placebo-controlledtrialofendoscopicsteroidinjectiontherapyforrecalci-trantesophagealpepticstrictures.AmJGastroenterol2005;100:2419–25RaijmanI,SiddiqueI,RachcalLT.Endoscopicstricturoplastyinthemanage-mentofrecurrentbenignesophagealstrictures.GastrointestEndosc1999;SharmaP,KozarekR.PracticeParametersCommitteeofAmericanCollegeofG.Roleofesophagealstentsinbenignandma

lignantdiseases.AmJGastroenterol2010;105:258–73[quiz:274]HindyP,HongJ,Lam-TsaiY,etal.Acomprehensivereviewofesophagealstents.GastroenterolHepatol(NY)2012;8:526–34 Fig.10.Completeddiverticulectomy. SmithCD.Esophagus.In:NortonJA,ChangAE,LowrySF,etal,editors.Essentialpracticeofsurgerybasicscienceandclinicalevidence.NewYork:Springer-Ver-lag;2003.p.167–84ZaninottoG,NarneS,CostantiniM,etal.TailoredapproachtoZenker’sdiver-ticula.SurgEndosc2003;17:129–33TangSJ.FlexibleendoscopicZenker’sdiverticulotomy:approachthatinvolvesthinkingoutsidethebox(withvideos).SurgEndosc2014;28:1355–9ParkerNP,MisonoS.Carbondioxidelaserversusstapler-assistedendoscopicZenker’sdiverticulotomy:asystematicreviewandmeta-analysis.OtolaryngolHeadNeckSurg2014;150:750–3LawR,BaronTH.TransoralflexibleendoscopictherapyofZenker’sdiverticulum.DigSurg2013;30:393HubertyV,ElBachaS,BleroD,etal.EndoscopictreatmentforZenker’sdivertic-ulum:long-termresults(withvideo).GastrointestEndosc2013;77:701–7IsaacsKE,GrahamSA,BerneyCR.Laparoscopictranshiatalapproachforresec-tionofmidesophagealdiverticula.AnnThoracSurg2012;94:e17–9GalataCL,BrunsCJ,PratschkeS,etal.Thoracoscopicresectionofagiantmid-esophagealdiverticulum.AnnThoracSurg2012;94:293–5GoldbergRF,BowersSP,ParkerM,etal.Technicalandperioperativeoutcomesofminimallyinvasiveesophagectomyintheproneposition.SurgEndosc2013;HerbellaFA,PattiMG.Modernpathophysiologyandtreatmentofesophagealdiverticula.LangenbecksArchSurg2012;397:29–35SoaresRV,MontenovoM,PellegriniCA,etal.Laparoscopyastheinitialapproachforepiphrenicdiverticula.SurgEndosc2011;25:3740–6MelmanL,QuinlanJ,RobertsonB,etal.Esophagealmanometriccharacteristicsandoutcomesforlaparoscopicesophagealdiverticulectomy,myotomy,andpar-tialfundoplicationforepiphrenicdiverticula.SurgEndosc2009;23:1337–41EsophagealStricturesandDiverticu