Epiphrenic Diverticulum Research Articles

Locally Advanced Esophageal Cancer Arising from an Epiphrenic Diverticulum Treated by Curative Esophagectomy Combined with Adjacent Organs Resection

Locally Advanced Esophageal Cancer Arising from an Epiphrenic Diverticulum Treated by Curative Esophagectomy Combined with Adjacent Organs Resection

Per-oral endoscopic myotomy with endoscopic septum division in a case of achalasia with large epiphrenic diverticulum.

Per-oral endoscopic myotomy with endoscopic septum division in a case of achalasia with large epiphrenic diverticulum.

Thoracoscopic Esophagectomy for a Patient With Perforated Esophageal Epiphrenic Diverticulum After Kidney Transplantation: A Case Report

A 58-year-old man who underwent cadaveric kidney transplantation twice presented to hospital with a perforated epiphrenic diverticulum. Computed tomography revealed epiphrenic diverticulitis and right pleural effusion. Upper gastrointestinal fibroscopy showed an epiphrenic diverticulum full of food residue. He was transferred to our hospital, where we performed percutaneous endoscopic gastrostomy under general anesthesia in the supine position before thoracoscopy. Thoracoscopic esophagectomy was performed in the semi-prone position under 6–10 mmHg artificial pneumothorax via the right thoracic cavity. We performed subtotal esophagectomy to remove sources of infection because the esophageal wall surrounding the diverticulum was too thick to close or to perform diverticulectomy. A cervical esophagostomy was constructed after the thoracic procedure. The patient was managed with continuous hemodiafiltration and administered immunosuppressants and steroids to preserve the transplanted kidney. Continuous hemodiafiltration was stopped on postoperative day (POD) 4. The patient was discharged from the intensive care unit on POD 10 and transferred to the original hospital on POD 24 for rehabilitation. The second operative stage was performed on POD 157 at our hospital. We performed gastric tube reconstruction via the ante-sternal route and anastomosed the tube to the cervical esophagus. The postoperative course was uneventful; the patient was transferred to the original hospital on POD 15 after the second operation. Minimally invasive surgery was sufficient to treat perforated epiphrenic diverticulum while preserving the transplanted kidney. We recommend completely removing the source of infection and reducing surgical invasiveness to preserve the transplanted kidney in cases of esophageal perforation following kidney transplantation.

Epiphrenic Diverticulum: 20-Year Single-Institution Experience

Epiphrenic diverticula are pulsion-type outpouchings of the distal esophagus associated with motility disorders. They can present with chronic symptoms of dysphagia, regurgitation, reflux, and aspiration. A prospectively collected surgical outcomes database was queried for patients who underwent surgical treatment of epiphrenic diverticula at a single institution between August 1997 and August 2018. Patient demographics, presenting symptoms, operative intervention, and perioperative data were retrospectively reviewed. Twenty-seven patients with a symptomatic epiphrenic diverticulum were identified. Abnormal esophageal motility was diagnosed in 16 patients (59.2%), most commonly achalasia (29.6%). All patients had a minimally invasive (26 laparoscopic, one thoracoscopic) diverticulectomy with no conversions to open required. Concurrent myotomy was performed in 88.9 per cent patients and anti-reflux procedure in 85.2 per cent patients. There was minimal morbidity with no esophageal leaks, mortalities, or recurrent diverticula noted after 35.8 months of follow-up. Dysphagia was the most common persistent symptom and occurred in 11.1 per cent; overall resolution of symptoms was achieved with surgery in 89.9 per cent of patients. As minimally invasive techniques have advanced, laparoscopic diverticulectomy seems to be an excellent surgical approach for symptomatic epiphrenic diverticula. Long-term resolution of symptoms was achieved in most patients, with a very low complication rate.

