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World Journal of Surgery

, Volume 39, Issue 1, pp 203–207 | Cite as

Is Resection of an Esophageal Epiphrenic Diverticulum Always Necessary in the Setting of Achalasia?

  • Marco E. Allaix
  • Bernardo A. Borraez Segura
  • Fernando A. Herbella
  • Piero M. Fisichella
  • Marco G. Patti
Surgical Symposium Contribution

Abstract

Background

Esophageal epiphrenic diverticulum (ED) is usually secondary to a primary esophageal motility disorder, such as achalasia. Whereas the recommended surgical treatment includes esophageal myotomy and diverticulectomy, the outcome of patients in whom a myotomy without ED resection is performed is not known. The purpose of this study was to compare the outcome of ED patients who underwent ED resection and myotomy and those of ED patients who had a myotomy only.

Methods

Retrospective review of a prospective database. Thirteen ED patients had symptom evaluation, barium swallow, endoscopy, and esophageal high-resolution manometry (HRM). All patients underwent laparoscopic myotomy and Dor fundoplication. In six patients, the ED was resected (excised ED group), whereas in seven it was left in place (nonexcised ED group): in three because it was small and in four for technical reasons.

Results

Preoperatively all patients had dysphagia and 85 % had regurgitation. The mean preoperative Eckardt score was 6.5 ± 2.1 in excised ED group and 6.6 ± 3.3 in nonexcised ED group (p = 0.95). HRM showed type II esophageal achalasia in 85 % of patients. One excised ED group patient had a staple line leak (17 %). At a median follow-up of 2 years, the Eckardt score was 0 in excised ED group and 0.1 in nonexcised ED group (p = 0.56).

Conclusions

The results of this study showed that patients in whom a myotomy without ED resection was performed had resolution of their symptoms. These findings suggest that in patients with achalasia and ED the underlying motility disorder rather than the ED may be the cause of symptoms. Studies with a larger number of patients and a longer follow-up will determine the validity of this approach.

Keywords

Achalasia Esophageal Manometry Heller Myotomy Staple Line Leak Epiphrenic Diverticulum 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgements

The authors did not receive Grant support for the research.

Conflict of interest

The authors have no conflicts of interest to declare.

References

  1. 1.
    Nehra D, Lord RV, Demeester TR et al (2002) Physiologic basis for the treatment of epiphrenic diverticulum. Ann Surg 235:346–354PubMedCentralPubMedCrossRefGoogle Scholar
  2. 2.
    Melman L, Quinlan J, Robertson B et al (2009) Esophageal manometric characteristics and outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication for epiphrenic diverticula. Surg Endosc 23:1337–1341PubMedCrossRefGoogle Scholar
  3. 3.
    Del Genio A, Rossetti G, Maffettone V et al (2004) Laparoscopic approach in the treatment of epiphrenic diverticula: long-term results. Surg Endosc 18:741–745PubMedCrossRefGoogle Scholar
  4. 4.
    Tedesco P, Fisichella PM, Way LW et al (2005) Cause and treatment of epiphrenic diverticula. Am J Surg 190:902–905CrossRefGoogle Scholar
  5. 5.
    Fernando HC, Luketich JD, Samphire J et al (2005) Minimally invasive operation for esophageal diverticula. Ann Thorac Surg 80:2076–2081PubMedCrossRefGoogle Scholar
  6. 6.
    Varghese TK, Marshall B, Chang AC et al (2007) Surgical treatment of epiphrenic diverticula: a 30-year experience. Ann Thorac Surg 84:1801–1809PubMedCrossRefGoogle Scholar
  7. 7.
    D’Journo XB, Ferraro P, Martin J et al (2009) Lower oesophageal sphincter dysfunction is part of the functional abnormality in epiphrenic diverticulum. Br J Surg 96:892–900PubMedCrossRefGoogle Scholar
  8. 8.
    Zaninotto G, Portale G, Costantini M et al (2008) Long-term outcome of operated and unoperated epiphrenic diverticula. J Gastrointest Surg 12:1485–1490PubMedCrossRefGoogle Scholar
  9. 9.
    Klaus A, Hinder RA, Swain J et al (2003) Management of epiphrenic diverticula. J Gastrointest Surg 7:906–911PubMedCrossRefGoogle Scholar
  10. 10.
    Fumagalli Romario U, Ceolin M, Porta M et al (2012) Laparoscopic repair of epiphrenic diverticulum. Semin Thorac Cardiovasc Surg 24:213–217PubMedCrossRefGoogle Scholar
  11. 11.
    Rossetti G, Fei L, del Genio G et al (2013) Epiphrenic diverticula mini-invasive surgery: a challenge for expert surgeons—personal experience and review of the literature. Scan J Surg 102:129–135CrossRefGoogle Scholar
  12. 12.
    Herbella FA, Patti MG (2012) Modern pathophysiology and treatment of esophageal diverticula. Langenbecks Arch Surg 397:29–35PubMedCrossRefGoogle Scholar
  13. 13.
    Müller A, Halbfass HJ (2004) Laparoscopic esophagotomy without diverticular resection for treating epiphrenic diverticulum in hypertonic lower esophageal sphincter. Chirurg 75:302–306PubMedCrossRefGoogle Scholar
  14. 14.
    Bello B, Zoccali M, Gullo R et al (2013) Gastroesophageal reflux disease and antireflux surgery. What is the proper preoperative work-up? J Gastrointest Surg 17:14–20PubMedCrossRefGoogle Scholar
  15. 15.
    Allaix ME, Dobrowolsky A, Patti MG (2014) Surgical treatment of esophageal achalasia. In: Fisichella PM, Soper NJ, Pellegrini CA, Patti MG (eds) Surgical management of benign esophageal disorders: The “Chicago Approach”. Springer-Verlag London, pp 155–164Google Scholar
  16. 16.
    Oelschlager BK, Chang L, Pellegrini CA (2003) Improved outcome after extended gastric myotomy for achalasia. Arch Surg 138:490–497PubMedCrossRefGoogle Scholar
  17. 17.
    Rebecchi F, Giaccone C, Farinella E et al (2008) Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for achalasia. Ann Surg 248:1023–1030PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2014

Authors and Affiliations

  • Marco E. Allaix
    • 1
  • Bernardo A. Borraez Segura
    • 1
  • Fernando A. Herbella
    • 1
  • Piero M. Fisichella
    • 2
  • Marco G. Patti
    • 1
  1. 1.Center for Esophageal Diseases and Department of Surgery, Pritzker School of MedicineUniversity of ChicagoChicagoUSA
  2. 2.Swallowing Center and Department of Surgery, Stritch School of MedicineLoyola University ChicagoChicagoUSA

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