Myotomy-First Approach to Epiphrenic Esophageal Diverticula

Introduction

The traditional surgical management for epiphrenic diverticula, Heller myotomy and diverticulectomy, developed before the advent of laparoscopic esophageal surgery when open surgery was necessary and it was assumed that the diverticulum was a primary disorder independent from a motility problem. When epiphrenic diverticula became amenable to minimally invasive approaches in the early 2000s, the same surgical strategy was applied. The combined approach was based on an assumption that epiphrenic diverticulectomy is essential to achieve adequate symptom response. Today it is recognized that epiphrenic diverticula are “pulsion” diverticula secondary to esophageal motility disorders, most often achalasia (58%–100%),^1–6 and that it is the motility disorder that is responsible for the majority of symptoms. Many studies have shown that the diverticulectomy is the main driver of morbidity. The most significant complication, a leak from the staple line, can result in potentially life-threatening sequelae.^7,8 Leak rates after epiphrenic diverticulectomy range from 5% to 33%,^9–12 with a mortality rate of 20%. ¹³

Heller myotomy has been performed routinely along with epiphrenic diverticulectomy to reduce pressure in the esophagus and decrease the risk of esophageal leak. The importance of myotomy is underscored by reports showing significantly higher complication rates and persistence of symptoms in cases of diverticulectomy with no concomitant myotomy.^1,6,13–19

Allaix et al. compared 7 patients who underwent myotomy without diverticulectomy with 6 patients who underwent myotomy with diverticulectomy. They found equivalent resolution of symptoms and no esophageal leaks in the myotomy-alone group, but a 17% leak rate when the diverticulectomy was performed. ¹⁹ Their study was in patients who had achalasia and diverticula technically difficult to resect because of the distance from the gastroesophageal junction or severe adhesions with surrounding structures. This report concluded that a diverteculectomy may not always be needed.

Based on the improved understanding of the pathophysiology of epiphrenic diverticula and reports regarding the morbidity of diverticulectomy, we decided to treat epiphrenic diverticula by a Heller myotomy and partial fundoplication without diverticulectomy. The hypothesis was that a myotomy-first strategy would allow resolution of symptoms in most patients, without the need for a diverticulectomy.

Methods

Patients were maintained in prospectively collected databases in two academic institutions between 2004 and 2018. Individuals were included in this study if they had diverticula in the distal thoracic esophagus treated by laparoscopic Heller myotomy and partial fundoplication without diverticulectomy. All 22 patients underwent laparoscopic included periesophageal dissection, gastric fundic mobilization, and Heller myotomy from the neck of the diverticulum to 2.5–3 cm onto the gastric wall. Proximal extension through the neck of the diverticulum was verified with intraoperative esophagscopy. In addition, a posterior (Toupet) partial fundoplication was performed in 14 patients, and an anterior (Dor) partial fundoplication was utilized in 8 patients. The primary outcomes were symptom resolution and reinterventions. Secondary outcomes included length of stay, ICU admission, and mortality.

Results

Twenty-two patients (13 females, 10 males) were treated using the myotomy-first approach. The average age was 68 years (range 55–84 years). Patients had been symptomatic for an average of 54 months (range 4–300 months). The most common presenting symptom was dysphagia (91%), followed by regurgitation (77%) and weight loss (27%) (Table 1).

Preoperatively all patients underwent esophogram, which showed that 15 of 22 epiphrenic diverticula (68%) were located on the right side of the esophagus. Work-up also included upper endoscopy in all cases to rule out cancer. Esophageal manometry was performed in 18 patients, and showed achalasia in 14 patients, nutcracker esophagus in 3 patients, and a nonspecific motility disorder in 1 patient. In the remaining 4 patients, the manometry catheter could not be passed into the stomach.

Preoperative comorbidities in this group included 4 patients with diabetes, 3 patients with chronic obstructive pulmonary disease, 1 patient with previous stroke, 1 patient with previous myocardial infarction, and 1 patient with liver disease. The average Charleston comorbidity index for this group was 2.64 (range 1–5).

