Joshua E Preiss, MD, Meredith Duke, MD, MBA, Timothy M Farrell, MD, FACS. University of North Carolina, Chapel Hill
Background: Epiphrenic diverticula (ED) arise from increased intraluminal pressures, often secondary to achalasia or another underlying esophageal motility disorder which causes “pulsion” physiology. ED are traditionally thought to contribute to patients’ symptoms of regurgitation and dysphagia, and are frequently resected at time of Heller myotomy and fundoplication done for treatment of the primary motility disorder. ED excision carries significant risks (staple line leak, pulmonary complications, mortality), and little is known regarding patients with ED and esophageal motility disorder who undergo surgical myotomy without ED resection. The goal of this study was to compare outcomes of patients with ED and esophageal motility disorder who did and did not undergo diverticulectomy at time of myotomy and fundoplication.
Methods: Retrospective analysis of prospectively collected database from 2004-2017 was performed. Patients with diagnosis of ED undergoing surgical treatment of symptomatic esophageal motility disorder were included. All patients underwent laparoscopic Heller myotomy with Toupet fundoplication by a single surgeon at a tertiary referral hospital. Patients were stratified according to whether ED was excised or not excised at time of primary surgery. Patient-reported symptoms were obtained from pre/post-operative clinic evaluations and mailed surveys during the follow-up period. Independent samples t-test and Fisher’s exact test were used to compare continuous and categorical variables respectively.
Results: ED was identified in 15 patients prior to surgery. Primary diagnoses included achalasia (n=11), nutcracker esophagus (n=3), and diffuse esophageal spasm (n=1). ED was excised in five patients (33.3%) and not excised in ten patients (66.6%), with no significant difference in frequency of preoperative dysphagia (80% vs. 90%, p=1.00) or regurgitation (40% vs. 60%, p=0.61) between groups respectively. Reasons for non-resection included ED was too proximal (n=7), patient/surgeon preference (n=2), and small ED size (n=1). The resection group did not experience any leaks and there were no mortalities in either cohort during the follow-up period. At mean clinic follow-up of 198 days, there was no difference in frequency of residual dysphagia in patients who did or did not undergo ED resection (20% vs. 20%, p=1.00) and neither cohort reported residual regurgitation symptoms.
Conclusions: This study suggests that leaving ED in place during surgical treatment of an esophageal motility disorder may achieve similar rates of postoperative symptom control. While ED excision in this study did not cause significant excess morbidity, ED resection introduces risk of leak and requires more extensive surgery that may not provide significant benefit to patients.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86201
Program Number: P387
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster