Epiphrenic Diverticulum Research Articles

Greater-curvature peroral endoscopic myotomy with diverticuloseptotomy for the treatment of achalasia in a patientwith a large epiphrenic diverticulum.

Greater-curvature peroral endoscopic myotomy with diverticuloseptotomy for the treatment of achalasia in a patientwith a large epiphrenic diverticulum.

Epiphrenic diverticula: An added source of complexity in achalasia management

Epiphrenic (pulsion) esophageal diverticula can occur in the setting of underlying esophageal motility disorders such as achalasia and present a unique management challenge to the gastroenterologist. Asymptomatic diverticula do not require treatment, but symptomatic diverticula require therapy targeted to the underlying esophageal motility disorder, or else the diverticula will recur. Generally, laparoscopic or combined laparoscopic/thoracoscopic myotomy, diverticulectomy, and anterior fundoplication are required. However, therapeutic options for epiphrenic diverticula are evolving as peroral endoscopic myotomy (POEM) becomes more commonplace. We review two cases of achalasia complicated by epiphrenic diverticula at our institution. In the first case, type II achalasia was identified and the patient underwent laparoscopic myotomy. In the second case, type III achalasia was present and the patient underwent successful POEM. We discuss the presentation, pathophysiology, and management of epiphrenic diverticula as well as the expanding role for POEM in diverticula.

Operative technical tricks and 12-month outcomes of diverticular peroral endoscopic myotomy (D-POEM) in patients with symptomatic esophageal diverticula.

Submucosal tunneling diverticular septotomy by diverticular peroral endoscopic myotomy (D-POEM) has emerged as an alternative to surgery for symptomatic esophageal diverticula, but its medium to long-term outcomes are currently unexplored. D-POEM for patients with symptomatic esophageal diverticula was prospectively studied to assess its safety and the 12-month outcomes. 25 patients (72 % male; median age 61 years [range 48 - 88]) with a Zenker's diverticulum (n = 20) or epiphrenic diverticulum (n = 5) were included. Major indications were dysphagia, recurrent bronchoaspiration, and foreign body sensation in 20 patients (80 %), with a mean symptom duration of 2.5 years (range 1 - : 4). Complete submucosal tunneling septotomy was achieved in a mean of 36 minutes (range 25 - : 45), with 100 % technical success. The median hospitalization was 5 days (range 4 - : 10). The mean (standard deviation) Eckardt Score improved significantly from 13.2 (1.0) at baseline to 3.2 (1.4) at 12 months (P < 0.001) with clinical success in 19/22 patients (86 %) and no long-term adverse events. D-POEM appears safe and durable in patients with esophageal diverticula. Further multicenter studies with a larger patient cohort are warranted.

3109 A Rare Cause of Dysphagia—Epiphrenic Diverticulum

INTRODUCTION: An epiphrenic diverticulum is a rare, benign disorder of the distal esophagus characterized by protrusion of the esophageal mucosa through the musclular layer, proximal to the gastroesophageal junction. They are false diverticula mainly associated with motility disorders. The most frequent symptoms experienced by patients are dysphagia, regurgitation, and aspiration, but most cases are usually asymptomatic. We present a rare case of epiphrenic diverticulum in a 71-year-old male. CASE DESCRIPTION/METHODS: The patient is a 71 year-old man with a medical history of cerebrovascular accident (with residual left sided weakness, and chronic encephalopathy), and hypertension who presented to our emergency department after family members noticed he was unable to tolerate oral intake and had multiple episodes of vomiting over the past two days. Notable imaging in the emergency department included a computed tomography (CT) of the chest which showed irregular wall thickening in the distal esophagus suggestive of a neoplasm. Laboratory workup including a complete blood count and comprehensive metabolic panel were within normal limits. Upon admission the gastroenterology service was consulted who recommended the patient undergo esophagogastroduodenoscopy (EGD) to rule out malignancy. Given the risks associated with EGD the patients family refused the procedure. They did however agree to a barium swallow to better evaluate the esophagus. This was done and showed an epiphrenic diverticulum in the distal esophagus (Figure 1). After this was discovered the patients family refused any intervention including EGD or surgery. During his admission the patient was able to tolerate a pureed diet and his medications were crushed which were also tolerated appropriately. He was then discharged home with follow up appointments scheduled. DISCUSSION: Esophageal diverticula are uncommon acquired disorders of the esophagus that have an estimated incidence of 1 in 500,000 people per year. As opposed to Zenkers diverticula which occur in the proximal esophagus, epiphrenic diverticula are rarer and occur in the distal esophagus. To put its rarity into context the estimated ratio of epiphrenic divertila to zenkers diverticula is 1:5. Although most cases are asymptomatic, some cases may present with dysphagia, regurgitation of undigested food, heartburn and aspiration pneumonia. Surgical resection is the treatment of choice, but endoscopic procedures such as per-oral endoscopic myotomy are challenging that concensus.