Average length of stay was 2.5 days (range 1–8 days). No patients required ICU stay. There were no leaks, significant complications, or death among the patients.

At a mean follow-up of 68 months, dysphagia resolved in 77% and regurgitation in 86% of patients. Thirty-six percent of patients were taking proton pump inhibitors. Two patients with persistent symptoms underwent a transthoracic diverticulectomy 5 and 8 months after the first operation. One patient had dysphagia resolution and the other had no response. Another patient underwent per oral endoscopic myotomy (POEM), but is still experiencing dysphagia.

Discussion

The classic surgical approach for epiphrenic diverticula was resection of the diverticulum combined with a Heller myotomy. Unfortunately, this approach was followed by a very high leak rate. In addition, eventually it became clear that the epiphrenic diverticula are not a primary problem, but are rather secondary to a primary motility disorder such as achalasia, which drives the symptoms. ¹ Therefore, it makes sense to approach patients with epiphrenic diverticula using a Heller myotomy and partial fundoplication performed by minimally invasive approach, leaving the diverticulum in place and resecting it only in patients with persistent or recurrent symptoms. A limitation of this study is its retrospective design. But it is multi-institutional and represents the largest reported group of esophageal diverticuli treated in this manner.

Patients who have epiphrenic diverticula typically present with dysphagia and regurgitation, similar to patients with achalasia. Preoperative barium contrast study and endoscopy identify the location and size of the diverticulum and may suggest a motility disturbance. Esophageal manometry usually characterizes the motility abnormality.

As stated in the introduction, there is already evidence to suggest that a concurrent diverteculectomy may not be needed. ¹⁹ In this series, we hope to go further and say that a diverteculectomy should not be performed without giving the patient a chance to first respond to a laparoscopic cardiomyotomy alone. If this morbid second surgery is needed, the surgeon and patient will be assured that it is necessary. It should be able to be completed with minimally invasive techniques, either thoracic or abdominal, robotic or laparoscopic, depending on location and surgeon preference. This conclusion is supported by the observation that only 3 of 22 patients progressed to either transthoracic diverticulectomy (2) or POEM (1) over a 5-year experience. For the vast majority, the myotomy-first strategy eliminated the risk of a concomitant diverticulectomy. Of the 2 patients who had a staged diverticulectomy, only 1 patient improved, suggesting the diverticulum was not the driver of the persistent dysphagia in that case. For the 1 patient who had POEM without diverticulectomy, symptoms did not improve and esophagectomy, rather than diverticulectomy, has been recommended.

Our findings indicate that the contribution of epiphrenic diverticula to the preoperative symptoms is less important than the impact of the lower esophageal sphincter that limits esophageal outflow. In cases of persistent or recurrent symptoms after primary Heller myotomy, use of POEM to provide a second myotomy may have a role in cases.^20,21 Given the minimally invasive nature of the primary treatment with Heller myotomy and partial fundoplication, it is likely a staged diverticulectomy will be amenable through a minimally invasive approach.

Our data suggest that a myotomy-first approach is safer than combination surgery. Even with significant advances in surgical technique and technology such as stapling devices, leak rates vary and remain as high as 27%,^12,22–26 with expected impact on cost and outcomes. ²⁷

Our data demonstrating high symptom response after myotomy without diverticulectomy may allow more high-risk patients to become candidates for surgical treatment. A laparoscopic Heller myotomy and partial fundoplication alone are more easily managed by elderly patients or those with significant comorbidities who have otherwise been deemed poor candidates for traditional surgery with diverticulectomy.

Conclusion

This series represents the largest cohort in the literature of the management of epiphrenic diverticula with Heller myotomy and partial fundoplication alone. Minimally invasive Heller myotomy and partial fundoplication have short hospital stay, low morbidity, and excellent resolution of symptoms. The majority of patients will have durable symptom response without need for a second-stage procedure. We, therefore, advocate for a myotomy-first strategy to reduce cumulative risk.

Ethical Approval

Institutional review board approval was obtained for the study.