Su1139 PRIMARY STUDY ON SUBMUCOSAL TUNNELING ENDOSCOPIC SEPTUM DIVISION FOR ESOPHAGEAL DIVERTICULUM

Submucosal tunneling endoscopic septum division (STESD) is a minimal invasive surgical therapy for esophageal diverticulum. This study is to evaluate the efficacy and safety of this operation. Patients with typical symptoms (dysphagia, regurgitation, foreign body sensation, etc.) who received STESD during April 2016 to June 2017 were included in this study. Patients with atypical symptoms or those with other esophageal motility disorders were excluded. STESD was performed by 4 steps: 1) mucosal incision; 2) submucosal tunneling; 3) septum division; and 4) mucosal closure. SF-36 health survey was used for the assessment of quality of life. A total of 8 patients were included in this study, the mean age was 59.9 years old (range, 39-80). There were 3 male patients and 5 females. Among them, 3 (3/8, 37.5%) were diagnosed with Zenker’s diverticulum, 4 (4/8, 50.0%) were diagnosed with epiphrenic diverticulum, 1 (1/8, 12.5%) was diagnosed with mid-esophageal diverticulum. The mean procedure time was 47.0 mins (range, 22-106mins, SD, 27.6mins). The mean of hospital stay after surgery was 4.3 days (range, 3-9days, SD, 2.0days). Mucosal injury was found in 2 patients during the procedure, and was closed by hemostatic clips, no major adverse event was found during hospital stay or after discharge. The depth of diverticulum (vertical distance from the septum to the bottom) was 23.13±8.43mm before and 19.25±8.88mm after STESD (mean±SD, p=0.281, two-tail-t-test). 2 patients (2/8, 25.0%) were completely symptom-free, 5 (5/8, 62.5%) reported relieved symptoms after the procedure, and only one (1/8, 12.5%) complained no significant change after the surgery (Table 1). One patient was lost to follow up the SF-36 scale. In patients who accomplished the follow-up, the total score of SF-36 was 112.1±27.1 before and 134.9±10.0 after the procedure (mean±SD, p=0.034, t-test). Among 8 sub-scales analysis of SF-36, GH (general health) and VT (vitality) analysis after surgery showed significant improvement with those before surgery (p=0.018 in GH, p=0.013 in VT, t-test). Various degrees of weight gain after STESD were observed, except one patient who lost weight through exercising. Submucosal tunneling endoscopic septum division can efficiently improve patients’ quality of life, especially in general health and vitality. Furthermore, based on our pilot study to date, this procedure is safe, although prospective studies in large scales are still needed.Tabled 1Table 1. Main symptoms before and after STESDCaseSiteBeforeAfterMain SymptomSeverityFrequencyMain SymptomSeverityFrequency1Zenker’sChest tightnessModerateEverydayChest tightnessMildEverydayForeign body sensationModerateEveryday---2EpiphrenicRegurgitation of foodSevere1∼2/monthAcid refluxModerate3∼4/half a year3EpiphrenicDysphagiaSevereEverydayDysphagiaModerateEverydayRegugitation of foodMild1∼2/weekAcid refluxModerate1∼2/week4EpiphrenicDysphagiaSevereEveryday---5Zenker’sDysphagiaSevereEveryday------Foreign body sensation*Mild2∼3/week6EpiphrenicDysphagiaModerateEveryday------Gurgling after meal*Mild3∼4/week7Zenker’sDysphagiaSevereEveryday---8**Mid-esophagealDysphagiaSevereEverydayDysphagiaMild3∼4/weekAcid refluxModerateEveryday---*Emerging symptoms **Lost to follow-up at 4-month after STESD Open table in a new tab

AB017. 94. Case report: surgical management of a large epiphrenic diverticulum

: Oesophageal diverticula are classified by location (pharyngeal, parabronchial or epiphrenic), by pathophysiology (traction or propulsion) and histopathology (true or false diverticula). Epiphrenic diverticula are pulsion diverticula that occur in the distal 10 cm of oesophagus and are associated with oesophageal motility disorders. Oesophageal mucosa and submucosa herniate through the muscular layers resulting in dysphagia, food regurgitation and even aspiration pneumonia. A 63-year-old man was referred with a 1-year history of progressive dysphagia to solids, food regurgitation and halitosis and a recent in-hospital admission with right middle lobe pneumonia. Investigations included a barium swallow, upper endoscopy, and high resolution impedance manometry (HRiM) which diagnosed a right sided epiphrenic diverticulum. HRiM confirmed an oesophagogastric junction (OGJ) outflow obstruction. A thoracoscopic diverticulectomy was performed. In the left lateral decubitus position a 5-port thoracoscopy was performed. Dissection begun by dividing the mediastinal pleura over the oesophagus. The diverticulum was mobilized and the neck of the diverticulum isolated. A 54-Fr bougie was placed into the oesophagus over a guidewire. A longitudinal myotomy was performed distal to the diverticulum to the OGJ to relieve the distal obstruction and prevent recurrence. Once haemostasis was achieved a 16-Fr chest drain and Jackson-Pratt drain were placed and incisions closed in layers. This patient underwent a thoracoscopic diverticulectomy and longitudinal myotomy without complication. A gastrografin swallow on day 3 confirmed an intact staple line and a straight oesophagus.