3093 Epiphrenic Diverticula: An Added Source of Complexity in Achalasia Management

INTRODUCTION: Epiphrenic esophageal diverticula are rare and almost always associated with an underlying esophageal motility disorder. Therapeutic options for epiphrenic diverticula are evolving as per oral endoscopic myotomy (POEM) is increasingly being used for treatment of achalasia. We present two cases of epiphrenic diverticula associated with achalasia at our institution and review the clinical presentation, pathophysiology, and current management of epiphrenic diverticula. CASE DESCRIPTION/METHODS: Case 1 A 77 year old female presented with dysphagia. An esophagram showed two diverticula with a distal narrowing. Upper endoscopy showed two epiphrenic diverticula and a narrowed gastroesophageal junction. Manometry showed an elevated median IRP of 22.5 mmHg and pan-esophageal pressurization with all swallows, consistent with type II achalasia. A CT scan of the chest did not show any evidence of malignancy. She is currently seeking a surgical opinion for consideration of myotomy. Case 2 A 66 year old male presented with dysphagia. An esophagram showed marked dysmotility with a 1.8 cm epiphrenic diverticulum. Upper endoscopy confirmed the presence of the diverticulum. Subsequent manometry showed a median IRP of 28.8 mmHg and spastic contractions in all swallows consistent with type III achalasia. Given his type III achalasia and the smaller size of the diverticulum, he was referred for consideration of POEM. DISCUSSION: Esophageal diverticula can be grouped into pharyngoesophageal, mid-esophageal, and epiphrenic diverticula. Epiphrenic diverticula are “false” diverticula, with herniation of the mucosa and submucosa only, that occur due to increases in intraluminal pressure. They are associated with major esophageal motility disorders. Management of epiphrenic diverticula requires addressing the underlying motility disorder, or else the diverticula may recur after diverticulectomy. Generally, laparoscopic or combined laparoscopic/thorascopic myotomy, diverticulectomy and anterior fundoplication is required. The overall mortality rate for surgical management of epiphrenic diverticula is around 5%, with morbidity rate as high as 20%. POEM without diverticulectomy has also been described for patients who either decline surgical intervention or are not surgical candidates. As POEM technique is refined for this indication, management of epiphrenic diverticula will require close collaboration between gastroenterologists, advanced endoscopists, and surgeons for selection of the optimal treatment for each patient.

The Abdominal Approach for Epiphrenic Esophageal Diverticulum as an Alternative to the Thoracic Approach.

