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

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.     

Laparoscopic treatment of epiphrenic diverticula

BACKGROUND AND PURPOSE: Epiphrenic diverticula are a rare disease probably caused by long-standing impairment of esophageal motor activity. Symptomatic disease, which may worsen clinically during follow-up even to severe symptoms, is usually considered an indication for surgical treatment. Surgery for epiphrenic diverticula consists of diverticulectomy, which traditionally is performed through a left thoracotomy; a myotomy and partial fundoplication are generally included in order to treat the underlying motor disorder and to prevent or correct reflux. The same principles of surgical treatment can be achieved through the laparoscopic transhiatal approach. The aim of this paper is to describe the technique and the results of laparoscopic diverticulectomy combined with esophageal myotomy and antireflux wrap to treat epiphrenic diverticula of the esophagus. PATIENTS AND METHODS: From January 1994 through May 2001, 11 patients underwent laparoscopic transhiatal diverticulectomy, esophageal myotomy, and partial fundoplication at our institution. RESULTS: In all patients, the operation was completed through the minimally invasive access. The postoperative course was complicated in one patient (9%), who had a leak from the staple line, which was repaired through a thoracotomy. At follow-up, this patient had persistence of a small pouch at the diverticuletomy site. However, he was asymptomatic. All other patients were free of symptoms and without recurrence. CONCLUSION: Laparoscopy offers good access to the distal esophagus and the inferior mediastinum. Removal of the diverticulum, treatment of the motor disorder, and prevention of postoperative reflux can all be obtained through this approach. The immediate postoperative and long-term results are satisfactory.     

Laparoscopic management of symptomatic achalasia associated with epiphrenic diverticulum

Background: We evaluated outcome after laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication. Methods: Patients with symptomatic achalasia and epiphrenic diverticula underwent laparoscopic diverticulectomy, Heller myotomy, and partial fundoplication. Intraoperative endoscopy and postoperative esophagography were performed in all patients. Patients graded preoperative and postoperative dysphagia and heartburn on a Likert scale. Results: Anterior fundoplication was performed in five patients and posterior fundoplication in one. Mean follow-up was 9 months (range, 1–17 months). One intraoperative complication occurred—an esophagotomy that was laparoscopically repaired. There were no postoperative leaks. Patient-reported dysphagia decreased from 4.5 ± 0.8 (mean ± SD) to 1.8 ± 1.7 (p < 0.05 matched pair analysis). Heartburn decreased from 4.3 ± 0.8 to 1.3 ± 1.3 (p < 0.05). All patients reported improvement in symptoms after operation. Conclusion: Laparoscopic esophageal diverticulectomy, Heller myotomy, and partial fundoplication with intraoperative endoscopy safely reduce dysphagia associated with achalasia and esophageal diverticula while limiting symptoms of gastroesophageal reflux. Paper presented at the 8th World Congress of Endsocopic Surgery, New York, NY, USA, March 2002.     

Laparoscopic approach for esophageal achalasia with epiphrenic diverticulum

We report the case of a 65-year-old woman with a 10-year history of dysphagia, regurgitation, cough, and 10-kg weight loss caused by an epiphrenic diverticulum associated with esophageal achalasia managed with a laparoscopic approach. A preoperative barium swallow showed a dilated sigmoid esophagus with a 6-cm epiphrenic diverticulum. Esophageal manometry confirmed the absence of peristalsis in the esophageal body. We performed a laparoscopic diverticulectomy and a 7-cm distal esophageal myotomy with a Dor fundoplication. The postoperative course was uneventful. On the third postoperative day a barium swallow showed no leak, and the patient started oral intake. She was discharged home 5 days after the operation free of symptoms and tolerating a soft diet. Sixteen months after surgery, she was asymptomatic and had gained 8 kg. A barium swallow showed a normal-size esophagus with regular emptying. We reaffirm the feasibility, safety, and efficacy of the laparoscopic diverticulectomy and distal myotomy with Dor fundoplication to manage epiphrenic diverticula resulting from esophageal achalasia.     

Diverticulectomy,myotomy, and fundoplication through laparoscopy: a new option to treat epiphrenic esophageal diverticula?

