title: A combined thoracoscopic and laparoscopic approach for high epiphrenic diverticula and the importance of complete myotomy.
abstract: 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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Thoracic and Esophageal Surgery, Swedish Cancer Institute and Medical Center, Thoracic and Foregut Surgery, 1101 Madison, Suite 900, Seattle, WA, 98104, USA.
authors.forename: Virginie
authors.initials: V
authors.lastname: Achim
authors.affiliation: Thoracic and Esophageal Surgery, Swedish Cancer Institute and Medical Center, Thoracic and Foregut Surgery, 1101 Madison, Suite 900, Seattle, WA, 98104, USA. Ralph.Aye@swedish.org.
authors.forename: Ralph W
authors.initials: RW
authors.lastname: Aye
authors.affiliation: Thoracic and Esophageal Surgery, Swedish Cancer Institute and Medical Center, Thoracic and Foregut Surgery, 1101 Madison, Suite 900, Seattle, WA, 98104, USA.
authors.forename: Alexander S
authors.initials: AS
authors.lastname: Farivar
authors.affiliation: Thoracic and Esophageal Surgery, Swedish Cancer Institute and Medical Center, Thoracic and Foregut Surgery, 1101 Madison, Suite 900, Seattle, WA, 98104, USA.
authors.forename: Eric
authors.initials: E
authors.lastname: Vallières
authors.affiliation: Thoracic and Esophageal Surgery, Swedish Cancer Institute and Medical Center, Thoracic and Foregut Surgery, 1101 Madison, Suite 900, Seattle, WA, 98104, USA.
authors.forename: Brian E
authors.initials: BE
authors.lastname: Louie
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003679:Deglutition; D004936:Diverticulum, Esophageal / Q000601:surgery*; D049630:Esophageal Sphincter, Lower / Q000601:surgery*; D005260:Female; D018662:Fundoplication / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011788:Quality of Life; D012189:Retrospective Studies; D017792:Surgical Stapling; D013906:Thoracoscopy / Q000379:methods*
keywords: Achalasia; Epiphrenic diverticulum; Esophageal diverticulum; Esophageal myotomy; Laparoscopic; Thoracoscopic