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Laparoscopic approach in the treatment of epiphrenic diverticula: long-term results

  • A. Del Genio
  • G. RossettiEmail author
  • V. Maffettone
  • A. Renzi
  • L. Brusciano
  • P. Limongelli
  • D. Cuttitta
  • G. Russo
  • G. Del Genio
Original article

Abstract

Background

Thoracotomy represents the traditional surgical approach for the treatment of epiphrenic diverticula. A mini-invasive procedure has been reported in only few series. This article describes the authors’ experience with the laparoscopic approach for performing diverticulectomy, myotomy and Nissen–Rossetti fundoplication.

Methods

From 1994 to 2002, 13 patients (6 men and 7 women), mean age 57 years (range 45–71 years), with symptomatic epiphrenic diverticulum underwent laparoscopic diverticulectomy, myotomy, and Nissen–Rossetti fundoplication.

Results

The mean operative time was 145 min (range 110–180 min). No operative mortality was observed. The mean hospital stay was 13.9 days (range 7–25 years). The first three patients (23.1%) who underwent surgery experienced a partial disruption of the suture staple line. One patient (7.7%) died of a myocardial infarction. After a mean clinical follow-up period of 58 months (range 3–96 months), all the patients were symptom free.

Conclusions

Laparoscopic management of epiphrenic diverticula seems to be as safe and effective as the traditional approach, although a longer follow-up period is necessary to confirm the study results.

Keywords

Dysphagia Esophageal manometry Epiphrenic diverticulum Laparoscopy Antireflux procedure 

Epiphrenic diverticula, although uncommon, represent a disease associated with motor disorders of the esophagus [4, 10, 22]: the hypothesis that increased intraluminal pressure could be implicated in the appearance of diverticula was suggested for the first time in 1833 [12]. Although general agreement exists about restricting surgical indications to symptomatic patients alone [11, 15, 18, 22], controversies regarding pathogenesis have led to different surgical procedures and approaches [2, 8, 9, 24]. Thoracotomy represents the traditional surgical approach, whereas only a few reports in the literature describe studies investigating mini-invasive management of epiphrenic diverticula [13, 16, 17, 19, 23]. The following article describes the authors’ experience with laparoscopic management of esophageal epiphrenic diverticula using diverticulectomy, myotomy, and Nissen–Rossetti fundoplication.

Patients and methods

From January 1994 to November 2002, 13 patients (6 men and 7 women), mean age 57 years; (range 45–71 years) affected by symptomatic epiphrenic diverticulum came to our observation. Dysphagia was the predominant symptom in 12 patients (92.3%). Other symptoms included regurgitation in 10 patients (76.9%), chest pain in 8 patients (61.5%), chronic cough in 4 patients (30.8%), and pyrosis in 3 patients (23.1%). Weight loss of more than 10 kg occurred in 5 patients (38.5%) and aspiration pneumonia in 2 patients (15.4%). The mean duration of symptoms was 115 months (range 8–255 months).

Preoperative evaluation for 12 patients included upper gastrointestinal barium meal (Fig. 1), gastrointestinal endoscopy, esophageal stationary manometry, and 24-h esophageal pH monitoring. Endoscopic guidance was used to introduce the manometric catheter when the lower esophageal sphincter (LES) was displaced by a large diverticulum.
Figure 1

A preoperative upper gastrointestinal radiograph.

For esophageal manometry, an eight-lumen catheter was used, with the four distal holes disposed radially on the same level at 90°, and the proximal holes spaced 5 cm apart 5, 10, 15, and 20 cm from the tip. The catheter was perfused with an infusion pump at a rate of 0.8 ml/min, with each lumen connected to an external pressure transducer. The analog signals were recorded on a computer polygraph and analyzed using Menfis software (Dyno 2000-Menfis bioMedica). Around-the-clock esophageal pH monitoring was performed with two glass electrodes connected to a data logger and placed 5 cm above and below the distal margin of manometrically relieved LES.

