Cause and treatment of epiphrenic diverticula.

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.

• Authors: Pietro Tedesco, Piero M Fisichella, Lawrence W Way, Marco G Patti
• Journal: American journal of surgery (Am J Surg) Vol. 190 Issue 6 Pg. 891-4 (Dec 2005) ISSN: 0002-9610 [Print] United States
• PMID: 16307941 (Publication Type: Comparative Study, Journal Article)

Topics

• Adult
• Aged
• Aged, 80 and over
• Diverticulum, Esophageal (etiology, surgery)
• Esophageal Motility Disorders (complications, physiopathology)
• Female
• Follow-Up Studies
• Fundoplication
• Humans
• Hydrogen-Ion Concentration
• Laparoscopy (methods)
• Male
• Manometry
• Middle Aged
• Muscle, Smooth (surgery)
• Pressure
• Retrospective Studies
• Stomach (surgery)
• Treatment Outcome