BackgroundThere is no established surgical procedure for the treatment of epiphrenic esophageal diverticulum. The aim of this study was to compare the clinical outcomes of esophageal diverticulectomy using abdominal and thoracic approaches.MethodsWe retrospectively reviewed 30 patients who underwent esophageal diverticulectomy through the thoracic or abdominal approach for an epiphrenic diverticulum at a single center between 1996 and 2018. We compared clinical outcomes, including the postoperative length of stay, time from the operation to oral feeding, leakage rate, and reoperation rate between the 2 groups.ResultsThe median age was 56 years. Of the 30 patients, 18 (60%) underwent diverticulectomy via the thoracic approach and 12 (40%) underwent the abdominal approach. The median hospital stay was 10 days (range, 5–211 days) in the thoracic approach group and 9.5 days (range, 5–18 days) in the abdominal approach group. The median time from the operation until oral feeding was 6.5 days (range, 3–299 days) when the thoracic approach was used and 5 days (range, 1–11 days) when the abdominal approach was used. In the thoracic approach group, the leakage rate was 16.67% and the reoperation rate was 27.78%. However, there were no cases of leakage or reoperation in the abdominal approach group.ConclusionThe abdominal approach for esophageal diverticulectomy is a feasible and appropriate alternative to the thoracic approach.

A Case Report of an Epiphrenic Esophageal Diverticulum was Treated via Laparoscopic Transhiatal Diverticulectomy

A Case Report of an Epiphrenic Esophageal Diverticulum was Treated via Laparoscopic Transhiatal Diverticulectomy

Intraoperative Intraluminal Endoscopy in the Surgical Treatment of Patients with Esophageal Diverticula of Various Localization

Aim. To improve the results of surgical treatment of patients with esophageal diverticulum of various localization using intraoperative intraluminal endoscopy. Materials and Methods: The Department of Surgery of the Esophagus and Stomach, the Petrovsky National Research Centre of Surgery, has accumulated a large experience in treating diverticulosis patients. Thus, during the 2010–2018 period, 74 patients with esophageal diverticula of various localization were operated. Out of them, 56 (75.7 %), 10 (13.5 %) and 8 (10.8 %) patients underwent surgical treatment with respect to faringo-esophageal, bifurcation and epiphrenic diverticula, respectively. The patients were divided into two groups: 31 people (41.9 %) in the main group underwent diverticulectomy with intraoperative intraluminal endoscopic assistance (IVEA), while 43 (58.1 %) people in the control group underwent diverticulectomy without IVEA. Intraoperatively, at the stage of discovering diverticulum, the endoscopist applied transillumination and air insufflation in the cavity of the diverticulum, followed by controlling the mobilization of diverticulum. At the resection stage, the completeness of the surgical removal was controlled, along with the absence of esophageal lumen narrowing after sewing the neck of the diverticulum using a linear stapler.Results. The average duration of the operation in patients with Zenker’s diverticula and those in the control group was 45.5 ± 8.8 min and 73.8 ± 12.7 min (p &lt; 0.05), respectively. In patients with the diverticula of the middle and lower third of the esophagus, the average surgery duration was equal to 120.3 ± 11.2 min and 150.5 ± 17.3 (p &lt;0.05) min in the main and control groups, respectively. Radiological examination 2–3 days after surgery revealed no complications in the main group. In the control group, 2 (4.7 %) patients showed a small leakage of the contrast agent outside the esophagus (stopped conservatively). Signs of mild dysphagia when taking solid foods were detected in 1 (2.4 %) patient of the control group. This condition was associated with excessive ingress of the esophageal wall into the apparatus suture, which led to a slight narrowing of its lumen. No patients with dysphagia in the postoperative period were recorded in the main group. Conclusion: The combination of surgical treatment of esophageal diverticula with IVEA allows the duration of surgery to be optimized, deformation of the esophageal lumen to be avoided, possible complications to be minimized, thereby improving the results of surgical treatment.

