Epiphrenic Diverticula: Diagnosis and Management

Abstract

Epiphrenic diverticula are thought to be secondary to an underlying esophageal motility disorder. These diverticula are quite rare with less than 120 operations for this disease performed annually in the United States, and therefore evidence in the management of this disease is limited. Workup includes upper GI series, manometry, and upper endoscopy. Achalasia is found in half of the patients with other common findings being distal esophageal spasm, hypercontractile peristalsis (nutcracker esophagus), and other motility disorders including subtle unnamed motility issues. When asymptomatic or minimally symptomatic, they can be safely observed with a small rate of complications such as perforation, bleeding, or malignancy. Management of symptomatic diverticula should include myotomy, with diverticulectomy and fundoplication. The extent of myotomy is controversial, but we recommend extending it proximally to the base of the diverticulum, at least 2 cm lateral to the diverticular base. We extend the myotomy distally 3 cm onto the gastric cardia in order to reduce the risk of recurrence. The need for a diverticulectomy is debated, as in many patients the symptoms are not due to the diverticulum but rather to the underlying motility disorder. In select patients, myotomy alone may suffice. The laparoscopic approach is recommended when feasible, although a thoracic or thoracoscopic approach may be needed in select patients. Because this is a rare disease, it should be managed by experienced esophageal surgeons in high volume centers.