幽門側胃切除後に横隔膜上憩室を合併した食道アカラシアに対する手術経験

幽門側胃切除後に横隔膜上憩室を合併した食道アカラシアに対する手術経験

Laparoscopic Surgery for Epiphrenic Esophageal Diverticulum.

Background and Objectives:We wanted to assess our surgical results focusing on the patients' quality of life. We present our experience with laparoscopic surgery for epiphrenic esophageal diverticulum. Short- and long-term results of surgical therapy were analyzed.Methods:Eight patients were examined with a symptom-causing epiphrenic diverticulum. Patients underwent complex gastroenterologic examinations before and after surgery. Laparoscopic transhiatal epiphrenic diverticulectomy, Heller cardiomyotomy, and Dor anterior partial fundoplication were performed on 7 patients. One patient underwent only diverticulectomy, where no motility disorder was present. Results from surgical treatments and changes in patients' pre- and postoperative complaints were evaluated.Results:In all cases except 1, the preoperative examination showed dysmotility of the esophagus. The average duration of the surgeries was 165 (130–195) minutes; blood loss was minimal. One patient developed bleeding in the early postoperative period, and a second laparoscopy was required. No other intraoperative complication was detected, and no mortality occurred. In one case, a staple line leak developed (1/8 [12.5%]), which was resolved with conservative therapy. Functional check-ups confirmed adequate esophageal function. The total symptom score for the patients was 6.3 points before surgery, and it decreased to 1.6 (P < .001) after surgery, an average of 74% subjective improvement. During the follow-up period (mean, 60 months; 10–138 months), proton pump inhibitor therapy was started in 4 patients to treat gastroesophageal reflux. In 3 cases, drug therapy was successful; in one case, Nissen antireflux surgery was performed.Conclusion:Laparoscopic transhiatal diverticulectomy and Heller–Dor surgery are effective interventions with low morbidity. Patient quality of life significantly improves in the long term, but gastroesophageal reflux disease may occur.

Achalasia Associated With Esophageal Intramural Pseudodiverticulosis: A Rarely Reported Condition

Intro: Esophageal intramural pseudodiverticulosis (EIP) is a benign, rare condition that most commonly presents in patients ages 50-70. It is often associated with diabetes mellitus, chronic alcoholism, malnutrition, or achalasia as depicted in the case below. It was first reported in 1960 with roughly 250 cases worldwide, and only 2 reports are associated with achalasia.Figure: Barium esophagram showing multiple classic button and flask shaped EIP in the upper esophagus.Figure: Barium esophagram depicting dilatation of the mid esophagus with tortuosity of the mid to distal portion.Case: An 87 year old male with a history diabetes and progressive dysphagia with regurgitation of solids and liquids over many years presented to the ER in septic shock secondary to aspiration pneumonia. He had endoscopy three years prior showing candidal esophagitis, epiphrenic diverticulum, and a schatzki ring. Follow-up endoscopy revealed tertiary contractions and he was prescribed a calcium channel blocker, which he did not take. Two months prior to this admission, a barium esophagram showed dilatation of the mid esophagus, several pseudodiverticula in the upper esophagus, tortuosity of the mid to distal portion, a 4.2x4.3cm epiphrenic esophageal diverticulum proximal to the gastroesophageal junction, silent aspiration of contrast, incomplete emptying and regurgitation to the oropharynx. High resolution manometry was significant for esophageal aperistalsis and lower esophageal sphincter pressure indicating achalasia. He presented with aspiration before achieving outpatient management. Given the patient's age and multiple comorbidities, palliative endoscopic treatment was given with botox injection and symptomatic improvement.Figure: Barium esophagram depicting a large 4.2x4.3 cm epiphrenic esophageal diverticulum proximal to the gastroesophageal junction, and regurgitation of contrast into the upper esophageal pseudodiverticula.Discussion: EIP is a rare condition caused by reactive hypertrophy and increased intramural pressure creating dilation and outpouching of the esophageal submucosal gland excretory ducts caused by a distal obstruction from chemical, infectious, or mechanical processes, such as achalasia. Dysphagia, reflux, and odynophagia are common presenting symptoms with stricture formation in up to 90% of cases. Barium esophagram shows flask or button-shaped outpouchings and may reveal dysmotility. The main goal of treatment is to correct the underlying disorder, which involved botox injection to palliate the patient's achalasia. EIP is generally benign though complications include aspiration pneumonia, candidal infection, fistulas, mediastinitis, and perforation. We present this case to raise physician awareness of this rare condition to aid in prompt diagnosis and management, in hopes of avoiding complications that result in increased patient morbidity and mortality.

Clinical Utility of Imaging Following Peroral Endoscopic Myotomy

Introduction: Per-oral endoscopic myotomy (POEM) is a safe and effective endoscopic procedure primarily for treatment of esophageal motility disorders. In recent studies, it has been shown to have similar efficacy when compared to Heller myotomy, and is associated with fewer complications and shorter recovery times. Post-POEM imaging protocols vary from hospital to hospital but are all designed to detect complications of the procedure. At our center, post procedure protocol included a CXR, performed immediately following POEM, as well as gastrograffin swallow study, performed 1 day after POEM. We evaluate the clinical utility of post-POEM imaging with CXR and/or gastrograffin swallow study. Methods: This was a retrospective study performed at a tertiary care university-setting hospital over a period of 3 years from December 2013-April 2017. POEM procedures were performed under general anesthesia using the previously described technique (Figure 1). Indications for POEM included achalasia, esophagogastric junction outlet obstruction, nutcracker esophagus, and epiphrenic diverticulum with or without previous unsuccessful pneumatic dilation, botulinum toxin, and/or Heller myotomy. CXR was performed immediately following POEM and gastrograffin swallow study was performed on post-operative day 1 well as 3-4 weeks following the procedure.Figure: (a) Mucosal incision after submucosal injection, (b) creation of submucosal tunnel via endoscopic submucosal dissection, (c) completed submucosal tunnel (d) circular muscle myotomy, (e) completed myotomy and, (f) closure of mucosal entry with clips.Results: POEM was performed on 79 patients with mean age of 55 years and a total of 46 males (58%). Details of indication for POEM and prior treatment are summarized in Table 1. Of the 79 patients, 65 patients underwent CXR immediately post-op with 36 patients having a normal CXR (46%). None of the patients required intervention based on CXR findings, summarized in Table 2. 68 of the 79 patients underwent gastrograffin swallow study 24 hours after POEM. Findings concerning for contrast leak were identified in 2 patients (Figure 2), both of whom were asymptomatic. The second patient underwent repeat EGD with fluoroscopy within 24 hours of the initial POEM, with no active contrast leak. All patients were discharged w/in 24-48 hours after POEM and were followed up in 4-6 weeks. No early (24-48 hours) or delayed (4-6 weeks) post-op events were noted.Figure: (a) Patient one post-op gastrograffin study with small contained submocosal leak at the site of the surgical clips (b) Patient two post-op gastrograffin study showing a linear tract of contrast coursing towards the right mediastinum.Table: Table. Indication for POEM and Prior TreatmentsTable: Table. Summary of CXR Findings and Interventions Based off of CXR FindingsConclusion: Our findings suggest that CXR as well as gastrograffin swallow study within 24 hours of POEM are of low clinically yield and should only be considered in patients who are symptomatic. Based on our findings, we suggest that if a patient is clinically stable, they can be discharged without any imaging.

Effects of Antibiotic Flush into the Submucosal Tunnel During Peroral Endoscopic Myotomy

