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Is Resection of an Esophageal Epiphrenic Diverticulum Always Necessary in the Setting of Achalasia?
Marco E. Allaix*1, Bernardo Borraez1, Fernando Herbella1, Piero M. Fisichella2, Marco G. Patti1
1Department of Surgery, Center for Esophageal Diseases, University of Chicago, Chicago, IL; 2Department of Surgery, Swallowing Center, Loyola University Chicago, Chicago, IL
Background: Epiphrenic diverticulum (ED) of the esophagus is secondary to a primary esophageal motility disorder such as achalasia. While the recommended treatment includes esophageal myotomy and diverticulectomy, the outcome of patients in whom a myotomy without ED resection is performed is not known.
Aims: The aim of this study was to compare the outcome of patients with ED who underwent ED resection and myotomy and those of ED patients who had a myotomy only.
Methods: Retrospective review of a prospective database. Thirteen ED patients had symptoms evaluation, barium swallow, endoscopy and esophageal high resolution manometry. All patients underwent laparoscopic myotomy and Dor fundoplication. In 6 patients the diverticulum was resected (group A), while in 7 it was left in place (Group B; in 3 because it was small and in 4 for technical reasons).
Results: Preoperatively all patients had dysphagia and 85% had regurgitation. The mean preoperative Eckardt score was 6.5 ± 2.1 in group A patients and 6.6 ± 3.3 in group B (p=0.9503). Size of ED was 46.3 ± 5.5 mm in group A and 40.6 ± 22.5 mm in group B (p=0.5595). High resolution manometry showed type II esophageal achalasia. One group A patient had a staple line leak. At a median follow-up of 2 years, the Eckardt score was 0 in group A and 0.1 ± 0.4 in group B (p=0.5553).
Conclusions: The results of this study suggest that in selected patients with achalasia and ED: 1) a myotomy alone gives excellent results; and 2) the underlying motility disorder rather than the ED may be the cause of symptoms.
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