Abstracts
1997 Digestive Disease Week

Physiologic basis for the treatment of epiphrenic diverticulum.

D Nehra, M Gadenstatter, CG Bremner, M Koch, JA Hagen, JH Peters, TR DeMeester. Department of Surgery, University of Southern California, Los Angeles, CA.

The surgical management of epiphrenic diverticula is controversial. The aim of this study was to characterize the motility abnormalities in patients with epiphrenic diverticula and assess the outcome of surgical treatment tailored to these findings.

The study population consisted of 15 patients with epiphrenic diverticula evaluated between 1990-1996 (median age 65, range 45-88 years; M:F ratio 3:1). All had video esophagogram, endoscopy and esophageal motility studies. The diverticula ranged in size from 5-10cm (median 7cm) and were predominantly right sided (13/15). Three patients had a hiatus hernia. Thirteen patients underwent a transthoracic diverticulectomy combined with esophageal myotomy and a Belsey partial fundoplication. The length of the myotomy (long n=3; short n=10) was determined by the extent of the motility abnormality. Two patients were not treated surgically, one with 'nutcracker' esophagus and another who declined treatment. Symptomatic outcome was assessed via a questionnaire at a median of 18 months (3 mths - 6 yrs) after surgery.

Dysphagia was present in 13 (87%) patients and regurgitation in 11 (73%). Three (20%) patients presented primarily with recurrent pulmonary symptoms due to aspiration. The median duration of symptoms was 10 years (2-40). Increased esophageal acid exposure was detected in 4 (27%) patients. The manometric results are shown in the table.

    Motor disorder      Mean LES       LES relaxation      Simultaneous
       (n=14)        pressure (mmHg)                       contractions
 Achalasia (8)            28*               46%                100%
 DES (2)                  28*               82%                 30%
 Hypertensive LES (3)     34*              100%                  0%
 Nutcracker (1)           17               100%                  0%
DES-Diffuse esophageal spasm; LES-Lower esophageal sphincter; *elevated

One patient had a normal stationary motility but there was evidence of increased high amplitude simultaneous contractions on an ambulatory motility study. Complete relief of symptoms was achieved in 11 of the 13 operated patients. One patient complained of heartburn and there was one mortality in the series resulting from myocardial infarction.

This study shows that there is a high prevalence of a named motility disorder associated with epiphrenic diverticula. The importance of an adequate esophageal myotomy guided by the manometric findings combined with an antireflux procedure is emphasized.