Abstract
Background
The traditional approach to epiphrenic diverticula is thoracotomy and diverticulectomy, together with myotomy ± partial fundoplication to address underlying dysmotility. A laparoscopic approach has been advocated but access to more proximal diverticula is problematic. We propose the selective addition of a thoracoscopic approach to overcome these challenges and reviewed our results.
Methods
A retrospective review from 2004 to 2015 identified 17 patients with an epiphrenic diverticulum who underwent surgery. Patients were grouped according to height of the diverticular neck (HDN) above the GEJ: group A < 5 cm, group B > 5 cm. Preoperative evaluation and type of surgery performed were recorded. Postoperative complications, mortality, and clinical outcomes using quality of life metrics and objective testing were assessed.
Results
The mean size of the diverticulum was 3.3 cm (2–6 cm) with a mean height above the GEJ of 5.5 cm (0–12 cm). A motility disorder was identified in 15/17. Group A, 9 patients, underwent laparoscopic diverticulectomy, myotomy, and partial fundoplication. For group B, 8 patients, the intended procedure was thoracoscopic diverticulectomy followed by laparoscopic myotomy and partial fundoplication, but this was only completed in 5. In 3 the myotomy was aborted or incomplete with subsequent staple line leaks resulting in 1 death. At a mean follow-up of 21 months, improvement of median QOLRAD scores from 3.42 to 6.2 (p = 0.18); GERD-HRQL from 23 to 1 (p = 0.05), swallowing score from 17.5 to 30 (p = 0.22), and Eckardt scores from 5 to 0 (p < 0.05) were observed.
Conclusions
A minimally invasive strategy for epiphrenic diverticula based HDN above the GEJ and selective thoracoscopy for higher diverticula is feasible and appropriate, and resulted in improved quality of life. Incomplete myotomy was associated with a substantially higher complication rate. Laparoscopic myotomy should precede diverticulectomy for all cases, especially for high diverticula.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Mondiere JT (1833) Notes sur quelques maladies de l’oesophage. Arch Gen Med 3:28–65
Nehra D, Lord RV, DeMeester TR, Theisen J, Peters JH, Crookes PF, Bremner CG (2002) Physiologic basis for the treatment of epiphrenic diverticulum. Ann Surg 235:346–354
Melman L, Quinlan J, Robertson B, Brunt LM, Halpin VJ, Eagon JC, Frisella MM, Matthews BR (2009) Esophageal manometric characteristics and outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication for epiphrenic diverticula. Surg Endosc. doi:10.1007/s00464-008-0165-9
Hudspeth DA, Thorne MT, Conroy R, Pennell TC (1993) Management of epiphrenic esophageal diverticula a fifteen-year experience. Am Surg 59:40–42
Varghese TK, Marshall B, Change AC, Pickens A, Lau CL, Orringer MB (2007) Surgical treatment of epiphrenic diverticula: a 30-year experince. Ann Thorac Surg 84:1801–1809
Benacci JC, Deschamps C, Trastek VF, Allen MS, Daly RC, Pairolero PC (1993) Epiphrenic diverticulum: results of surgical treatment. Ann Thorac Surg 55:109–114
Rosati R, Fumagalli U, Bona S, Bonavina L, Peracchia A (1998) Diverticulectomy, myotomy, and fundoplication through laparoscopy: A new option to treat epiphrenic esophageal diverticula? Ann Surg 227:174–178
Rosati R, Fmagalli U, Elmore U, de Pascale S, Massaron S, Perrachia A (2011) Long-term results of minimally invasive surgery for symptomatic epiphrenic diverticulum. Am J Surg 201:132–135
Patti MG, Pellegrini CA, Horgan S, Arcerito M, Omelanczuk P, Tamburini A, Diener U, Eubanks TR, Way LW (1999) Minimally invasive surgery for achalasia: an 8-year experience with 168 patients. Ann Surg 4:587–594
Soares RV, Montenovo M, Pellegrini CA, Oelschlager BK (2011) Laparoscopy as the initial approach for epiphrenic diverticula. Surg Endosc. doi:10.1007/s00464-011-1779-x
Fernando HC, Luketich JD, Samphire J, Alvelo-Rivera M, Christie NA, Buenaventura PO, Landreneau RJ (2005) Minimally invasive operation for esophageal diverticula. Ann Thorac Surg 80:2076–2081
Dakkak M, Bennett JR (1992) A new dysphagia score with objective validation. J Clin Gastroenterol 14:99–100
Allaix ME, Borraez Segura BA, Herbella FA, Fisichella PM, Patti MG (2015) Is resection of an esophageal epiphrenic diverticulum always necessary in the setting of achalasia? World J Surg. doi:10.1007/s00268-014-2770-1
Macke RA, Luketich JD, Pennathur A, Bianco V, Awais O, Gooding WE (2015) Thoracic esophageal diverticula: a 15-year experience of minimally invasive surgical management. Ann Thorac Surg 100:1795–1803
Zaninotto G, Portlae G, Costantini M, Zanatta L, Salvador R, Ruol A (2011) Therapeutic strategies for epiphrenic diverticula: systematic review. World J Surg. doi:10.1007/s00268-011-1065-z
Kilic A, Schubert MJ, Awais O, Luketich JD, Landreneau RJ (2009) Surgical management of epiphrenic diverticula in the minimally invasive era. JSLS 13:160–164
Fisichella PM, Jalilvand A, Dobrowlsky A (2015) Achalasia and epiphrenic diverticulum. World J Surg. doi:10.1007/s00268-015-2950-7
Steward KC, Finley RJ, Clifton JC, Graham AJ, Storseth C, Inculet R (1999) Thoracoscopic versus laparoscopic modified heller myotomy for achalasia: efficacy and safety in 87 patients. J Am Coll Surg 189:164–170
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
Virginie Achim, Ralph W. Aye, Alexander S. Farivar, Eric Vallières, and Brian E. Louie have none to disclose.
Rights and permissions
About this article
Cite this article
Achim, V., Aye, R.W., Farivar, A.S. et al. A combined thoracoscopic and laparoscopic approach for high epiphrenic diverticula and the importance of complete myotomy. Surg Endosc 31, 788–794 (2017). https://doi.org/10.1007/s00464-016-5033-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-016-5033-4