New Look at Epiphrenic Diverticula

Abstract

Twenty-five patients with epiphrenica diverticula were studied to clarify the mechanism for esophageal regurgitation and to evaluate methods of treatment. Esophagogastroduodenoscopy, esophageal motility, and cineradiographic studies were performed. With probes in the tubular esophagus and diverticula of two patients, motility and cineradiographic studies were performed simultaneously to correlate symptoms and pressure changes with movement of diverticular and esophageal contents. Nineteen patients were operated, and six relatively asymptomatic patients were not. There was no operative mortality, and the one esophageal fistula that occurred healed spontaneously. Results were excellent or good in 10 operated patients followed long term after resection or imbrication of the diverticula. Eight patients did not undergo myotomy. Results in four of these patients followed long term were excellent. Retrograde movement of diverticular contents into the esophagus depends on pouch volume and a pressure gradient between the pouch and the tubular esophagus after an esophageal contraction wave in the tubular esophagus has dissipated. The height of esophageal reflux and resulting symptoms depend on these factors and the lower esophageal sphincter pressure (LESP). Asymptomatic patients with an epiphrenic diverticulum do not require operation. Resection or imbrication of a diverticulum are the operative methods of treatment. We prefer the abdominal approach when this is possible. Myotomy in contraindicated when gastroesophageal reflux exists or the LESP is below normal.

Modern pathophysiology and treatment of esophageal diverticula

“…Some authors propose treatment for symptomatic diverticula only [21,28,29], while others advise operative intervention even in the absence of symptoms to protect patients from the risk of aspiration. Also, other serious complications may occur, such as: aerodigestive fistula, hemorrhage, and retained foreign body [30][31][32].…”

Minimally invasive therapy of epiphrenic diverticula: Systematic review of the literature and report of 6 cases

“…[10][11][12][13] Nowadays, there is no consensus on the type of surgical access, the length of the myotomy or the type of antirefl ux technique. [1,7,14,[16][17][18][19][20][21] The conventional surgical procedure that was usually performed consisted a left thoracotomy, di-verticulectomy, myotomy and a Belsey Mark IV procedure, nonetheless, this treatment implicates a non-negligible morbidity rate reaching up to 20-25% of patients, the most important one being suture line leakage and a mortality up 5%.…”

Epiphrenic Diverticula. "Primum Non Nocere" (First Do Not Harm)

“…When evaluating a patient with ED the risk related to its surgical treatment should be balanced against the benefit of the operation. The overall mortality rate for surgery for epiphrenic diverticula is nearly 5% (higher than in esophagectomy for "benign" diseases) and the morbidity rate is nearly 20%, the most common complication being leakage (10,17,18,19,20,21) from the suture line.…”