Paper presented
Cause and treatment of epiphrenic diverticula

Presented at the 57th Annual Meeting of the Southwestern Surgical Congress, San Antonio, Texas, April 10–12, 2005
https://doi.org/10.1016/j.amjsurg.2005.08.016Get rights and content

Abstract

Background

Epiphrenic diverticula of the esophagus are often associated with a concomitant esophageal motor disorder, which is thought to be the cause of the diverticulum and some of the patient’s symptoms. At one time diverticula were best removed via a left thoracotomy, but now the operation can be performed laparoscopically in most cases. We hypothesized that: (1) a motor disorder is the underlying cause of the diverticulum; and (2) optimal treatment consists of laparoscopic resection of the diverticulum, a Heller myotomy, and Dor fundoplication.

Methods

We performed a retrospective review of a prospectively collected database from a university hospital tertiary care center. Between June 1994 and December 2002, we evaluated 21 patients with epiphrenic diverticula. An associated motility disorder of the esophagus was found in 81% of patients (achalasia, 9%; diffuse esophageal spasm, 24%; nonspecific esophageal motility disorder, 24%; nutcracker esophagus, 24%). Seven (33%) of these patients, all with esophageal dysmotility, were referred for treatment. The laparoscopic operation entailed resection of the diverticulum (using an endoscopic stapler), a Heller myotomy, and a Dor fundoplication.

Results

All operations were completed laparoscopically. The postoperative course of 6 patients was uneventful and they left the hospital after 72 ± 21 hours. In 1 patient an acute paraesophageal hernia developed, which was repaired on the second postoperative day. Late follow-up (median 57 months) showed that all 7 patients were asymptomatic.

Conclusions

These data support the conclusions that: (1) a primary esophageal motility disorder is the underlying cause of most epiphrenic diverticula; and (2) laparoscopic treatment is successful and should be the method of choice. The diverticular neck can be exposed satisfactorily from the abdomen; a stapler inserted from this angle is better orientated to transect the neck than one inserted through a thoracoscopic approach. Furthermore, the myotomy and fundoplication are much more easily performed from the abdomen than from alternative approaches.

Section snippets

Patients and Methods

Between June 1, 1994 and December 23, 2002, we evaluated 21 patients with epiphrenic diverticula. There were 15 men and 6 women, with a mean age of 64 years (range 31 to 86 years).

Symptoms

Seventeen patients (81%) complained of dysphagia, 17 patients (81%) of regurgitation, 13 patients (62%) of chest pain, and 12 (57%) of heartburn. In 10 patients (48%) the history was typical for intermittent episodes of aspiration, mostly during the night. The median duration of symptoms was 60 months.

Barium swallow

The barium study showed that the diverticulum was located on the right side of the esophagus in 16 patients (76%). The average size of the pouch was 7 cm. Findings suggestive of a primary

Comments

These results show that: (1) an esophageal motility disorder is present in most patients with an epiphrenic diverticulum; and (2) the laparoscopic approach to removing an epiphrenic diverticulum is safe and effective.

Conclusions

The laparoscopic approach to epiphrenic diverticula, although technically challenging, is the surgical treatment of choice for this disorder.

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