Dysphagia

Dysphagia may be oropharyngeal or esophageal. Evaluation is described, including a thorough dysphagia history of associated painful swallowing, location, solids versus liquids, intermittent versus progressive, acute versus gradual onset, and associated symptoms such as weight loss. Physical examination and key diagnostic tests are also reviewed. The evidence-based management of various etiologies of esophageal dysphagia are summarized. Motor disorders described include achalasia, the other primary esophageal motility disorders, and the most common secondary esophageal motility disorders. Esophageal diverticulae are also reviewed in this section. Mechanical esophageal obstruction is presented, including discussions of esophageal webs, rings, peptic stricture, and cancer. Important inflammatory and infectious causes of dysphagia are described, including caustic ingestion, eosinophilic esophagitis, and esophageal infections. The oral phases of liquid and solid swallowing are presented, as are the pharyngeal and esophageal phases of swallowing. Figures show the results of several diagnostic tests and other conditions, including pharyngeoesophageal diverticulum, giant epiphrenic diverticulum, Schatzki ring, and midesophageal squamous cell carcinoma. A flowchart outlines evaluation and management of dysphagia. This review contains 13 figures, 12 tables, and 68 references. Keyword: Esophageal cancer, Achalasia, Diffuse esophageal spasm, Esophageal ring, Peptic esophagitis, Eosinophilic esophagitis, Scleroderma, Esophageal stricture, Chagas disease, Stroke

Dysphagia

Dysphagia may be oropharyngeal or esophageal. Evaluation is described, including a thorough dysphagia history of associated painful swallowing, location, solids versus liquids, intermittent versus progressive, acute versus gradual onset, and associated symptoms such as weight loss. Physical examination and key diagnostic tests are also reviewed. The evidence-based management of various etiologies of esophageal dysphagia are summarized. Motor disorders described include achalasia, the other primary esophageal motility disorders, and the most common secondary esophageal motility disorders. Esophageal diverticulae are also reviewed in this section. Mechanical esophageal obstruction is presented, including discussions of esophageal webs, rings, peptic stricture, and cancer. Important inflammatory and infectious causes of dysphagia are described, including caustic ingestion, eosinophilic esophagitis, and esophageal infections. The oral phases of liquid and solid swallowing are presented, as are the pharyngeal and esophageal phases of swallowing. Figures show the results of several diagnostic tests and other conditions, including pharyngeoesophageal diverticulum, giant epiphrenic diverticulum, Schatzki ring, and midesophageal squamous cell carcinoma. A flowchart outlines evaluation and management of dysphagia. This review contains 13 figures, 12 tables, and 68 references. Keyword: Esophageal cancer, Achalasia, Diffuse esophageal spasm, Esophageal ring, Peptic esophagitis, Eosinophilic esophagitis, Scleroderma, Esophageal stricture, Chagas disease, Stroke

Revisional Surgery in Patients with Recurrent Dysphagia after Heller Myotomy

BackgroundRecurrent/persistent symptoms of achalasia occur in 10–20% of individuals after Heller myotomy. The causes and treatment outcomes are ambiguous. Our aim is to assess the causes and outcomes of a multidisciplinary approach to this patient population. MethodsAll patients undergoing revisional operations after a Heller myotomy were reviewed retrospectively. Data collected: demographics, date of initial Heller myotomy, preoperative evaluation, etiology of recurrent symptoms, date of revisional operation, and surgical outcomes. ResultsA total of 34 patients underwent 37 revisional operations. Operations were tailored based on preoperative multidisciplinary evaluation. Causes of symptoms: periesophageal/perihiatal fibrosis 11 (27%), obstructing fundoplication 11 (27%), incomplete myotomy 8 (20%), progression of disease 9 (22%), and epiphrenic diverticulum 1 (2%). Operations performed: reversal/no creation of fundoplication with or without re-do myotomy 22 (59%), revision/creation of fundoplication with or without myotomy 6 (16%), and esophagectomy 9 (24%). Ten patients in the 37 operations (27%) developed postoperative complications. Of 33 patients for 36 operations with follow-up, 25 patient-operations (69%) resulted in resolution or improved dysphagia. Although there was variation in symptomatic improvement by cause and operation type, none reached statistical significance. ConclusionThere are several causes of dysphagia after Heller myotomy and a thoughtful evaluation is required. Complication rates are higher than first-time operations. Symptomatic improvement occurs in the majority of cases, but a significant minority will have persistent dysphagia. Although an individualized approach to dysphagia after Heller myotomy may improve symptoms and passage of food, the perception of dysphagia may persist in patients.

