Surgery Today

, Volume 43, Issue 1, pp 1–7 | Cite as

Minimally invasive surgery for esophageal epiphrenic diverticulum: the results of 133 patients in 25 published series and our experience

  • Yuki Hirano
  • Hiroya TakeuchiEmail author
  • Takashi Oyama
  • Yoshiro Saikawa
  • Masahiro Niihara
  • Hiroyuki Sako
  • Kenshi Omagari
  • Tomohiko Nishi
  • Hidekazu Suzuki
  • Toshifumi Hibi
  • Yuko Kitagawa
Review Article


Esophageal epiphrenic diverticula are uncommon. Traditionally, thoracotomy has been the preferred surgical approach. Recently, minimally invasive approaches have been reported in a few series. However, the best surgical approach remains uncertain. In this study, we review the results of 25 articles discussing laparoscopic or thoracoscopic surgery. From January 1995 to December 2008, there were a total of 133 patients reported in English-language journals in PubMed. Nineteen patients (14 %) underwent thoracoscopic surgery, 112 (84 %) laparoscopic surgery and two patients (2 %) were treated using a combination approach. The diverticulectomy was performed using an endostapler device in all patients. A myotomy was added in 103 patients (83 %). A fundoplication was added in 106 patients (85 %). There were two deaths during surgery (2 %). The post-operative morbidity rate was 21 %. The most severe complication was suture-line leakage, which occurred in 20 patients (15 %). Recently, we successfully treated a patient with an epiphrenic esophageal diverticulum by performing a minimally invasive laparoscopic transhiatal resection and Heller myotomy with Dor fundoplication after observing its enlargement on radiological and endoscopic examinations over 2 years. We believe laparoscopic transhiatal resection and Heller myotomy with Dor fundoplication may therefore become the standard treatment modality for minimally invasive surgery for esophageal epiphrenic diverticulum.