Introduction: Per-Oral Endoscopic Myotomy (POEM) is a relatively novel endoscopic treatment option for management of esophageal motility disorders. Antibiotics such as bacitracin (6% solution) is often flushed in to the submucosal tunnel during the procedure and the usefulness of this is unclear. Our aim was to evaluate the effect and outcomes of antibiotic flush in to the submucosal tunnel during the POEM. Methods: This was a retrospective cohort study performed at a tertiary care university-setting over a period of 3 years. POEM was performed in patients diagnosed with achalasia, esophagogastric junction (EGJ) outlet obstruction, nutcracker esophagus, or epiphrenic diverticulum with or without previous unsuccessful pneumatic dilation, botulinum toxin, and/or Heller myotomy. All patients who received antibiotic flush in to the submucosal tunnel during the POEM were compared with those who did not receive the antibiotic flush. The outcomes were compared based on the Eckardt scores (pre and 4-6 weeks after POEM), symptomatology immediately after POEM (< 24 hours), and any adverse events post POEM. Fisher's exact test and Student t-test were used for statistical analysis. Results: POEM was performed on a total of 79 patients with a mean age of 55 years. Of the 79 patients, 46 (58%) were males. Three patients were excluded as one patient developed cardiac arrest with return of spontaneous circulation during the POEM, and there was no documentation regarding antibiotic flush in 2 patients. Of the 79 patients, initial 35 received antibiotic flush during POEM (cases). Pre-POEM Eckardt scores for the cases and control were 4.66 and 5.84 respectively. The post POEM Eckardt scores for those exposed to antibiotics and not were 0.58 and 0.48 respectively (p=0.59). Severe chest pain requiring narcotics immediately after the POEM was noted in 6 (17.1%) patients from the antibiotic group however, only one patient (2%) experienced severe chest pain in the control group (p=0.11). No major immediate post-op symptoms or complications were noted in either group. None of the patients in either group required any intervention including repeat POEM after the initial POEM procedure. There were no cases of infection. Conclusion: Antibiotic flush into the submucosal tunnel during POEM does not seem to be of any benefit. Although patients with antibiotic flush seem to experience severe chest pain requiring narcotics more often immediately following POEM, statistical significance was not observed.

A superficial esophageal cancer in an epiphrenic diverticulum treated by endoscopic submucosal dissection

BackgroundWe report a unique case of a superficial esophageal cancer arising in a single diverticulum, diagnosed with magnifying image-enhanced endoscopy and then successfully treated by endoscopic submucosal dissection (ESD).Case presentationA 66-year-old man with alcohol-related liver injury visited our hospital for endoscopy for investigation of varix. Esophagogastroduodenoscopy showed no varix but a large epiphrenic diverticulum with an area of fainted redness just above the esophagogastric junction. Narrow band imaging revealed a sharply demarcated brownish dotted area, and dilated intra-epithelial papillary capillary loops (IPCL) were subsequently seen after magnification. Chromoendoscopy with 1% Lugol’s iodine solution demonstrated a well-demarcated unstained area, approximately 20 mm in diameter. Endoscopic biopsy revealed a squamous cell carcinoma (SCC).ConclusionThe tumor was completely resected by ESD without perforation. Histologically, it was an intraepithelial SCC without lympho-vascular invasion of cancer cells. No local recurrence or metastasis was detected at the last follow-up of 42 months.

Surgical management of epiphrenic diverticulum: A single-center experience and brief review of literature

BackgroundWe present single-center experience of surgery for primary epiphrenic diverticulum (PED) over a 12-year period. MethodsProspectively maintained database was queried to identify patients who underwent PED surgery. Preoperative and postoperative symptoms, operative data, perioperative complications, and follow-up were reviewed. ResultsTwenty-seven patients (14 females; mean age–67-years) underwent PED surgery. The most common primary presenting symptoms were dysphagia and regurgitation (mean duration–3.6-years). 82% patients underwent laparoscopic procedures (one conversion), 11% operated via left thoracotomy and 7% via combined laparoscopy–right trans-thoracic approach. All patients received myotomy, all but one received diverticulectomy. Five-patients experienced intraoperative complications that were managed intraoperatively without sequelae. There was no perioperative mortality. Morbidity was seen in 3-patients, including one staple-line leak managed with endoscopic washes and stent placement. 90% patients with ≥1-year follow-up reported “excellent” satisfaction. ConclusionsMinimally invasive surgery for PED is both feasible and safe. We observed low morbidity, short hospital stay, and excellent patient-reported outcomes.

Relief of dysphagia due to advanced achalasia by endoscopic creation of an esophagogastric bypass anastomosis through an epiphrenic diverticulum.

Relief of dysphagia due to advanced achalasia by endoscopic creation of an esophagogastric bypass anastomosis through an epiphrenic diverticulum.

