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Epiphrenic Diverticula: Diagnosis and Management

  • Jennifer A. MinnemanEmail author
  • Andrew S. Wright
Chapter
First Online:

Abstract

Epiphrenic diverticula are thought to be secondary to an underlying esophageal motility disorder. These diverticula are quite rare with less than 120 operations for this disease performed annually in the United States, and therefore evidence in the management of this disease is limited. Workup includes upper GI series, manometry, and upper endoscopy. Achalasia is found in half of the patients with other common findings being distal esophageal spasm, hypercontractile peristalsis (nutcracker esophagus), and other motility disorders including subtle unnamed motility issues. When asymptomatic or minimally symptomatic, they can be safely observed with a small rate of complications such as perforation, bleeding, or malignancy. Management of symptomatic diverticula should include myotomy, with diverticulectomy and fundoplication. The extent of myotomy is controversial, but we recommend extending it proximally to the base of the diverticulum, at least 2 cm lateral to the diverticular base. We extend the myotomy distally 3 cm onto the gastric cardia in order to reduce the risk of recurrence. The need for a diverticulectomy is debated, as in many patients the symptoms are not due to the diverticulum but rather to the underlying motility disorder. In select patients, myotomy alone may suffice. The laparoscopic approach is recommended when feasible, although a thoracic or thoracoscopic approach may be needed in select patients. Because this is a rare disease, it should be managed by experienced esophageal surgeons in high volume centers.

Keywords

Epiphrenic diverticulum Dysphagia Regurgitation Achalasia Esophageal manometry Esophageal myotomy Dor fundoplication Toupet fundoplication Diverticulectomy 
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Notes

Conflict of Interest

The authors have no conflict of interest to declare.

