From the Research
The initial approach to managing a patient with an esophageal diverticulum should be a laparoscopic myotomy-first strategy, reserving diverticulectomy for patients with persistent or recurrent symptoms, as this approach reduces the risk of unnecessary surgery and associated morbidity. This approach is supported by a study published in 2019 1, which demonstrated that a laparoscopic Heller myotomy and partial fundoplication provided excellent resolution of symptoms for most patients with epiphrenic esophageal diverticula. The study found that at a mean follow-up of 68 months, dysphagia resolved in 77% and regurgitation in 86% of patients, with only a few patients requiring a staged resection of the diverticulum.
Key considerations in the management of esophageal diverticula include:
- Symptom management and lifestyle modifications, such as eating slowly and avoiding late evening meals
- Dietary modifications, including a soft diet and avoidance of alcohol, caffeine, and spicy foods
- Medications, such as proton pump inhibitors and prokinetic agents, to reduce acid reflux and improve esophageal motility
- Avoidance of medications that decrease lower esophageal sphincter pressure, such as calcium channel blockers and nitrates
Surgery is generally reserved for patients with severe symptoms, large diverticula, or complications such as aspiration, regurgitation, or significant dysphagia that do not respond to conservative measures. The choice of surgical approach depends on the location and size of the diverticulum, as well as the presence of underlying motility disorders. A myotomy should always be included in the procedure to address the underlying motility disorder.
It is essential to note that the risk of malignant transformation is low, but it should be considered in the decision-making process, especially in older patients with large diverticula or a long-standing history of symptoms 2. A thorough evaluation, including endoscopy and manometry, is necessary to determine the best course of treatment for each patient.
In summary, a laparoscopic myotomy-first approach is a safe and effective initial strategy for managing patients with esophageal diverticula, with surgery reserved for patients with severe symptoms or complications that do not respond to conservative measures.