Achalasia Epiphrenic diverticulum Laparoscopy Thoracoscopy Transhiatal approach 


  1. 1.
    Wheeler D. Diverticula of the foregut. Radiology. 1947;49:476–81.PubMedGoogle Scholar
  2. 2.
    Bruggeman LL, Seaman WB. Epiphrenic diverticula. An analysis of 80 cases. Am J Roentgenol Radium Ther Nucl Med. 1973;119:266–76.PubMedGoogle Scholar
  3. 3.
    Benacci JC, Deschamps C, Trastek VF, Allen MS, Daly RC, Pairolero PC. Epiphrenic diverticulum: results of surgical treatment. Ann Thorac Surg. 1993;55:1109–13.PubMedCrossRefGoogle Scholar
  4. 4.
    Zaninotto G, Portale G, Costantini M, Merigliano S, Guirroli E, Rizzetto C, et al. Long-term outcome of operated and unoperated epiphrenic diverticula. J Gastrointest Surg. 2008;12:1485–90.PubMedCrossRefGoogle Scholar
  5. 5.
    Peracchia A, Rosati R, Bona S, Fumagalli U, Bonavina L, Chella B. Laparoscopic treatment of functional diseases of the esophagus. Int Surg. 1995;80:336–40.PubMedGoogle Scholar
  6. 6.
    Saw EC, McDonald TP, Kam NT. Video-assisted thoracoscopic resection of an epiphrenic diverticulum with esophagomyotomy and partial fundoplication. Surg Laparosc Endosc. 1998;8:145–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Chami Z, Fabre JM, Navarro F, Domergue J. Abdominal laparoscopic approach for thoracic epiphrenic diverticulum. Surg Endosc. 1999;13:164–5.PubMedCrossRefGoogle Scholar
  8. 8.
    Mainprize KS, Dehn TC. Laparoscopic management of pseudoachalasia, esophageal diverticulum, and benign esophageal stromal tumor. Dis Esophagus. 2001;14:73–5.PubMedCrossRefGoogle Scholar
  9. 9.
    Rosati R, Fumagalli U, Bona S, Zago M, Celotti S, Bisagni P, et al. Laparoscopic treatment of epiphrenic diverticula. J Laparoendosc Adv Surg Tech A. 2001;11:371–5.PubMedCrossRefGoogle Scholar
  10. 10.
    van der Peet DL, Klinkenberg-Knol EC, Berends FJ, Cuesta MA. Epiphrenic diverticula: minimal invasive approach and repair in five patients. Dis Esophagus. 2001;14:60–2.PubMedCrossRefGoogle Scholar
  11. 11.
    Neoral C, Aujesky R, Bohanes T, Klein J, Kral V. Laparoscopic transhiatal resection of epiphrenic diverticulum. Dis Esophagus. 2002;15:323–5.PubMedCrossRefGoogle Scholar
  12. 12.
    Champion JK. Thoracoscopic Belsey fundoplication with 5-year outcomes. Surg Endosc. 2003;17:1212–5.PubMedCrossRefGoogle Scholar
  13. 13.
    Fraiji E Jr, Bloomston M, Carey L, Zervos E, Goldin S, Banasiak M, et al. Laparoscopic management of symptomatic achalasia associated with epiphrenic diverticulum. Surg Endosc. 2003;17:1600–3.PubMedCrossRefGoogle Scholar
  14. 14.
    Pitchford TJ, Price PD. Laparoscopic Heller myotomy with epiphrenic diverticulectomy. JSLS. 2003;7:165–9.PubMedGoogle Scholar
  15. 15.
    Costantini M, Zaninotto G, Rizzetto C, Narne S, Ancona E. Oesophageal diverticula. Best Pract Res Clin Gastroenterol. 2004;18:3–17.PubMedCrossRefGoogle Scholar
  16. 16.
    Del Genio A, Rossetti G, Maffetton V, Renzi A, Brusciano L, Limongelli P, et al. Laparoscopic approach in the treatment of epiphrenic diverticula: long-term results. Surg Endosc. 2004;18:741–5.PubMedGoogle Scholar
  17. 17.
    Fernando HC, Luketich JD, Samphire J, Alvelo-Rivera M, Christie NA, Buenaventura PO, et al. Minimally invasive operations for esophageal diverticula. Ann Thorac Surg. 2005;80:2076–80.PubMedCrossRefGoogle Scholar
  18. 18.
    Tedesco P, Fisichella PM, Way LW, Patti MG. Cause and treatment of epiphrenic diverticula. Am J Surg. 2005;190:891–4.PubMedCrossRefGoogle Scholar
  19. 19.
    Valentini M, Pera M, Vidal O, Lacima G, Belda J, de Lacy AM. Incomplete esophageal myotomy and early recurrence of an epiphrenic diverticulum. Dis Esophagus. 2005;18:64–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Feo CV, Sortini D, Liboni A. Oesophageal achalasia with epiphrenic diverticulum with laparoscopic approach: a 6-year follow-up. Dig Surg. 2006;23:27.PubMedCrossRefGoogle Scholar
  21. 21.
    Motoyama S, Maruyama K, Okuyama M, Sasaki K, Sato Y, Ogawa J. Laparoscopic long esophagomyotomy with Dor fundoplication using a transhiatal approach for an epiphrenic esophageal diverticulum. Surg Today. 2006;36:758–60.PubMedCrossRefGoogle Scholar
  22. 22.
