Virginie Achim, MD, Ralph W Aye, MD, Brian Louie, MD, Alex Farivar, MD. Swedish Medical Center, Division of Thoracic and Esophageal Surgery
Introduction
The traditional approach to epiphrenic diverticula is thoracotomy, diverticulectomy, and myotomy to address dysmotility with/without partial fundoplication. A laparoscopic approach has been advocated but access to higher diverticula is problematic. We hypothesized a thoracoscopic and/or laparoscopic approach may overcome these challenges and sought to review our results.
Methods and Procedures
A retrospective review from 2004 to 2013 identified 13 patients with an epiphrenic diverticulum who underwent surgery. Patients were grouped according to height of the diverticular neck above the GEJ: group A < 5 cm, group B > 5 cm. Preoperative studies including EGD, manometry, and UGI, presenting symptoms, location and size of the diverticulum, as well as type of surgery performed were recorded. Post-operative complications, mortality, and clinical outcomes using quality of life metrics (QOLRAD, GERD-HRQL and Eckardt score) and objective testing were assessed. Mean follow up was 19 months.
Results
A motility disorder was identified in 11/13. The mean size of the diverticulum was 2.7 cm (2-4 cm); and the mean height above the GEJ was 5 cm (0-12 cm); there were 7 (54%) in group A and 6(46%) in group B.
Group A patients underwent laparoscopic diverticulectomy, myotomy and partial fundoplication. The intended procedure in group B was thoracoscopic diverticulectomy followed by laparoscopic myotomy and partial fundoplication. This was completed in 3 but myotomy was compromised in 3 due to prior myotomy and adhesions, and bleeding from platelet inhibition. All 3 had staple line leaks resulting in 1 death. At a mean follow of 19 months, the median QOLRAD scores improved from 3.29 to 5.97; GERD-HRQL improved from 22.5 to 13.5, and Eckardt scores improved from 6.14 to 1.5.
Conclusions
A minimally invasive strategy for epiphrenic diverticula based on location of the diverticulum above the GEJ and utilizing selective thoracoscopy for higher diverticula was successful and resulted in improved quality of life. Incomplete myotomy was associated with a substantially higher failure.