Esophageal epiphrenic diverticulum: principles of management and decision making

Diverticular disorders of the esophagus are well described as an outpouching of the esophageal wall, often representing the phenotypic manifestation of various systemic or local diseases. Epiphrenic diverticula of the esophagus are pulsion-type, arising in the distal esophagus, often secondary to underlying motility disorders of the esophagus, like achalasia (Figure 1). This is a rare disorder with an estimated prevalence of 0.015% to 2% (1). As most of the epiphrenic diverticula are asymptomatic, the true prevalence remains unknown. The management of epiphrenic diverticula is complex due to its association with primary esophageal dysmotility and the surgical and anatomical complexity requires an experienced and dedicated surgeon. Considering its rarity, there is lack of standardized treatment algorithms. The key clinical questions to consider when managing epiphrenic diverticula include the necessity and timing of a surgical intervention, the appropriate surgical approach and non-operative management including endoscopic alternatives.

Figure 1 Epiphrenic diverticulum.

Is treatment always required for epiphrenic diverticula and what is the appropriate treatment?

Patients presenting with worsening symptoms, most often severe dysphagia, regurgitation, food retention, and subsequent aspiration, warrant treatment. However, asymptomatic patients or those with mild symptoms can be managed expectantly without an increased risk of diverticular complications (2). In a series of 17 patients of whom six patients underwent conservative non-operative management, there were comparable outcomes in a two-year follow-up (3). In another series of 13 patients who underwent conservative management with a mean follow-up of 64 months, none of the patients reported on symptom worsening or any complication. One patient showed enlargement of the diverticulum from 2 to 4 cm after two years of follow-up (4). Neither size nor the dependent location of the diverticulum correlates directly with symptom severity. However, large diverticula are often associated with food retention and regurgitation (5). One might argue that a diverticulum left intact might pose a higher risk for malignancy due to carcinogenic effects of the obstructed food, however, cancer within a diverticulum is rare and probably does not warrant resection solely for its prevention (1,6).

Diverticulectomy is the treatment of choice and is performed in most cases. Esophageal myotomy is an essential part of the treatment since epiphrenic diverticulum is created by an underlying motility disorder. Moreover, performing a diverticulectomy without myotomy has higher rate of staple line leak and recurrence of symptoms (5,7,8). The myotomy is ideally done on the contralateral side of the diverticulum to avoid inadvertent injury to the staple line or to the diverticulum in cases where the diverticulum was not resected. The proximal extent of the myotomy should extend beyond the diverticulum neck and distally 2 to 3 cm beyond the esophagogastric junction (EGJ). Before stapling the diverticulum, a bougie can be used to prevent luminal narrowing. Alternatively, intraoperative endoscopy can assist in checking the integrity of the staple line and ruling out mucosal injury during myotomy. Following the myotomy a partial fundoplication should be done to lower the risk of a subsequent gastro-esophageal reflux. Some surgeons have shown that myotomy alone, without diverticulectomy, provides acceptable outcomes and resolution of symptoms without the risk of an esophageal leak at the staple line (9). Furthermore, small diverticula may spontaneously resolve after successful myotomy.

What is the appropriate surgical approach for treating epiphrenic diverticula?

Historically, epiphrenic diverticulectomy was performed via open transthoracic approach, usually left thoracotomy, which enables direct access to the lower esophagus with good exposure of the diverticulum and a myotomy (4). The transthoracic approach allows for direct access to the diverticulum, especially for its proximal part with easier release of the pouch adhesions (4,5). This approach requires single lung ventilation and was associated with higher morbidity rates (10). The transabdominal laparoscopic approach offers the advantage of direct access to the EGJ and hiatus with easier creation of a fundoplication. Usually, in the transabdominal minimally invasive approach, one can expose and mobilize the esophagus up to the level of the inferior pulmonary vessels, which usually covers most diverticula locations. If the diverticulum neck is wide and is far from the hiatus, one might want to consider the transthoracic approach or even a combined approach to appropriately resect the pouch, perform a myotomy and create a partial fundoplication. The robotic approach has the advantage of enhanced visualisation and precision with improved ergonomics. It enables improved dissection at difficult angles as well as reaching well above the neck of the diverticulum, and easier suturing with staple line reinforcement (11).

The endoscopic approach

Third space endoscopy has been adopted in the last decade and is now being performed in various situations (12). Per-oral endoscopic myotomy (POEM) has been shown to be an effective procedure for the treatment of achalasia (13) and is also being adopted for use in the treatment of esophageal diverticula (14). The advantage of POEM was specifically proven in cases where long myotomy is needed, such as type III achalasia (15). The rationale for performing POEM for the treatment of esophageal diverticula claims that diverticulectomy is not needed, and a myotomy only is sufficient to provide a good clinical effect for the patients. This approach was proven safe and effective only in small retrospective cohort studies with short-term follow-up (14,16). More recently, POEM with diverticular septum division (D-POEM) has emerged as an option to treat esophageal diverticulum (17). While considered a promising option, D-POEM has failed to demonstrate complete disappearance of the diverticulum with a risk for symptom relapse. The lack of anti-reflux fundoplication is another major drawback of the POEM with a high rate of patients suffering from reflux esophagitis following this procedure (18). Ultimately, both POEM and surgery are complementary tools. The choice hinges on weighing the immediate risks and recovery against the completeness of anatomic correction and reflux prevention. A stratified approach maximizes patient safety and quality of life by taking advantage of the strengths of each technique.

Summary

Despite the rarity of epiphrenic diverticula, effective treatment can be achieved through a collaborative, multidisciplinary approach. The integration of minimally invasive surgical techniques with individualized care plans has demonstrated high rates of symptom resolution, low complication risks, and favorable long-term outcomes. As diagnostic and surgical advancements continue to evolve, the management of this condition is expected to improve further.

Acknowledgments

The authors thank Yotam Giladi from the Institute of Medical-Legal Illustration for designing the diverticulum figure.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Esophagus. The article has undergone external peer review.

Peer Review File: Available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-6/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-6/coif). The authors have no conflicts of interest to declare.

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