The mean diameter of the diverticular sac was 43 mm (range 33–57 mm), and exceeded 50 mm in three patients. The manometric findings were as follows: achalasia in six patients (46.2%), hypertensive LES in three patients (23.1%), nonspecific esophageal motility disorders in three patients (23.1%), and nutcracker esophagus in one patient (7.7%). Pathologic acid gastroesophageal reflux was diagnosed in three patients (23.1%).

Operative technique

For laparoscopic management of epiphrenic diverticula, the patient is placed in the lithotomic position with the operator standing between the patients legs. The first assistant is at the right of the surgeon, and the second is at his left. After pneumoperitoneum induction by a Veress needle introduced at the umbilicus, five trocars are positioned as in Fig. 2. The left liver is lifted up under endoscopic control, and the esophagogastric junction is identified. The abdominal esophagus is mobilized from the diaphragmatic pillars, and the dissection is performed all around the esophageal circumference, with special care focused on the anterior and posterior vagal nerves.
Figure 2

Disposition of trocars.

Once a wide retroesophageal space has been created gentle traction is applied to the esophagus by a retractor. Then mediastinal dissection of the inferior thoracic esophagus is started and carried out until the diverticular pouch is reached. Endoscopy is used to ensure complete identification of the diverticulum with its insufflation and transillumination properties. Monopolar cauthery, ultrasonic shears, or Ligasure (Valleylab, Boulder, CO, USA) can be used to perform this part of the procedure. Once preparation of diverticular pouch is completed, an Endo-GIA (USSC, Norwalk, CT, USA) is introduced. The stapler jaws are closed, with endoscopic control used to verify the presence of an adequate esophageal lumen. Then the staple is fired, and the integrity of the suture line is checked using endoscopic assistance. Most of the diverticular pouches in the current series, required a second staple firing to complete the diverticulectomy.

After confection of the diverticulectomy, myotomy is started below the inferior margin of the staple suture line and prolonged for 2 cm on the anterior gastric wall. Endoscopy allows the absence of mucosal tears to be verified, whereas intraoperative esophageal manometry confirms the completeness of myotomy (resting LES pressure <4 mmHg) [6].

For all the patients, an antireflux procedure is performed at the end of the intervention to prevent pathologic acid gastroesophageal reflux. We prefer to perform a Nissen–Rossetti fundoplication routinely without section of short gastric vessels neither esophagus transfixing stitches. Endoscopy then is used to verify the regular transit of the esophagogastric junction and correct wrap realization. A further manometry measures the new high-pressure zone calibrated at a range of 20 to 40 mmHg. Whenever pressure values are out of range, the wrap is taken down, and a new fundoplication is performed.

Results

The mean operative time was 145 min (range 110–180 min). No operative mortality was observed. In one patient (7.7%), a mucosal tear was repaired during the intervention by direct suture. The postoperative complications included a partial disruption of the suture staple line in the first three surgically managed patients (23.1%) during postoperative day 4. Two of these patients were successfully treated with apposition of a computed tomography (CT)-guided drain and total parenteral nutrition (TPN). The third patient required only TPN. One patient (7.7%) died on postoperative day 4 of a myocardial infarction. Oral intake of liquids usually started on postoperative day 6 after a Gastrografin esophageal and gastric transit. The mean postoperative hospital stay was 13.9 days (range 7–25 days).

After a mean clinical follow-up period of 58 months (range 3–96 months), all the patients were symptom free. An upper gastrointestinal barium meal obtained for six patients (46.2%) at 6 months from the intervention showed no diverticular recurrence and a regular esophagogastric transit. Stationary manometry and esophageal pH monitoring were performed for four patients (30.8%) after a mean follow-up period of 45 months (range 4–89 months). The mean value of the new HPZ was 18.7 mmHg (range 15.1–22.3 mmHg), with 75.5% of postdeglutitive relaxation (range 69.8–80 mmHg). No peristalsis abnormality of the esophageal body was observed. Esophageal pH monitoring showed a total absence of pathologic acid gastroesophageal reflux.