OBJECTIVE: To describe the technique and the results of laparoscopic diverticulectomy combined with esophageal myotomy and antireflux wrap for epiphrenic diverticula of the esophagus. SUMMARY BACKGROUND DATA: The epiphrenic diverticulum of the esophagus is a rare disease probably caused by a longstanding impairment of the esophageal motor activity. Although there is almost universal agreement to operate only on symptomatic patients, the optimal treatment is controversial. The best-accepted guideline is to treat the underlying motor disorder. This is generally done through a left thoracotomic approach that allows diverticulectomy, esophageal myotomy, and partial fundoplication. METHODS: From January 1994 through February 1996, 4 patients underwent laparoscopic transhiatal diverticulectomy, esophageal myotomy, and partial fundoplication at our institution. A thorough preoperative study was done with barium swallow, esophagoscopy, and manometry in all patients; 24-hour pH monitoring was done in one case. RESULTS: No postoperative complications were observed. Short- and medium-term results are satisfactory. CONCLUSIONS: No theoretical objection should be made to this approach, because the principle of treatment of the diverticular pouch and the underlying motor disorder and the prevention of reflux is respected. Longer follow-up and a wider series are mandatory to substantiate these initially favorable results.     

Epiphrenisches Divertikel

INTRODUCTION: In the majority of patients suffering from epiphrenic diverticula, functional disorders of the esophagus are evident. The significance of surgical therapy is unclear, especially in case of nonspecific esophageal motility disorders. Besides "triple therapy" with diverticulectomy, myotomy, and semifundoplication, myotomy alone is also applied. Based on our own long-term results, we intended to prove if a treatment concept modeled on the motility disorder is justified. PATIENTS AND METHODS: Between July 1989 and December 2002, 12 patients with symptomatic epiphrenic diverticula underwent surgery at our clinic. Myotomy was carried out with diverticulectomy (and semifundoplication) only if achalasia had been proven, and an antireflux procedure was done only in case of gastroesophageal reflux. Surgery was performed openly in ten patients, and laparoscopically in two. RESULTS: After a median follow-up of 46 months (range 9-169), all patients regarded the operative results as good to very good (11 follow-up investigations). CONCLUSION: To alleviate symptoms in patients with epiphrenic diverticula, myotomy is only rarely indicated. As with diverticulectomy, it is only necessary, if achalasia has been proven. Our long-term results do not suggest performing myotomy as a rule for underlying unspecific motility disorders of the esophagus.     

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

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.     

Esophageal manometric characteristics and outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication for epiphrenic diverticula

Purpose  The purpose of this study is to characterize the esophageal motor and lower esophageal sphincter (LES) abnormalities associated with epiphrenic esophageal diverticula and analyze outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication. Methods  The endoscopic, radiographic, manometric, and perioperative records for patients undergoing laparoscopic esophageal diverticulectomy, anterior esophageal myotomy, and partial fundoplication from 8/99 until 9/06 were reviewed from an Institutional Review Board (IRB)-approved outcomes database. Data are given as mean ± standard deviation (SD). Results  An esophageal body motor disorder and/or LES abnormalities were present in 11 patients with epiphrenic diverticula; three patients were characterized as achalasia, one had vigorous achalasia, two had diffuse esophageal spasm, and five had a nonspecific motor disorder. Presenting symptoms included dysphagia (13/13), regurgitation (7/13), and chest pain (4/13). Three patients had previous Botox injections and three patients had esophageal dilatations. Laparoscopic epiphrenic diverticulectomy with an anterior esophageal myotomy was completed in 13 patients (M:F; 3:10) with a mean age of 67.6 ± 4.2 years, body mass index (BMI) of 28.1 ± 1.9 kg/m² and American Society of Anesthesiologists (ASA) 2.2 ± 0.1. Partial fundoplication was performed in 12/13 patients (Dor, n = 2; Toupet, n = 10). Four patients had a type I and one patient had a type III hiatal hernia requiring repair. Mean operative time was 210 ± 15.1 min and mean length of stay (LOS) was 2.8 ± 0.4 days. Two grade II or higher complications occurred, including one patient who was readmitted on postoperative day 4 with a leak requiring a thoracotomy. After a mean follow-up of 13.6 ± 3.0 months (range 3–36 months), two patients complained of mild solid food dysphagia and one patient required proton pump inhibitor (PPI) for gastroesophageal reflux disease (GERD) symptoms. Conclusion  The majority of patients with epiphrenic esophageal diverticula have esophageal body motor disorders and/or LES abnormalities. Laparoscopic esophageal diverticulectomy and anterior esophageal myotomy with partial fundoplication is an appropriate alternative with acceptable short-term outcomes in symptomatic patients.     