Per-oral endoscopic myotomy for esophageal diverticula with or without esophageal motility disorders

Mid-esophageal and epiphrenic diverticula (MED) can be associated with esophageal motility disorders. Per-oral endoscopic myotomy (POEM) is an established treatment for esophageal motility disorders that has also been introduced for the treatment of MED. Data were prospectively collected from patients with MED treated with POEM at our institution. When esophageal motility disorders were present, myotomy was performed extending the myotomy to the lower esophageal sphincter (LES) to treat the motility dysfunction associated with the diverticulum. In the absence of esophageal motility disorder, POEM was performed without including the LES in the myotomy to achieve diverticulotomy. Four patients were treated with POEM for MED between April 2017 and March 2018. The patients suffered from distal esophageal spasm, jackhammer esophagus or esophago-gastric junction outflow obstruction. One patient had no esophageal motility disorder. Diverticulum size was 3 cm in one case and 6 cm in the others. Preoperative Eckardt scores ranged from 6 to 8. No life-threatening complications were reported. Intraoperative pneumoperitoneum was described in two cases and one patient experienced aspiration pneumonia. The patients with motility disorders were asymptomatic at 6-8 months follow-up. The patient without documented underlying esophageal motility disorder had an Eckardt score of 3 at 9-months follow-up. Two cases of gastro-esophageal reflux were successfully managed with proton pump inhibitors. In the case of MED and esophageal motility disorder, POEM permitted treatment of the underlying cause of the diverticulum, achieving favorable early clinical outcomes. In the absence of motility disorder, POEM was feasible with promising early outcomes, and could be a valid alternative to surgical diverticulectomy in selected patients.

Myotomy-First Approach to Epiphrenic Esophageal Diverticula.

Introduction: Epiphrenic esophageal diverticula are typically treated with concurrent cardiomyotomy and diverticulectomy. However, resection of these diverticula can be technically difficult and associated with significant morbidity with a staple line leak rate ranging up to 27%. For this reason, and because the diverticulum is secondary to a primary esophageal motility disorder such as achalasia, we decided to adopt a laparoscopic myotomy-first strategy, reserving the diverticulectomy for patients with persistent or recurrent symptoms. Methods: From 2004 to 2018, 22 patients with epiphrenic diverticula were treated by laparoscopic Heller myotomy and partial fundoplication alone, with the plan to add the diverticulectomy as a second stage if needed. There were 13 women and 9 women, with a mean age of 68 years. Results: Patients had been symptomatic for an average of 36 months. The most common presenting symptom was dysphagia (91%), followed by regurgitation (77%). More than half of the diverticula were solitary and on the right side. Esogphagoscopy ruled out cancer. Esophageal manometry (18 patients) showed achalasia in 14 patients, nutcracker esophagus in 3 patients, and nonspecific motility disorder in 1 patient. There were no perioperative complications, and average length of stay was 2.5 days. At a mean follow-up of 68 months, dysphagia resolved in 77% and regurgitation in 86% of patients. Three patients had persistent symptoms: 2 patients underwent a transthoracic diverticulectomy (1 patient with resolution of symptoms and 1 patient with no improvement). Another patient had per oral endoscopic myotomy, but his dysphagia persisted. Conclusions: The laparoscopic myotomy-first approach reduces risk and unnecessary surgery. A laparoscopic Heller myotomy and partial fundoplication provide excellent resolution of symptoms for most, whereasonly a few will need a staged resection of the diverticulum.

Esophageal diverticulum: New perspectives in the era of minimally invasive endoscopic treatment.

Esophageal diverticula are rare conditions that cause esophageal symptoms, such as dysphagia, regurgitation, and chest pain. They are classified according to their location and characteristic pathophysiology into three types: epiphrenic diverticulum, Zenker’s diverticulum, and Rokitansky diverticulum. The former two disorders take the form of protrusions, and symptomatic cases require interventional treatment. However, the esophageal anatomy presents distinct challenges to surgical resection of the diverticulum, particularly when it is located closer to the oral orifice. Since the condition itself is not malignant, minimally invasive endoscopic approaches have been developed with a focus on alleviation of symptoms. Several types of endoscopic devices and techniques are currently employed, including peroral endoscopic myotomy (POEM). However, the use of minimally invasive endoscopic approaches, like POEM, has allowed the development of new disorder called iatrogenic esophageal diverticula. In this paper, we review the pathophysiology of each type of diverticulum and the current state-of-the-art treatment based on our experience.