References

  1. 1.
    Onwugbufor MT, Obirieze AC, Ortega G, Allen D, Cornwell EE 3rd, Fullum TM. Surgical management of esophageal diverticulum: a review of the Nationwide inpatient sample database. J Surg Res. 2013;184(1):120–5.CrossRefGoogle Scholar
  2. 2.
    D'Journo XB, Ferraro P, Martin J, Chen LQ, Duranceau A. Lower oesophageal sphincter dysfunction is part of the functional abnormality in epiphrenic diverticulum. Br J Surg. 2009;96(8):892–900.CrossRefGoogle Scholar
  3. 3.
    Rossetti G, Fei L, del Genio G, et al. Epiphrenic diverticula mini-invasive surgery: a challenge for expert surgeons–personal experience and review of the literature. Scand J Surg. 2013;102(2):129–35.CrossRefGoogle Scholar
  4. 4.
    Zaninotto G, Portale G, Costantini M, et al. Long-term outcome of operated and unoperated epiphrenic diverticula. J Gastrointest Surg. 2008;12(9):1485–90.CrossRefGoogle Scholar
  5. 5.
    Kao AM, Arnold MR, Schlosser KA, et al. Epiphrenic diverticulum: 20-year single-institution experience. Am Surg. 2018;84(7):1159–63.PubMedGoogle Scholar
  6. 6.
    Mondiere J. Notes sur quelques maladies de l’oesophage. Arch Gen Med Paris. 1833;3:28–65.Google Scholar
  7. 7.
    Belsey R. Functional disease of the esophagus. J Thorac Cardiovasc Surg. 1966;52(2):164–88.PubMedGoogle Scholar
  8. 8.
    Effler DB, Barr D, Groves LK. Epiphrenic diverticulum of the esophagus: surgical treatment. Arch Surg. 1959;79:459–67.CrossRefGoogle Scholar
  9. 9.
    Thomas ML, Anthony AA, Fosh BG, Finch JG, Maddern GJ. Oesophageal diverticula. Br J Surg. 2001;88(5):629–42.CrossRefGoogle Scholar
  10. 10.
    Zaninotto G, Portale G, Constantini M, et al. Long-term outcome of operated and unoperated epiphrenic diverticulum. J Gastrointest Surg. 2008;12:1485–90.CrossRefGoogle Scholar
  11. 11.
    Nehra D, Lord RV, DeMeester TR, et al. Physiologic basis for the treatment of epiphrenic diverticulum. Ann Surg. 2002;235(3):346–54.CrossRefGoogle Scholar
  12. 12.
    Vicentine FP, Herbella FA, Silva LC, Patti MG. High resolution manometry findings in patients with esophageal epiphrenic diverticula. Am Surg. 2011;77(12):1661–4.PubMedGoogle Scholar
  13. 13.
    Stroh C, Hohmann U, Meyer F, Manger T. Epiphrenic esophageal diverticulum after laparoscopic placement of an adjustable gastric band. Obes Surg. 2006;16(3):372–4.CrossRefGoogle Scholar
  14. 14.
    Fisichella PM, Jalilvand A, Dobrowolsky A. Achalasia and epiphrenic diverticulum. World J Surg. 2015;39(7):1614–9.CrossRefGoogle Scholar
  15. 15.
    Stalheim AJ. Spontaneous perforation of diverticulum of distal esophagus. Minn Med. 1978;61(7):424–6.PubMedGoogle Scholar
  16. 16.
    Tse CS, Parikh ND. An uncommon source of upper gastrointestinal bleeding: epiphrenic esophageal diverticulum. Gastroenterol Rep (Oxf). 2017;5(4):313–5.Google Scholar
  17. 17.
    Herbella FA, Dubecz A, Patti MG. Esophageal diverticula and cancer. Dis Esophagus. 2012;25(2):153–8.CrossRefGoogle Scholar
  18. 18.
    Katsinelos P, Chatzimavroudis G, Zavos C, Pilpilidis I, Paroutoglou G, Kountouras J. Long-term botulinum toxin treatment for dysphagia due to large epiphrenic diverticulum in elderly patients: a report of two cases. Dysphagia. 2009;24(1):109–13.CrossRefGoogle Scholar
  19. 19.
    Aiolfi A, Bona D, Bonavina L. Endoscopic treatment of an epiphrenic diverticulum using a fully covered self-expanding metal stent. Endoscopy. 2013;45:E101.CrossRefGoogle Scholar
  20. 20.
    Wright AS, Williams CW, Pellegrini CA, Oelschlager BK. Long-term outcomes confirm the superior efficacy of extended Heller myotomy with Toupet fundoplication for achalasia. Surg Endosc. 2007;21(5):6.CrossRefGoogle Scholar
  21. 21.
    Valentini M, Pera M, Vidal O, Lacima G, Belda J, de Lacy AM. Incomplete esophageal myotomy and early recurrence of an epiphrenic diverticulum. Dis Esophagus. 2005;18(1):64–6.CrossRefGoogle Scholar
  22. 22.
    Rosati R, Fumagalli U, Elmore U, de Pascale S, Massaron S, Peracchia A. Long-term results of minimally invasive surgery for symptomatic epiphrenic diverticulum. Am J Surg. 2011;201(1):132–5.CrossRefGoogle Scholar
  23. 23.
    Herbella FA, Patti MG. Achalasia and epiphrenic diverticulum. World J Surg. 2015;39(7):1620–4.CrossRefGoogle Scholar
  24. 24.
    Allaix ME, Borraez Segura BA, Herbella FA, Fisichella PM, Patti MG. Is resection of an esophageal epiphrenic diverticulum always necessary in the setting of achalasia? World J Surg. 2015;39(1):203–7.CrossRefGoogle Scholar
  25. 25.
    Rawlings A, Soper NJ, Oelschlager B, et al. Laparoscopic dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial. Surg Endosc. 2012;26(1):18–26.CrossRefGoogle Scholar
  26. 26.
    Tatum RP, Pellegrini CA. How I do it: laparoscopic Heller myotomy with Toupet fundoplication for achalasia. J Gastrointest Surg. 2009;13(6):1120–4.CrossRefGoogle Scholar
  27. 27.
    Macke RA, Luketich JD, Pennathur A, et al. Thoracic esophageal diverticula: a 15-year experience of minimally invasive surgical management. Ann Thorac Surg. 2015;100(5):1795–802.CrossRefGoogle Scholar
  28. 28.
    Yang J, Zeng X, Yuan X, et al. An international study on the use of peroral endoscopic myotomy (POEM) in the management of esophageal diverticula: the first multicenter D-POEM experience. Endoscopy. 2019;51(4):346–9.CrossRefGoogle Scholar
  29. 29.
    Demeter M, Banovcin P Jr, Duricek M, Kunda R, Hyrdel R. Peroral endoscopic myotomy in achalasia and large epiphrenic diverticulum. Dig Endosc. 2018;30(2):260–2.CrossRefGoogle Scholar
  30. 30.
    Nabi Z, Ramchandani M, Darisetty S, Kotla R, Reddy DN. Per-oral endoscopic myotomy with endoscopic septum division in a case of achalasia with large epiphrenic diverticulum. VideoGIE. 2019;4(1):14–6.CrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of SurgeryUniversity of WashingtonSeattleUSA

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