Esophageal diverticula. Physiopathological basis for surgical management.

From 1980 to 1990, 31 patients were treated surgically in our department for esophageal diverticula: 12 Zenker's diverticula (ZD); 11 mid-thoracic diverticula (MTD); 8 epiphrenic diverticula (ED). Cricopharyngeal dysfunction was detectable in 8 of 12 ZD patients (66.6%). Cricopharyngeal myotomy with diverticulectomy was performed in all cases. There were no deaths. Relief of dysphagia was obtained in all cases. No recurrences of dysphagia or diverticulum were observed at a mean follow-up of 3 years. A motility disorder was observed in 10 of 11 MTD (90.9%). An extended esophageal myotomy with diverticulectomy was performed in 3 cases, an extended myotomy alone in 3 cases, a diverticulectomy alone in 5 cases; an anti-reflux procedure was added in 6 cases. One patient died on the 7th postoperative day. All remaining patients were free of symptoms at a mean follow-up of 3.2 years. A motor dysfunction was detected in all 8 ED patients (100%). No diverticulectomy was performed. Six patients underwent Heller-Dor myotomy and 2 underwent Nissen fundoplication. There were no deaths. Relief of symptoms was obtained in all patients, at a mean follow-up of 3.1 years. Myotomy with diverticulectomy represents the treatment of choice in ZD. As regards MTD and ED, the treatment of the underlying motor disorder is the main therapeutic goal, whereas diverticulectomy is reserved to selected patients.     

Surgical Management of Epiphrenic Diverticula in the Minimally Invasive Era

Background:

Epiphrenic diverticula are rare outpouchings of the distal esophagus that infrequently require surgical intervention for the treatment of symptoms. In cases where surgical therapy is indicated, the traditional approach is through a thoracotomy. Advances in minimally invasive techniques have led to thoracoscopic and more recently laparoscopic management of epiphrenic diverticula. The purpose of this article is to review the literature on minimally invasive surgery for epiphrenic diverticula with particular attention to the operative approach and technique, surgical mortality and morbidity, and symptomatic outcomes.

Methods:

A review of the literature limited to studies in the English language and performed on humans was conducted on PubMed using the following key words: “esophageal diverticula” and “epiphrenic”. Articles retrieved by the PubMed search were reviewed.

Conclusions:

A minimally invasive approach to epiphrenic diverticula offers reduced operative mortality, decreased length of stay, and similar symptom relief compared with open surgery in the hands of experienced laparoscopic surgeons.     

Esophageal diverticula

Esophageal diverticula are classified by location-phrenoesophageal (Zenker's diverticulum-70%), thoracic and mediastinal (10%), and epiphrenic (20%). Almost all esophageal diverticula are acquired pulsion diverticula. The most common symptoms are dysphagia, regurgitation, thoracic pain, and pulmonary manifestations related to aspiration. Barium swallow and upper endoscopy will help to establish the diagnosis while esophageal manometry may reveal underlying dysmotility. Diverticula should not be treated unless they are symptomatic. The treatment of Zenker's diverticulum is surgical and consists of either diverticulectomy or diverticular suspension with a myotomy of the cricopharyngeus muscle via cervical approach. Transoral endoscopic stapled diverticulostomy is a new and simple approach which may become the treatment of choice, particularly in elderly and high-risk patients. Treatment of diverticula of the mid and low esophagus must take into account any motor anomalies or associated lesions. Diverticulectomy with esophageal myotomy and an anti-reflux procedure through a left thoracotomy is the standard approach, but endoscopic approaches seem feasible, particularly for epiphrenic diverticula, and may become the norm in years to come.     

Minimally invasive treatment of esophageal diverticula.

Minimally invasive approaches are ideally suited to treat diverticula of the mid- and lower esophagus. The most commonly reported procedure is a laparoscopic diverticulectomy and myotomy, particularly when the diverticulum is located within 10 cm of the lower esophageal sphincter. Treatment is the same as for the open approach: Symptomatic patients are offered surgical treatment, the diverticulum is excised without compromise of the esophageal lumen, the proximal extent of the myotomy is dictated by preoperative manometry, and postoperative evaluation is performed to exclude recurrence and gastroesophageal reflux. The results of laparoscopic treatment of esophageal diverticula are similar to the results reported in the open procedure. The laparoscopic technique used to treat esophageal diverticula is described.     