The laparoscopic approach for epiphrenic diverticula with achalasia.

Epiphrenic diverticulum (ED) is an uncommon disease that is invariably associated with an underlying oesophageal motility disorder such as achalasia. Management of ED should always be accompanied by treatment of the underlying motility disorder to prevent recurrence of symptoms. Traditionally, ED were approached via a left thoracotomy but as laparoscopy offers better access to the distal oesophagus, its use is becoming more widespread. A total of 72 patients with oesophageal achalasia underwent laparoscopic surgery at our centre over a period of 7 years. Five (6.9%) of these had associated symptomatic ED. These patients were treated with a laparoscopic transhiatal epiphrenic diverticulectomy using intraoperative oesophagoscopy guidance, combined with a Heller myotomy and Dor fundoplication. Patients were followed up regularly and symptoms were assessed at 12 months. The median age of the five patients with associated symptomatic ED was 56 years (range: 38-69 years). Three were male. The mean duration of surgery was 150 minutes (range: 120-180 minutes). One patient (20%) developed a postoperative oesophageal leak. The mean follow-up duration was 25 months (range: 12-36 months). At 12 months, the mean Eckardt score reduced from 6.8 to 1.6. Three patients (60%) reported an excellent outcome, one (20%) reported a good outcome and one (20%) reported a fair outcome. Along with diverticulectomy, treating the underlying motility disorder with an adequate Heller myotomy and partial fundoplication is of prime importance for a good surgical outcome without symptom recurrence. Laparoscopy offers better access to the distal oesophagus than the conventional thoracic approach for ED.

A Large Epiphrenic Esophageal Diverticulum Communicating with the Left Lower Lobe

Epiphrenic diverticula are known to cause a series of complications. We report the case of a 54-year-old woman who was diagnosed with an epiphrenic diverticulum at a regular checkup in November 2006. Ten years later, she presented with massive hematemesis. Imaging studies revealed an epiphrenic diverticulum measuring 7.8 cm in diameter and a large amount of bleeding inside the diverticulum. Computed tomography showed fistula formation between the diverticulum and the left lower lobe of the lung, leading to the development of a pulmonary abscess. Diverticulectomy and 180° posterior partial fundoplication were performed transabdominally. The pulmonary abscess was treated with antibiotics alone. She was discharged 16 days after the operation without any complications over 7 months of follow-up.

Esophagogastric Junction Distensibility on Functional Lumen Imaging Probe Topography Predicts Treatment Response in Achalasia-Anatomy Matters!

To compare the utility of the distensibility index (DI) on functional lumen imaging probe (FLIP) topography to other esophagogastric junction (EGJ) metrics in assessing treatment response in achalasia in the context of esophageal anatomy. We prospectively evaluated 79 patients (at ages 17-81 years; 47% female patients) with achalasia during follow-up after pneumatic dilation, Heller myotomy, or per-oral endoscopic myotomy with timed barium esophagram, high-resolution impedance manometry, and FLIP. Anatomic deformities were identified based on consensus expert opinion. Patients were classified based on anatomy and EGJ opening to determine the association with radiographic outcome and Eckardt score (ES). Twenty-seven patients (34.1%) had an anatomic deformity-10 pseudodiverticula at myotomy, 7 epiphrenic diverticula, 5 sigmoid, and 5 sinktrap. A 5-minute column area of >5 cm was best associated with an ES of >3, with a sensitivity of 84% (P = 0.0013). Area under the curve for EGJ metrics in association with retention was as follows: DI, 0.90; maximal EGJ diameter, 0.76; integrated relaxation pressure, 0.64; and basal esophagogastric junction pressure, 0.53. Only FLIP metrics were associated with retention given normal anatomy (DI 2.4 vs 5.2 mm/mm Hg and maximal EGJ diameter 13.1 vs 16.6 mm in patients with and without retention, respectively; P values < 0.0001 and 0.002). Using a DI cutoff of <2.8 as abnormal, 40 of 45 patients with retention (P = 0.0001) and 23 of 25 patients with an ES of >3 (P = 0.02) had a low DI and/or anatomic deformity. With normal anatomy, 21 of 22 patients with retention had a low or borderline low DI. The FLIP DI is most useful metric for assessing the effect of achalasia treatment on EGJ opening. However, abnormal anatomy is an important mediator of outcome and treatment success will be modulated by anatomic defects that impede bolus emptying.

