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.
