Ezra N Teitelbaum, MD, Christy M Dunst, MD, Marc A Ward, MD, Ahmed M Sharata, MD, Kevin M Reavis, MD, Lee L Swanstrom, MD. The Oregon Clinic
Introduction: Epiphrenic diverticula arise secondary to functional or mechanical esophageal outflow obstruction. Patients often have underlying esophageal motility disorders; however due to their rarity, few series have described results of high-resolution manometry in such patients, and no studies have categorized patients according to the current Chicago Classification of esophageal motility disorders.
Methods: A single-institution database was retrospectively examined. Patients with preoperative manometry who underwent operations for esophageal diverticula were included. Patients undergoing surgery for pharyngeal (Zenker’s) diverticula and those with mechanical obstruction as the etiology of their esophageal diverticula were excluded. Results of pre and postoperative manometries were interpreted using version 3.0 of the Chicago Classification.
Results: From September 2007 to July 2016, 10 patients underwent operations for epiphrenic diverticula. Five were female and the median age was 64 years. The most common presenting symptoms were dysphagia (80%) and regurgitation (80%). All diverticula were in the distal third of the esophagus and ranged 1-7cm in diameter. On preoperative manometry, 2 patients had normal motility and 8 had disorders of esophagogastric junction (EGJ) outflow. Categorizing those 8 patients based on esophageal body activity, 4 had type II achalasia and 4 had EGJ outflow obstruction with preserved peristalsis. Of the 4 with preserved peristalsis, 3 exhibited hypercontractile swallows. A preoperative hiatal hernia was present in 50% of patients (all Type I, median axial length 3cm). Seven patients underwent laparoscopic diverticulectomy, Heller myotomy, and partial fundoplication. One patient underwent left thoracotomy, diverticulectomy, myotomy, and Belsey fundoplication. One had an endoscopic myotomy and laparoscopic diverticulectomy and partial fundoplication performed concurrently. One patient underwent endoscopic myotomy without diverticulectomy. Myotomy length ranged 3-20cm, in all cases beginning proximal to the diverticulectomy and ending distal to the EGJ. Median length of stay was 2.5 days. Two Grade IIIb complications occurred: a contained esophageal leak that resolved with endoscopic stenting and a left pleural effusion without leak that resolved with tube thoracostomy. At median 10 month follow-up, 7 patients had resolution of dysphagia and 2 had infrequent (less than weekly) dysphagia. One patient had recurrence of daily dysphagia that responded to endoscopic dilation. Four patients had postoperatively manometry with 75% demonstrating resolution of EGJ outflow obstruction.
Conclusions: In this series, 40% of patients with epiphrenic diverticula had achalasia according to the Chicago Classification and the frequency of hiatal hernia was higher than expected. Patients with epiphrenic diverticula may represent a unique subpopulation of patients with esophageal motility disorders.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80113
Program Number: P394
Presentation Session: Poster (Non CME)
Presentation Type: Poster
