Take it or Leave it: Myotomy First approach to epiphrenic diverticula

Sean C O’Connor, MD, Myron Powell, MD, FACS, Aldolfo Fernandez, MD, FACS, Carl Westcott, MD, FACS. Wake forest University

Background: Epiphrenic diverticula are a challenging surgical problem. Resection of these diverticula carries a reported leak rate from 5-24% (Brandeis et al, 2017). Post operative esophageal leak is a morbid, high risk complication. Some small reviews have published promising results with myotomy alone, however this approach has been limited to small or un-resectable diverticula (Allax et al, 2015). We present a single-center experience with a “Myotomy first” approach for all patients, regardless of diverticular size. The hypothesis is that cardiomyotomy alone will provide satisfactory symptom abatement in some patients. And MIS Cardiomyotomy causes minimal scarring, so a staged MIS diverticulectomy is feasible at a later date if diverticular retention/stasis continues. In order to discuss this treatment algorithm we present our experience with cardiomyotomy alone for patients with epiphrenic diverticula.

Methods: The electronic medical record was queried for patients with esophageal diverticula who were managed with cardiomyotomy and Dor fundoplication alone. Pre and post-operative reflux/dysphagia questionnaires were gathered; imaging studies, operative data, complications and follow up were reviewed.

Results: From March of 2016 until the present, 7 patients with esophageal diverticula were treated using the “myotomy first” approach. Intraoperative Esophagoscopy was done to internally visualize the elimination of the inciting spastic esophageal muscle. Preoperatively, all patients complained of regurgitation, followed by Dysphagia in 6 (85%) and Weight loss 3 (42%). Postoperatively, dysphagia and weight loss resolved in all subjects. Regurgitation symptoms resolved in 6 (85%) patients. The average size of the diverticula was 22.7 cm2, the range was 2 to 62 cm2. Post operative esophagream's showed persistent diverticual, however most had decreased in size. There were no perioperative complications, average length of stay was 2.1 days and there were no ICU admissions or returns to the OR. The average length of follow up for these patients was 116 days where all patients reported being satisfied with their results and none of them have yet desired to pursue diverticulectomy.

Discussion: A “Myotomy first” approach resulted in excellent short term symptomatic control. None of the 7 have retained or re-experienced symptoms of diverticular retention worthy of surgical intervention. In the age of laparoscopic surgery, an esophageal epiphrenic diverteculectomy should be staged. This step wise approach seeks to assure surgical necessity for a morbid endeavor.