Is resection of an esophageal epiphrenic diverticulum always necessary in the setting of achalasia?

Abstract

Esophageal epiphrenic diverticulum (ED) is usually secondary to a primary esophageal motility disorder, such as achalasia. Whereas the recommended surgical treatment includes esophageal myotomy and diverticulectomy, the outcome of patients in whom a myotomy without ED resection is performed is not known. The purpose of this study was to compare the outcome of ED patients who underwent ED resection and myotomy and those of ED patients who had a myotomy only. Retrospective review of a prospective database. Thirteen ED patients had symptom evaluation, barium swallow, endoscopy, and esophageal high-resolution manometry (HRM). All patients underwent laparoscopic myotomy and Dor fundoplication. In six patients, the ED was resected (excised ED group), whereas in seven it was left in place (nonexcised ED group): in three because it was small and in four for technical reasons. Preoperatively all patients had dysphagia and 85 % had regurgitation. The mean preoperative Eckardt score was 6.5 ± 2.1 in excised ED group and 6.6 ± 3.3 in nonexcised ED group (p = 0.95). HRM showed type II esophageal achalasia in 85 % of patients. One excised ED group patient had a staple line leak (17 %). At a median follow-up of 2 years, the Eckardt score was 0 in excised ED group and 0.1 in nonexcised ED group (p = 0.56). The results of this study showed that patients in whom a myotomy without ED resection was performed had resolution of their symptoms. These findings suggest that in patients with achalasia and ED the underlying motility disorder rather than the ED may be the cause of symptoms. Studies with a larger number of patients and a longer follow-up will determine the validity of this approach.