John M Swanson, MD, Jonathan Svahn, MD. UCSF – East Bay
Introduction: Achalasia is well defined disorder of increased lower esophageal sphincter tone (1). Epiphrenic esophageal diverticulum are a rare disorder believed to result from increased intra-esophageal pressure often in conjunction with a motility disorder causing functional outflow obstruction. They are a pulsion-type pseudo-diverticulum with mucosal bulging most frequently from the right posterior esophageal wall (2). We present a very rare case of achalasia associated with multiple esophageal diverticula successfully treated with laparoscopic Heller myotomy with Dor fundoplication.
Case Presentation: A 75 year old woman presented with 4 years of dysphagia, chest discomfort, regurgitation, and weight loss. Esophagoscopy showed a patulous esophagus with multiple esophageal diverticula (Figure 1). Barium esophogram demonstrated 5 esophageal diverticula in the distal esophagus and delayed clearance of esophageal contrast (Figure 2). High resolution monometry revealed a hypertensive mean LES, an aperistaltic body on 10 of 10 wet swallows, and panesophageal pressurization in 7 of 10 wet swallows – consistent with Type II Achalasia by Chicago classification (1).
We performed a laparoscopic Heller Myotomy with Dor fundoplication. The myotomy was extended 6cm above the gasgtroesophageal junction and 3cm onto the gastric cardia. An anterior diaphragmatic defect with a moderate type 1 hiatal hernia was repaired with two sutures, ensuring to not impinge the esophagus (Figure 3).
At 10 weeks post operatively the patient reports excellent results. Her dysphagia and chest discomfort have entirely resolved. Her Eckhardt score improved from seven preoperatively to one post operatively.
Discussion: Type II Achalasia is successfully treated in the majority of cases with laparoscopic Heller myotomy and partial fundoplication (3). However, esophageal diverticula typically require both myotomy as well as diverticulectomy for successful treatment (4). There is little experience with the surgical management of multiple esophageal diverticula. We propose a two stage surgical approach for these patients. We reason that the risk of esophageal leak or stenosis in the case of multiple esophageal diverticulectomies out weighs the proposed benefit. Indeed epidemiologic studies indicate that the majority of esophageal diverticula are asymptomatic (4). In the event the patient remains symptomatic after myotomy a second stage operation with diverticulectomies would be possible. This single experience suggests that diverticulectomy may not be necessary in the case of multiple diverticula associated with Achalasia. Instead, treatment may be directed at relieving the functional obstruction responsible for the symptoms by performing laparoscopic Heller Myotomy with Dor fundoplication.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88081
Program Number: P398
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster