Selective Use of Myotomy for Treatment of Epiphrenic Diverticula

Abstract

The pathogenesis and treatment of epiphrenic diverticula remain controversial subjects. Most surgeons recommend esophagomyotomy in association with diverticulectomy in every patient. We believe that selective use of myotomy, based on manometry, should be used. From 1960 to 1990, 16 patients underwent surgical treatment for epiphrenic diverticulum at the Lahey Clinic Medical Center, Burlington, Mass. Six patients, three of whom underwent diverticulectomy alone and three who underwent an associated long myotomy, had the lower esophageal sphincter left intact; long-term results were good in all patients. The remaining 10 patients underwent myotomy of the lower esophageal sphincter. Reflux esophagitis developed in two of these patients who had a normal lower esophageal sphincter. Clinical results support the selective use of esophagomyotomy applied to areas of demonstrated dysmotility. A normal lower esophageal sphincter should be left intact to prevent reflux complications.

Physiologic Basis for the Treatment of Epiphrenic Diverticulum

“…The findings from motility studies in patients with epiphrenic diverticula have concurred with this suggestion and indicate that the occurrence of a diverticulum is a complication of an esophageal motility disorder rather than a primary anatomic abnormality. [2][3][4][5][6] The major obstacle to the acceptance of this concept has been the inconsistency in identifying a motility disorder in patients with a diverticulum. This has led to controversy over the use and extent of an esophageal myotomy in the therapy of the disease.…”

“…This prevalence is higher than that reported in other series. 3,7,9 The difference is probably explained by our efforts to clarify the motility findings in questionable situations by obtaining a 24-hour ambulatory motility study. In this situation, instead of making a diagnosis based on 10 swallows in the fasting state, as occurs with stationary motility, we were able to analyze more than 1,000 swallows, during and between meals, awake and asleep, over a complete day.…”

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

“…Benacci et al [39] reported that patients with asymptomatic or mild symptoms do not require surgical treatment because 100% of their series showed no symptomatic progression; conversely, authors like Altorki et al [40] are in favor of surgical treatment in all patients to prevent respiratory complications.…”

“…In Japan, the Dor fundoplication it is recommended because it is easier to perform and can potentially prevent the formation of a pseudodiverticulum or leakage if an intraoperative esophageal mucosa perforation occurs. [40] Regarding the complications rate, Rosati et al [1] associated the risk of suture line leakage with the size of the diverticulum (more than 9 cm) and Zaninotto et al [24] with the use of more than one stapling shot.…”

Type III Achalasia Cardia with Epiphrenic Diverticulum Treated By Subtotal Esophagectomy

“…If symptoms are incapacitating or recurrent respiratory complications from aspiration are reported or suspected, surgical therapy is mandatory. (18) The standard and extended heller myotomies are the major procedures for treatment of achalasia. Currently, an esophagectomy is only used in extremely rare cases of end-stage disease in any motility disorder including achalasia that has failed all other therapies and in which the patient is experiencing severe symptoms of sequelae.…”