What is the recommended treatment for epiphrenic diverticulum?

Treatment of Epiphrenic Diverticulum

Symptomatic epiphrenic diverticula require surgical intervention with diverticulectomy, long esophageal myotomy, and antireflux procedure, preferably via laparoscopic approach, while asymptomatic diverticula can be managed conservatively with observation. 1, 2, 3

Initial Assessment and Risk Stratification

The critical first step is determining whether the diverticulum is symptomatic, as this fundamentally determines management strategy:

• Asymptomatic patients do not require treatment and can be observed, as these diverticula may remain stable without clinical progression 1, 2
• Symptomatic presentation typically includes dysphagia (most common), regurgitation, chest pain, or aspiration symptoms 4, 3
• Evaluate for underlying esophageal motility disorders, particularly achalasia, as 91% of patients have identifiable esophageal obstruction (functional in 80%, mechanical in 60%, with overlap) 4
• Perform high-resolution esophageal manometry to identify the specific motility disorder (Type II or Type III achalasia most common) 1
• Assess diverticulum size, as larger diverticula are more likely to be symptomatic and require excision rather than inversion 2

Surgical Management: The Definitive Approach

For symptomatic patients, surgery provides superior long-term outcomes compared to conservative management, with significantly lower recurrence rates (22% vs 61%) and improved quality of life despite perioperative risks 3:

Surgical Technique Components

The operation must address three pathophysiologic elements simultaneously:

• Diverticulectomy: Remove the diverticulum completely if large; smaller diverticula may be inverted with good results 2
• Long esophageal myotomy: Essential to treat the underlying motor disorder and prevent recurrence; extends from the diverticulum site down through the lower esophageal sphincter 2, 5, 4
• Antireflux procedure: Mandatory to prevent postoperative gastroesophageal reflux, typically partial fundoplication (Dor or Toupet) 2, 5, 4

Preferred Surgical Approach

• Laparoscopic transhiatal approach is the surgical treatment of choice, offering excellent access to the distal esophagus and inferior mediastinum with minimal morbidity 2, 5
• Open thoracotomy is reserved for cases not amenable to laparoscopic access or when conversion is necessary 2, 5
• Peroral endoscopic myotomy (POEM) is emerging as an alternative, particularly for Type III achalasia with epiphrenic diverticula, though long-term data are limited 1

Critical Surgical Principles to Prevent Complications

Failure to perform myotomy significantly increases leak risk at the diverticulectomy site 2:

• One study reported esophageal leak in a patient where no myotomy was added 2
• Consider prophylactic esophageal stenting intraoperatively in high-risk cases, though this reduced leak rates from 50% to 33% in one series 3
• Omitting antireflux procedure leads to symptomatic postoperative heartburn in most patients 2
• New reflux symptoms occur in 33% of patients without preoperative reflux if antireflux procedure is not performed 4

Conservative Management: Limited Role

Conservative management is appropriate only for:

• Truly asymptomatic patients with incidentally discovered diverticula 1, 2
• Patients with small diverticula (<3 cm) who are poor surgical candidates 2
• Patients who decline surgery after informed discussion of recurrence risk 3

However, conservatively managed patients have 61% recurrence/progression rate versus 22% with surgery, and significantly worse dysphagia and quality of life scores at long-term follow-up 3.

Expected Outcomes and Counseling Points

Surgical Outcomes

• Perioperative morbidity is substantial at 43-50%, primarily due to anastomotic leaks (33-43% even with prophylactic measures) 3
• In-hospital mortality is essentially zero in modern series 4, 3
• Long-term symptom improvement occurs in most patients (statistically significant improvement, P = 0.0004), with less restricted diet postoperatively 4
• Only 6-9% require postoperative dilatation or reoperation after diverticulectomy 4
• 5-year survival is 90% and 10-year survival is 72% 4

Minimally Invasive vs Open Surgery

• Open surgery has lower recurrence rates than minimally invasive approaches (7% vs 42%, P = 0.030) in one comparative series 3
• However, laparoscopic approach remains preferred due to reduced perioperative morbidity and faster recovery, accepting slightly higher recurrence risk 2, 5

Common Pitfalls to Avoid

• Performing diverticulectomy without myotomy virtually guarantees recurrence or leak 2, 4
• Omitting antireflux procedure leads to new reflux symptoms in one-third of patients 2, 4
• Failing to identify and address underlying achalasia or other motility disorders preoperatively 1, 4
• Attempting conservative management in symptomatic patients, which leads to progressive symptoms and eventual need for more complex surgery 3
• Not counseling patients about the high leak rate (33-43%) despite optimal surgical technique 3