Myotomy-First Approach to Epiphrenic Esophageal Diverticula.

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. 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. 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. 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.