Transhiatale laparoskopische Divertikelresektion bei einem epiphrenischen Oesophagusdivertikel

Epiphrenic diverticula are rare. The exact prevalence of this condition is unknown because asymptomatic patients are usually not discovered. Symptoms are more often the result of an esophageal motility disorder than the diverticulum itself and no correlation exists between the size of the diverticulum and the severity of symptoms. We present a patient suffering from dysphagia, chest pain, food retention and regurgitation because of an epiphrenic diverticulum. The current treatment of choice for symptomatic epiphrenic diverticula is diverticulectomy via a left thoracic approach. We performed a successful abdominal laparoscopic approach.     

Laparoscopic management of oesophageal epiphrenic diverticulum: a case report

Epiphrenic diverticuli are rare pulsion "pseudodiverticuli" of the distal oesophagus that are commonly associated with oesophageal motility disorders. Surgical treatment is usually reserved for patients with symptoms. Traditionally, patients are treated with diverticulectomy, myotomy and fundoplication via a left thoracotomy. The aim of this study was to describe the laparoscopic technique and review the international literature on this minimally invasive approach. We report the case of a 66-year-old woman with a 1-year history of retrosternal pain, regurgitation and weight loss caused by an oesophageal epiphrenic diverticulum. The patient underwent barium oesophagography and oesophagogastroduodenoscopy. The oesophageal diverticulum measured 5 cm. We treated the condition with a laparoscopic oesophageal diverticulectomy, Heller myotomy and Dor fundoplication with intraoperative endoscopy. The operative time was 210 minutes. The postoperative course was complicated by a suspected leakage from the staple line, which was not subsequently confirmed. The patient is now totally asymptomatic after 3 months. Laparoscopy offers good access to the distal oesophagus and the inferior mediastinum. Resection of the diverticulum, treatment of the motor disorder and prevention of postoperative reflux can be obtained with this approach. It should be considered as an alternative to the traditional transthoracic approach and may eventually become the standard technique.     

Physiologic basis for the treatment of epiphrenic diverticulum

OBJECTIVE: To quantitate and characterize the motility abnormalities present in patients with epiphrenic diverticula and to assess the outcome of surgical treatment undertaken according to these abnormalities. SUMMARY BACKGROUND DATA: The concept that epiphrenic diverticula are complications of esophageal motility disorders rather than primary anatomic abnormalities is gradually becoming accepted. The inconsistency in identifying motility abnormalities in patients with epiphrenic diverticula is a major obstacle to the general acceptance of this concept. METHODS: The study population consisted of 21 consecutive patients with epiphrenic diverticula. All patients underwent videoesophagography, upper gastrointestinal endoscopy, and esophageal motility studies. The diverticula ranged in size from 3 to 10 cm and were predominantly right-sided. Seventeen patients underwent transthoracic diverticulectomy or diverticulopexy with esophageal myotomy and an antireflux procedure. The length of the myotomy was determined by the extent of the motility abnormality. Transhiatal esophagectomy was performed in one patient with multiple diverticula. Two patients declined surgical treatment and another patient died of aspiration before surgery. Symptomatic outcome was assessed via a questionnaire at a median of 24 months after surgery. RESULTS: The primary symptoms were dysphagia in 5 (24%) patients, dysphagia and regurgitation in 11 (52%) patients, and pulmonary symptoms in 5 (24%) patients. The median duration of the primary symptoms was 10 years. Esophageal motility abnormalities were identified in all patients. An esophageal motor disorder was diagnosed only by 24-hour ambulatory motility testing in one patient, and 24-hour ambulatory motility testing clarified the motility diagnosis in five other patients. The most common underlying disorder was achalasia, which was detected in nine (43%) patients. A hypertensive lower esophageal sphincter was diagnosed in three patients, diffuse esophageal spasm in five, "nutcracker" esophagus in two, and a nonspecific motor disorder in two patients. One patient had an intraoperative myocardial infarction and died. Two patients had persistent mild dysphagia after surgery. The remaining patients had complete relief of their primary symptoms. CONCLUSIONS: There is a high prevalence of named motility disorders in patients with epiphrenic diverticula, and this condition is associated with the potential for lethal aspiration. Twenty-four-hour ambulatory motility testing can be helpful if the results of the stationary examination are normal or indefinite. Resection of the diverticula and a surgical myotomy of the manometrically defined abnormal segment results in relief of symptoms and protection from aspiration.     