Multiple huge epiphrenic esophageal diverticula with motility disease treated with video-assisted thoracoscopic and hand-assisted laparoscopic esophagectomy: a case report

BackgroundEpiphrenic esophageal diverticulum is a rare condition that is often associated with a concomitant esophageal motor disorder. Some patients have the chief complaints of swallowing difficulty and gastroesophageal reflux; traditionally, such diverticula have been resected via right thoracotomy. Here, we describe a case with huge multiple epiphrenic diverticula with motility disorder, which were successfully resected using a video-assisted thoracic and laparoscopic procedure.Case presentationA 63-year-old man was admitted due to dysphagia, heartburn, and vomiting. An esophagogram demonstrated an S-shaped lower esophagus with multiple epiphrenic diverticula (75 × 55 mm and 30 × 30 mm) and obstruction by the lower esophageal sphincter (LES). Esophageal manometry showed normal peristaltic contractions in the esophageal body, whereas the LES pressure was high (98.6 mmHg). The pressure vector volume of LES was 23,972 mmHg2 cm. Based on these findings, we diagnosed huge multiple epiphrenic diverticula with a hypertensive lower esophageal sphincter and judged that resection might be required. We performed lower esophagectomy with gastric conduit reconstruction using a video-assisted thoracic and hand-assisted laparoscopic procedure. The postoperative course was uneventful, and the esophagogram demonstrated good passage, with no leakage, stenosis, or diverticula.ConclusionsThe most common causes of mid-esophageal and epiphrenic diverticula are motility disorders of the esophageal body; appropriate treatment should be considered based on the morphological and motility findings.

Epiphrenic diverticulum of esophagus: a rare case report

A rare acquired epiphrenic diverticulum of esophagus was identified in a 60-year-old male patient. He was presented with 8 months history of dysphagia and regurgitation. Barium swallow study and upper gastrointestinal endoscopy confirmed the diagnosis and showed normal mucosa. No suspicion of malignancy was present. Manometry was normal. The diverticulum was surgically excluded by continuous suturing, along with esophagomyotomy. Avoidance of diverticulectomy facilitated early oral feeding and speedy recovery.

Type III Achalasia Cardia with Epiphrenic Diverticulum Treated By Subtotal Esophagectomy

Type III Achalasia Cardia with Epiphrenic Diverticulum Treated By Subtotal Esophagectomy

Achalasia associated with two epiphrenic diverticula.

Achalasia associated with two epiphrenic diverticula.

Surgical Treatment of Epiphrenic Diverticulum: Technique and Controversies.

The goal of this article is to illustrate the current minimal invasive approaches to patients with epiphrenic diverticulum in terms of preoperative evaluation, surgical technique, and outcomes. Two techniques will be presented: a laparoscopic and a video-assisted thoracic repair. Indications for each technique will be discussed as well as proper patient selection and management. Current controversies in the treatment of patients with this rare disease will be addressed.

A combined thoracoscopic and laparoscopic approach for high epiphrenic diverticula and the importance of complete myotomy.

The traditional approach to epiphrenic diverticula is thoracotomy and diverticulectomy, together with myotomy±partial fundoplication to address underlying dysmotility. A laparoscopic approach has been advocated but access to more proximal diverticula is problematic. We propose the selective addition of a thoracoscopic approach to overcome these challenges and reviewed our results. A retrospective review from 2004 to 2015 identified 17 patients with an epiphrenic diverticulum who underwent surgery. Patients were grouped according to height of the diverticular neck (HDN) above the GEJ: group A<5cm, group B>5cm. Preoperative evaluation and type of surgery performed were recorded. Postoperative complications, mortality, and clinical outcomes using quality of life metrics and objective testing were assessed. The mean size of the diverticulum was 3.3cm (2-6cm) with a mean height above the GEJ of 5.5cm (0-12cm). A motility disorder was identified in 15/17. Group A, 9 patients, underwent laparoscopic diverticulectomy, myotomy, and partial fundoplication. For group B, 8 patients, the intended procedure was thoracoscopic diverticulectomy followed by laparoscopic myotomy and partial fundoplication, but this was only completed in 5. In 3 the myotomy was aborted or incomplete with subsequent staple line leaks resulting in 1 death. At a mean follow-up of 21months, improvement of median QOLRAD scores from 3.42 to 6.2 (p=0.18); GERD-HRQL from 23 to 1 (p=0.05), swallowing score from 17.5 to 30 (p=0.22), and Eckardt scores from 5 to 0 (p<0.05) were observed. A minimally invasive strategy for epiphrenic diverticula based HDN above the GEJ and selective thoracoscopy for higher diverticula is feasible and appropriate, and resulted in improved quality of life. Incomplete myotomy was associated with a substantially higher complication rate. Laparoscopic myotomy should precede diverticulectomy for all cases, especially for high diverticula.