Discussion

Although it seems generally accepted that esophageal dismotility is associated with the occurrence of epiphrenic diverticula [3, 14, 21], it is not always simple to recognize the associated motor disorder despite recent progress in the knowledge about the pathophysiology of esophageal functional disease. A wide spectrum of esophageal functional disorders can be responsible for the occurrence of epiphrenic diverticula: achalasia, hypertensive LES, diffuse esophageal spasm, nutcracker esophagus, and other nonspecific esophageal motor disorders. Also a hypotensive LES with noncoordinative postdeglutitive relaxations can be associated with diverticula [4, 5, 20]. Furthermore, it is possible that stationary manometry cannot detect the motor abnormality at the moment of its execution [15].

As a result of epiphrenic diverticula, there have been many controversies about the indications and the choice of an adequate treatment. Because surgical treatment is not without risks and more than minimal morbidity and mortality rates [4, 9], there is almost a general consensus for treating only symptomatic patients. The diameter of the diverticular sac is not a determining factor for the surgical choice [11, 15, 18, 22].

Concerning the surgical technique, there is general agreement that it is necessary to perform a myotomy in association with diverticulectomy to correct the underlying motor dysfunction [3, 7] Diverticulectomy alone has been associated with a higher incidence of diverticular recurrence and a suture line leak rate of 10% to 20% [1, 4, 9, 18].

Extension of myotomy below the diverticular neck still remains a matter of discussion: Streitz et al. [22] reported good long-term results after selective use of myotomy, preserving the gastric wall muscular fibers in patients with normal LES pressure; Nehra et al. [14] believed that, in all cases, the myotomy should include the whole sphincter zone to prevent a potential early postoperative dysphagia resulting from inappropriate LES relaxations, with increased staple suture line leakage. The diffusion of the laparoscopic approach has led most authors to perform a myotomy extended to the gastric wall with an added antireflux procedure [13, 17, 18, 19, 23].

In our experience, before the laparoscopic era, the only diverticular recurrence happened after a diverticulectomy with a LES-sparing myotomy in a patient with preoperative manometric evidence of normotensive LES. Actually, like most authors, we support the necessity of extending the myotomy at least 2 cm on the anterior gastric wall regardless of LES manometric values, associated with an antireflux procedure. In contrast with other authors [18] we think it is easier to perform the myotomy on the same side as the diverticulectomy on the esophageal wall. This procedure is not without risks, but the endoscopic properties of insufflation and transillumination can, in our opinion, check any eventual mucosal tear, as occurred for one patient in our series.

A partial fundoplication generally is performed at the end of the procedure to protect esophageal mucosa from pathologic acid reflux [11, 17, 18, 19, 23]. The abolition of LES pressure and a defective esophageal clearance caused by peristalsis abnormalities are two determining factors in the occurrence of such complication. In contrast with general data from the literature, we prefer to perform a total Nissen–Rossetti fundoplication because we believe it can represent the best protection against reflux without increasing the postoperative dysphagia rates. Intraoperative manometric measurement of the new high-pressure zone [6] and its calibration at a range of 20 to 40 mmHg helps us to prevent persistent postoperative dysphagia. Also, we believe our disappointing morbidity rates (23.1% disruption of the staple suture line) could be attributable to technical mistakes made at the beginning of the experience and not to an esophageal outflow obstacle created by a 360° valve. All three cases of suture leaks in the current series occurred among the first three patients who underwent operation and no persistent dysphagia was observed at the clinical follow-up assessment, even among the patients who experienced postoperative leaks.