    Granderath FA, Pointner R. Laparoscopic transhiatal resection of giant epiphrenic esophageal diverticulum. Dis Esophagus. 2007;20:353–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Kinoshita Y, Udagawa H, Tsutsumi K, Ueno M, Mine S, Ehara K, et al. Modified Dor fundoplication technique following diverticulectomy and myotomy for epiphrenic diverticulum combined with esophageal motility disorders: prevention of esophageal leak at the diverticulectomy staple line. Esophagus. 2008;5:57–60.CrossRefGoogle Scholar
  24. 24.
    Miyashita M, Ohkawa K, Akagi I, Nomura T, Makino H, Tajiri T. Esophagoscopy-guided thoracoscopic resection of large epiphrenic esophageal diverticulum. Esophagus. 2008;5:225–8.CrossRefGoogle Scholar
  25. 25.
    Palanivelu C, Rangarajan M, John SJ, Parthasarathi R, Senthilkumar R. Laparoscopic transhiatal approach for benign supra-diaphragmatic lesions of the esophagus: a replacement for thoracoscopy? Dis Esophagus. 2008;21:176–80.PubMedCrossRefGoogle Scholar
  26. 26.
    Palanivelu C, Rangarajan M, Maheshkumaar GS, Senthilkumar R. Minimally invasive surgery combined with perioperative endoscopy for symptomatic middle and lower esophageal diverticula: a single institute’s experience. Surg Laparosc Endosc Percutan Tech. 2008;18:133–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Silecchia G, Casella G, Recchia CL, Bianchi E, Lomartire N. Laparoscopic transhiatal treatment of large epiphrenic esophageal diverticulum. JSLS. 2008;12:104–8.PubMedGoogle Scholar
  28. 28.
    Melman L, Quinlan J, Robertson B, Brunt LM, Halpin VJ, Eagon JC, et al. Esophageal manometric characteristics and outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication for epiphrenic diverticula. Surg Endosc. 2009;23:1337–41.PubMedCrossRefGoogle Scholar
  29. 29.
    Nehra D, Lord RV, DeMeester TR, Theisen J, Peters JH, Crookes PF, et al. Physiologic basis for the treatment of epiphrenic diverticulum. Ann Surg. 2002;235:346–54.PubMedCrossRefGoogle Scholar
  30. 30.
    Allen TH, Clagett OT. Changing concepts in the surgical treatment of pulsion diverticula of the lower esophagus. J Thorac Cardiovasc Surg. 1965;50:455–62.PubMedGoogle Scholar
  31. 31.
    Fekete F, Vonns C. Surgical management of esophageal thoracic diverticula. Hepatogastroenterology. 1992;39:97–9.PubMedGoogle Scholar
  32. 32.
    Evander A, Little AG, Ferguson MK, Skinner DB. Diverticula of the mid- and lower esophagus: pathogenesis and surgical management. World J Surg. 1986;10:820–8.PubMedCrossRefGoogle Scholar
  33. 33.
    Rosati R, Fumagalli U, Bona S, Bonavina L, Peracchia A. Diverticulectomy, myotomy, and fundoplication through laparoscopy: a new option to treat epiphrenic esophageal diverticula? Ann Surg. 1998;227:174–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Belsey R. Functional disease of the esophagus. J Thorac Cardiovasc Surg. 1966;52:164–88.PubMedGoogle Scholar
  35. 35.
    Effler DB, Barr D, Groves LK. Epiphrenic diverticulum of the esophagus: surgical treatment. Arch Surg. 1959;79:459–67.PubMedCrossRefGoogle Scholar
  36. 36.
    Kjellin AP, Granqvist S, Ramel S, Thor KB. Laparoscopic myotomy without fundoplication in patients with achalasia. Eur J Surg. 1999;165:1162–6.PubMedCrossRefGoogle Scholar
  37. 37.
    Wang PC, Sharp KW, Holzman MD, Clements RH, Holcomb GW, Richards WO. The outcome of laparoscopic Heller myotomy without antireflux procedure in patients with achalasia. Am Surg. 1998;64:515–20.PubMedGoogle Scholar
  38. 38.
    Richards WO, Torquati A, Holzman MD, Khaitan L, Byrne D, Lutfi R, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg. 2004;240:405–12.PubMedCrossRefGoogle Scholar
  39. 39.
    Gawande AS, Batiuchok W, Barman AA, Mule JE. Carcinoma within lower esophageal (epiphrenic) diverticulum. N Y State J Med. 1972;72:1749–51.PubMedGoogle Scholar
  40. 40.
    Fujita H, Kakegawa T, Shima S, Kumagaya Y. Carcinoma within a middle esophageal (parabronchial) diverticulum: a case report and the review of the literature. Jpn J Surg. 1980;10:142–8.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Japan 2012

Authors and Affiliations

  • Yuki Hirano
    • 1
  • Hiroya Takeuchi
    • 1
    Email author
  • Takashi Oyama
    • 1
  • Yoshiro Saikawa
    • 1
  • Masahiro Niihara
    • 1
  • Hiroyuki Sako
    • 1
  • Kenshi Omagari
    • 1
  • Tomohiko Nishi
    • 1
  • Hidekazu Suzuki
    • 2
  • Toshifumi Hibi
    • 2
  • Yuko Kitagawa
    • 1
  1. 1.Department of Surgery, School of MedicineKeio UniversityTokyoJapan
  2. 2.Internal Medicine, School of MedicineKeio UniversityTokyoJapan

Personalised recommendations