Minimally invasive surgery combined with peroperative endoscopy for symptomatic middle and lower esophageal diverticula: a single institute's experience

INTRODUCTION: Esophageal diverticula are rare, accounting for less than 5% of dysphagia cases. Midesophageal and epiphrenic esophageal diverticula account for about 30% of all esophageal diverticula. Traditionally, thoracotomy or laparotomy were the preferred approaches for surgical therapy. Recently, minimally invasive therapies have been described. MATERIALS AND METHODS: We present our experiences of 12 patients with diverticula of the distal two-thirds of the esophagus. Thoracoscopic approach was used to treat midesophageal diverticula and a transhiatal approach was used for the epiphrenic diverticula. Peroperative endoscopy was used in all cases. Underlying causes were also simultaneously dealt with. DISCUSSION: According to our series, epiphrenic diverticula were more common; lateral wall being the most common location. Myotomy and fundoplication were done depending on the underlying disorder. We highlight the importance of peroperative endoscopy to accurately localize and determine extent of diverticulectomy. RESULTS: Males were more common than females and most patients were elderly. Postoperatively, 2 cases had complications and 1 patient had leak. The length of hospital stay was 3 to 23 days. CONCLUSIONS: Esophageal diverticula are rare conditions, and minimally invasive surgery is certainly feasible and effective in terms of reduced morbidity.     

Laparoscopic repair of a large symptomatic epiphrenic esophageal diverticulum

PURPOSE: The diagnosis of symptomatic epiphrenic esophageal diverticula is uncommon. Even less common are published reports regarding the efficacy of laparoscopic repair of this malady. METHODS: We report the case of a 59-year-old male patient with Parkinsonism found to have a large, symptomatic epiphrenic diverticulum and discuss the surgical treatment performed. The patient presented with a 6-month history of worsening dysphagia to both solids and liquids, regurgitation of undigested food, and weight loss. Barium esophagram identified the presence of a large distal esophageal diverticulum. Esophagoscopy confirmed the epiphrenic location of the diverticulum and the absence of other pathology. Laparoscopic transhiatal diverticulectomy was performed utilizing a gastrointestinal endoscopic stapler. Intraoperative esophagoscopy was performed to confirm resection of the diverticulum without constriction of the lumen. RESULTS: The patient resumed intake of liquids on postoperative day 1 after a water-soluble contrast esophagram revealed no extravasation. The patient was discharged on hospital day 3. He reported residual dysphagia to solids postoperatively, which appeared to resolve after pneumatic dilation. CONCLUSIONS: We conclude that laparoscopic epiphrenic diverticulectomy is technically feasible and safe. The comorbidity of Parkinsonism adds complexity to the diagnosis and treatment of this uncommon disorder.     

The epiphrenic esophageal diverticulum. Its transhiatal laparoscopic treatment]

A new laparoscopic surgical approach to treat an esophageal epiphrenic diverticulum is described. This is a rare disease. Today only 4 cases of laparoscopic transhiatal treatment with good results are reported in the literature. The present case report is an 80 years-old male with medium size epiphrenic diverticulum (10 cm) and very symptomatic dysphagia. Preoperative investigations include barium swallow, upper gastrointestinal endoscopy and esophageal manometry. The laparoscopic transhiatal treatment was carried out without difficulty. Diverticulectomy esophageal myotomy and partial gastric fundoplication (Dor) were performed. No postoperative complication was recorded and optimal result was achieved. In conclusion, the efficacy of laparoscopic approach is underlined and the short and medium-term results are satisfactory.     

Laparoscopic Resection of an Esophageal Epiphrenic Diverticulum

Epiphrenic diverticulum of the esophagus is an uncommon disease. In the light of the benefits of minimally invasive treatment of such a functional disorder, we used the laparoscopic approach for resection of an epiphrenic diverticulum. We found that laparoscopic repair of symptomatic esophageal epiphrenic diverticula is a safe and effective technique with minimal postoperative pain and morbidity. It should be considered as an alternative to the traditional transthoracic approach, and may become the standard technique.     

Laparoscopic resection of an esophageal epiphrenic diverticulum

Epiphrenic diverticulum of the esophagus is an uncommon disease. In the light of the benefits of minimally invasive treatment of such a functional disorder, we used the laparoscopic approach for resection of an epiphrenic diverticulum. We found that laparoscopic repair of symptomatic esophageal epiphrenic diverticula is a safe and effective technique with minimal postoperative pain and morbidity. It should be considered as an alternative to the traditional transthoracic approach, and may become the standard technique.