Heller Myotomy for Epiphrenic Diverticula Compared to Nondiverticula Esophageal Motility Disorders, A Single Institution Experience and Appraisal of Patient Characteristics, High-Resolution Manometry and Outcomes

Purpose: The purpose of this study was to compare demographics, symptoms, prior interventions, operation, and outcomes of patients who underwent Heller myotomy for esophageal motility disorders and epiphrenic diverticulectomy with Heller myotomy. Methods: We identified all patients who underwent Heller myotomy for esophageal motility disorders with and without esophageal diverticulectomy over an 80-month period. Primary data points included patient demographics, presenting symptoms, prior intervention, high-resolution manometry, surgery performed with rate of laparoscopic, conversion to open, and open procedures; postoperative complications, and symptom resolution. Results: Over the study period, 308 Heller esophagomyotomy operations were performed on 301 patients. Of these, 277 cases were without epiphrenic diverticula and 31 included diverticula. One patient with an asymptomatic epiphrenic diverticulum did not undergo surgery was included, for a total of 32 diverticula patients. Six patients in the non-diverticula group and 1 in the diverticula group required a second operation for recurrent symptoms or residual diverticulum. The diverticula group was significantly older, had different manometry findings, required more open operations, and had longer length of stay. The diverticula group had a lower frequency of patients with prior interventions, but similar postoperative leaks, higher overall postoperative complications, and no difference in reported symptomatic improvement. Conclusions: Esophageal diverticula patients have a unique profile compare to patients with non-diverticula motility disorders. Operations are more complex, with increased complication rate and a longer length of stay. In spite of this, there is no statistically significant difference in symptomatic outcomes between the groups.

Treatment of an epiphrenic diverticulum.

Treatment of an epiphrenic diverticulum.

Evolving Options in Management of Minimally Invasive Diverticular Disease: A Single Surgeon's Experience and Review of the Literature.

Background: Esophageal thoracic diverticular disease is a rare condition resulting from multiple etiologies. Surgical management is recommended when symptomatic. Traditionally, a thoracotomy was considered the standard approach; however, the use of minimally invasive approaches has been associated with improved outcomes. Methods: We retrospectively reviewed a single surgeon's experience with minimally invasive esophageal diverticulectomy. Results: Fifteen patients with symptomatic esophageal diverticular disease underwent minimally invasive diverticulectomy between 2005 and 2018. Most patients (86.7%) had epiphrenic diverticula and 53.3% underwent a video-assisted thoracoscopic surgery approach. All patients had a diverticulectomy, while 14 patients (93.3%) also had an esophageal myotomy. Three patients (20%) underwent an extended myotomy, 4 patients (26.7%) underwent a concomitant fundoplication, and 2 patients (13.3%) underwent a concomitant paraesophageal hernia repair. Median length of hospital stay was 2 days (range, 1-16 days). There were no mortalities. Two patients (13.3%) were readmitted with delayed esophageal leaks. Median follow-up was 10.7 months (range, 10 days to 6.3 years). One patient presented with recurrent disease 5 years after his initial operation. Conclusions: In experienced hands, a minimally invasive diverticulectomy is safe, effective, and associated with excellent patient outcomes. A minimally invasive approach should be performed when possible and should be tailored to the individual patient's disease and preoperative workup.