Optimal surgical approaches for esophageal epiphrenic diverticulum: literature review and our experience

Abstract

Esophageal epiphrenic diverticulum is a rare condition usually secondary to a primary esophageal motility disorder. Although epiphrenic diverticulum may be treated by thoracoscopic and laparoscopic management, the optimal surgical approach have not been established. We successfully treated a left epiphrenic diverticulum along with achalasia and paraesophageal hernia by a planned combination of thoracoscopic and laparoscopic procedures aided by preoperative simulation using three-dimensional imaging. We reviewed a series of 17 reports on esophageal epiphrenic diverticulum that required either planned or unplanned unexpected transthoracic surgery. The main reasons for requiring a transthoracic approach were adhesions, site and size of the diverticulum, and length of the diverticulum neck. Unplanned procedure changes were required in 12 of the 114 cases for a conversion rate of 10.5%. Diverticulectomy, myotomy, and fundoplication were the most common surgical treatments administered at 42.6%. Based on literature review and our experience, we have developed a flowchart to identify the characteristics of epiphrenic diverticulum cases that require a transthoracic approach. This flowchart can help to determine therapeutic strategies and the optimal surgical approach to esophageal epiphrenic diverticulum treatment and may reduce unplanned changes in the surgery.

An Epiphrenic Diverticulum with Previous Perforation Excised Laparoscopically

“…It is described as the best approach to perform all the three components of the surgery when the diverticulum is closer to the oesophageal hiatus and is less than 4 cm across the base [ 3 , 15 ]. A recent article suggested that laparoscopic approach has been shown to have lower conversion rates to open surgery, improved dysphagia, shorter stay, and less reflux [ 21 ].…”

A case of recurrent epiphrenic esophageal diverticulum treated with lower esophagogastric resection and interstitial jejunal reconstruction

“…More recently, it has become common to combine endoscopic techniques as minimal invasive procedures. Advantages of the laparoscopic transhiatal approach include two advantages: first, optimal visualization of both the EGJ and lower mediastinum to perform a long myotomy; and second, perfect alignment of the stapler to the longitudinal axis of the esophagus and the possibility of construction of a fundoplication [ 8 ]. Soares et al .…”

Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues—A Comprehensive Review

“…Common symptoms of ZD include halitosis, dysphagia, regurgitation, and chest pain. Nevertheless, most patients remain asymptomatic [119,120]. According to ESGE guidelines, treatment is recommended upon the onset of symptoms, with a comprehensive assessment of the risk-benefit ratio, regardless of the size of the diverticulum [121].…”