Cause and treatment of epiphrenic diverticula.
BACKGROUND
Epiphrenic diverticula of the esophagus are often associated with a concomitant esophageal motor disorder, which is thought to be the cause of the diverticulum and some of the patient's symptoms. At one time diverticula were best removed via a left thoracotomy, but now the operation can be performed laparoscopically in most cases. We hypothesized that: (1) a motor disorder is the underlying cause of the diverticulum; and (2) optimal treatment consists of laparoscopic resection of the diverticulum, a Heller myotomy, and Dor fundoplication.


METHODS
We performed a retrospective review of a prospectively collected database from a university hospital tertiary care center. Between June 1994 and December 2002, we evaluated 21 patients with epiphrenic diverticula. An associated motility disorder of the esophagus was found in 81% of patients (achalasia, 9%; diffuse esophageal spasm, 24%; nonspecific esophageal motility disorder, 24%; nutcracker esophagus, 24%). Seven (33%) of these patients, all with esophageal dysmotility, were referred for treatment. The laparoscopic operation entailed resection of the diverticulum (using an endoscopic stapler), a Heller myotomy, and a Dor fundoplication.


RESULTS
All operations were completed laparoscopically. The postoperative course of 6 patients was uneventful and they left the hospital after 72 +/- 21 hours. In 1 patient an acute paraesophageal hernia developed, which was repaired on the second postoperative day. Late follow-up (median 57 months) showed that all 7 patients were asymptomatic.


CONCLUSIONS
These data support the conclusions that: (1) a primary esophageal motility disorder is the underlying cause of most epiphrenic diverticula; and (2) laparoscopic treatment is successful and should be the method of choice. The diverticular neck can be exposed satisfactorily from the abdomen; a stapler inserted from this angle is better orientated to transect the neck than one inserted through a thoracoscopic approach. Furthermore, the myotomy and fundoplication are much more easily performed from the abdomen than from alternative approaches.
Tedesco
Pietro
P
Department of Surgery, University of California San Francisco, San Francisco, CA, USA.
Fisichella
Piero M
PM
Way
Lawrence W
LW
Patti
Marco G
MG
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004936:Diverticulum, Esophageal / Q000209:etiology* / Q000601:surgery*; D015154:Esophageal Motility Disorders / Q000150:complications* / Q000503:physiopathology; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication; D006801:Humans; D006863:Hydrogen-Ion Concentration; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008365:Manometry; D008875:Middle Aged; D009130:Muscle, Smooth / Q000601:surgery; D011312:Pressure; D012189:Retrospective Studies; D013270:Stomach / Q000601:surgery; D016896:Treatment Outcome