Regarding surgical approach, there is increasing consensus for the laparoscopic treatment of epiphrenic diverticula [13, 17, 18, 19, 23]. The better cosmetic results and the well-known advantages in terms of morbidity rates and postoperative recovery lead us to prefer this approach. Technical factors also support this choice including better visualization of the esophagogastric junction, easier myotomy and performance of antireflux wrap, and better alignment of the stapler cartridge to the longitudinal axis of the esophagus. Potential disadvantages could be a difficult dissection of the upper part of the diverticular neck and the major risks of pleural lesions, although we never observed any difficulty in performing the surgical procedure. In this article, we report the results of the largest published series via either the traditional (Table 1) or the mini-invasive approach (Table 2). The morbidity, mortality and success rates are similar between the two approaches, notwithstanding the limited number of patients who underwent operation via the mini-invasive access route.
Table 1

Epiphrenic diverticula-results of surgical treatment (traditional approach)

Author

Patients (n)

Access

Intervention

Morbidity

Mortality

Results

Streitz [22]

16

Thoracotomy

8 Diverticulectomy + myotomy

1 Leak (6.3%)

13 Excellent/good (86.7%)

   

5 Long myotomy

  

2 poor (13.3%)

   

3 Diverticulectomy

  

1 patient lost to follow-up

Altorki [2]

17

Thoracotomy

Diverticulectomy + myotomy + fundoplication

1 patient (5.9%)

15 Excellent/good (93.8%)

      

1 Poor (6.3%)

Hudspeth [10]

9

Thoracotomy

Diverticulectomy + myotomy

1 Leak (11.1%)

9 Excellent/good (100%)

Jordan P [11]

19

15 Thoracotomy

5 Diverticulectomy + myotomy

1 Leak (5.3%)

8 Excellent/good (88.9%)

  

4 Laparotomy

5 Diverticulectomy

  

1 Poor (11.1%)

   

4 Diverticulectomy + myotomy + fundoplication

  

9 Patients lost to follow-up

   

2 Gastroesophageal resection

  

1 Patient died of carcinoma

   

1 Imbrication + myotomy

   
   

1 Imbrication + fundoplication

   
   

1 Imbrication

   

Nehra [14]

18

Thoracotomy

17 Diverticulectomy + myotomy + fundoplication

1 Leak

1 patient (5.5%)

15 Excellent/good (88.2%)

   

(14 Belsey MK IV, 2 Dor, 1 Nissen)

1 Bleeding (11.1%)

 

2 Poor (11.8%)

   

1 Transhiatal esophagectomy

   
Table 2

Epiphrenic diverticula-results of surgical treatment (mini-invasive approach)

Authors

Patients (n)

Access

Intervention

Morbidity

Conversions

Results

Peracchia [16]

10

Thoracoscopy

5 Diverticulectomy

2 Leaks (20%)

9 Excellent/good (90%)

   

5 Diverticulectomy + cardial dilation

  

1 poor (10%)

Myers [13]

3

Laparoscopy

Diverticulectomy + myotomy

1 Pneumothorax (33.3%)

1 Patient (33.3%)

3 Excellent/good (100%)

Rosati [19]

11

Laparoscopy

Diverticulectomy + myotomy + fundoplication

1 Leak (9.1%)

11 Excellent/good (100%)

Van der Peet [23]

5

Thoracoscopy

3 Diverticulectomy

1 Leak (20%)

5 Excellent/good (100%)

   

2 Diverticulectomy + myotomy

   

Raakow [17]

3

Laparoscopy

Diverticulectomy + myotomy + fundoplication

3 Excellent/good (100%)

Our results seem comparable with those reported in the other mini-invasive series, except for the high morbidity rates (23.1%), which we think can be attributed to the learning curve of this challenging procedure.

Conclusions

According to the literature data and our experience, laparoscopic treatment of epiphrenic diverticula seems to be as safe and effective as the traditional approach, although a limited number of patients were treated and longer follow-up evaluation is necessary to confirm these encouraging results.

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Copyright information

© Springer-Verlag 2004

Authors and Affiliations

  • A. Del Genio
    • 1
  • G. Rossetti
    • 1
    • 2
    Email author
  • V. Maffettone
    • 1
  • A. Renzi
    • 1
  • L. Brusciano
    • 1
  • P. Limongelli
    • 1
  • D. Cuttitta
    • 1
  • G. Russo
    • 1
  • G. Del Genio
    • 1
  1. 1.First Division of General and Gastrointestinal SurgerySecond University of NaplesNaplesItaly
  2. 2.NaplesItaly

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