What are the treatment options and potential complications for lower esophageal diverticulum?

Lower Esophageal Diverticulum: Treatment, Pathophysiology, and Complications

Surgical treatment with myotomy is the primary intervention for symptomatic lower esophageal diverticula, as most cases are associated with underlying esophageal motility disorders that must be addressed to prevent recurrence and complications. 1, 2

Pathophysiology

• Lower esophageal (epiphrenic) diverticula are pulsion pseudodiverticula found in the distal 10 cm of the esophagus, resulting from increased intraluminal pressure 2
• In approximately 75-80% of cases, these diverticula are associated with underlying esophageal motility disorders, most commonly achalasia, diffuse esophageal spasm, or nutcracker esophagus 1
• The remaining cases may be associated with mechanical obstruction such as hiatal hernia or distal esophageal stricture 1
• The diverticulum forms when increased intraluminal pressure pushes the mucosa and submucosa through a weakness in the muscular layer of the esophageal wall 3

Clinical Presentation

• Common symptoms include dysphagia (91%), regurgitation (77%), chest pain, and respiratory complaints 4, 2
• Importantly, symptoms are usually related to the underlying motility disorder rather than the diverticulum itself 1, 2
• Only a minority of patients have symptoms directly attributable to the diverticulum alone 1

Diagnostic Evaluation

• Upper gastrointestinal endoscopy is essential to rule out malignancy and identify associated conditions 4, 2
• Barium esophagogram helps visualize the diverticulum and assess for other structural abnormalities 2
• Esophageal manometry is crucial to identify underlying motility disorders, which are present in most patients 1, 2
• CT imaging may be necessary in cases of suspected complications 5

Treatment Options

Conservative Management

• Asymptomatic diverticula generally do not require intervention 5
• Dietary modifications and proton pump inhibitors may help manage mild symptoms 5

Surgical Management

• Surgical intervention is indicated for symptomatic patients 6, 4
• The primary surgical approaches include:

1. Myotomy-First Approach:

   • Laparoscopic Heller myotomy with partial fundoplication without diverticulectomy 4
   • This approach addresses the underlying motility disorder while avoiding the complications associated with diverticulectomy 4
   • Studies show resolution of dysphagia in 77% and regurgitation in 86% of patients with this approach 4
   • Diverticulectomy is reserved for patients with persistent symptoms after myotomy 4

2. Combined Approach:

   • Diverticulectomy with concurrent myotomy and partial fundoplication 6, 2
   • The diverticulum is excised without compromising the esophageal lumen 6
   • Myotomy extends from above the diverticulum to the gastric cardia 2

3. Minimally Invasive Techniques:

   • Laparoscopic or thoracoscopic approaches are preferred over open surgery 6, 2
   • Laparoscopic approach is particularly suitable for diverticula within 10 cm of the lower esophageal sphincter 6
   • Peroral endoscopic myotomy (POEM) is emerging as an option for patients unfit for surgery 2

Endoscopic Management

• Flexible endoscopy may be used for diagnostic purposes and in some cases for therapeutic intervention 5
• Endoscopic dilatation may be considered in cases with associated strictures or rings 5

Complications

Disease-Related Complications

• Food retention leading to regurgitation and aspiration pneumonia 3, 2
• Inflammation of the diverticulum (diverticulitis) 3
• Bleeding from ulceration within the diverticulum 1
• Perforation (rare but serious) 5, 3

Treatment-Related Complications

• Staple line leaks occur in up to 27% of diverticulectomy cases 4
• Perforation during surgical intervention 5
• Recurrence of the diverticulum if the underlying motility disorder is not addressed 1
• Post-surgical gastroesophageal reflux, especially if a fundoplication is not performed 2

Post-Treatment Management

• Monitor patients for at least 2 hours in recovery following any endoscopic procedure 5
• Ensure patients are tolerating water before discharge 5
• Provide clear instructions regarding diet progression and warning signs of complications 5
• Suspect perforation if patients develop persistent pain, breathlessness, fever, or tachycardia 5
• Follow-up imaging is not routinely required unless complications are suspected 5

Special Considerations

• In patients with achalasia and epiphrenic diverticulum, pneumatic balloon dilatation (30-40 mm) may be considered as part of the treatment approach 5
• Proton pump inhibitor therapy should be considered after myotomy to prevent reflux complications 5
• The surgical approach should be tailored to the location of the diverticulum and patient comorbidities 5

Treatment Algorithm

1. Confirm diagnosis with endoscopy, barium esophagogram, and manometry
2. For asymptomatic patients: observation
3. For symptomatic patients with confirmed motility disorder:
   • First-line: Laparoscopic Heller myotomy with partial fundoplication
   • Follow-up at 3 months to assess symptom resolution
   • If symptoms persist: Consider diverticulectomy as a second stage
4. For symptomatic patients without motility disorder but with mechanical obstruction:
   • Address the underlying cause (stricture dilatation, hernia repair)
   • Consider diverticulectomy if symptoms are directly related to the diverticulum