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Physiologic basis for the treatment of epiphrenic diverticulum.
Ann Surg 2002; 235(3):346-54AnnS

Abstract

OBJECTIVE

To quantitate and characterize the motility abnormalities present in patients with epiphrenic diverticula and to assess the outcome of surgical treatment undertaken according to these abnormalities.

SUMMARY BACKGROUND DATA

The concept that epiphrenic diverticula are complications of esophageal motility disorders rather than primary anatomic abnormalities is gradually becoming accepted. The inconsistency in identifying motility abnormalities in patients with epiphrenic diverticula is a major obstacle to the general acceptance of this concept.

METHODS

The study population consisted of 21 consecutive patients with epiphrenic diverticula. All patients underwent videoesophagography, upper gastrointestinal endoscopy, and esophageal motility studies. The diverticula ranged in size from 3 to 10 cm and were predominantly right-sided. Seventeen patients underwent transthoracic diverticulectomy or diverticulopexy with esophageal myotomy and an antireflux procedure. The length of the myotomy was determined by the extent of the motility abnormality. Transhiatal esophagectomy was performed in one patient with multiple diverticula. Two patients declined surgical treatment and another patient died of aspiration before surgery. Symptomatic outcome was assessed via a questionnaire at a median of 24 months after surgery.

RESULTS

The primary symptoms were dysphagia in 5 (24%) patients, dysphagia and regurgitation in 11 (52%) patients, and pulmonary symptoms in 5 (24%) patients. The median duration of the primary symptoms was 10 years. Esophageal motility abnormalities were identified in all patients. An esophageal motor disorder was diagnosed only by 24-hour ambulatory motility testing in one patient, and 24-hour ambulatory motility testing clarified the motility diagnosis in five other patients. The most common underlying disorder was achalasia, which was detected in nine (43%) patients. A hypertensive lower esophageal sphincter was diagnosed in three patients, diffuse esophageal spasm in five, "nutcracker" esophagus in two, and a nonspecific motor disorder in two patients. One patient had an intraoperative myocardial infarction and died. Two patients had persistent mild dysphagia after surgery. The remaining patients had complete relief of their primary symptoms.

CONCLUSIONS

There is a high prevalence of named motility disorders in patients with epiphrenic diverticula, and this condition is associated with the potential for lethal aspiration. Twenty-four-hour ambulatory motility testing can be helpful if the results of the stationary examination are normal or indefinite. Resection of the diverticula and a surgical myotomy of the manometrically defined abnormal segment results in relief of symptoms and protection from aspiration.

Authors+Show Affiliations

Department of Surgery, University of Southern California, Los Angeles, California 90033-4612, USA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

11882756

Citation

Nehra, Dhiren, et al. "Physiologic Basis for the Treatment of Epiphrenic Diverticulum." Annals of Surgery, vol. 235, no. 3, 2002, pp. 346-54.
Nehra D, Lord RV, DeMeester TR, et al. Physiologic basis for the treatment of epiphrenic diverticulum. Ann Surg. 2002;235(3):346-54.
Nehra, D., Lord, R. V., DeMeester, T. R., Theisen, J., Peters, J. H., Crookes, P. F., & Bremner, C. G. (2002). Physiologic basis for the treatment of epiphrenic diverticulum. Annals of Surgery, 235(3), pp. 346-54.
Nehra D, et al. Physiologic Basis for the Treatment of Epiphrenic Diverticulum. Ann Surg. 2002;235(3):346-54. PubMed PMID: 11882756.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Physiologic basis for the treatment of epiphrenic diverticulum. AU - Nehra,Dhiren, AU - Lord,Reginald V, AU - DeMeester,Tom R, AU - Theisen,Jörg, AU - Peters,Jeffrey H, AU - Crookes,Peter F, AU - Bremner,Cedric G, PY - 2002/3/8/pubmed PY - 2002/4/16/medline PY - 2002/3/8/entrez SP - 346 EP - 54 JF - Annals of surgery JO - Ann. Surg. VL - 235 IS - 3 N2 - OBJECTIVE: To quantitate and characterize the motility abnormalities present in patients with epiphrenic diverticula and to assess the outcome of surgical treatment undertaken according to these abnormalities. SUMMARY BACKGROUND DATA: The concept that epiphrenic diverticula are complications of esophageal motility disorders rather than primary anatomic abnormalities is gradually becoming accepted. The inconsistency in identifying motility abnormalities in patients with epiphrenic diverticula is a major obstacle to the general acceptance of this concept. METHODS: The study population consisted of 21 consecutive patients with epiphrenic diverticula. All patients underwent videoesophagography, upper gastrointestinal endoscopy, and esophageal motility studies. The diverticula ranged in size from 3 to 10 cm and were predominantly right-sided. Seventeen patients underwent transthoracic diverticulectomy or diverticulopexy with esophageal myotomy and an antireflux procedure. The length of the myotomy was determined by the extent of the motility abnormality. Transhiatal esophagectomy was performed in one patient with multiple diverticula. Two patients declined surgical treatment and another patient died of aspiration before surgery. Symptomatic outcome was assessed via a questionnaire at a median of 24 months after surgery. RESULTS: The primary symptoms were dysphagia in 5 (24%) patients, dysphagia and regurgitation in 11 (52%) patients, and pulmonary symptoms in 5 (24%) patients. The median duration of the primary symptoms was 10 years. Esophageal motility abnormalities were identified in all patients. An esophageal motor disorder was diagnosed only by 24-hour ambulatory motility testing in one patient, and 24-hour ambulatory motility testing clarified the motility diagnosis in five other patients. The most common underlying disorder was achalasia, which was detected in nine (43%) patients. A hypertensive lower esophageal sphincter was diagnosed in three patients, diffuse esophageal spasm in five, "nutcracker" esophagus in two, and a nonspecific motor disorder in two patients. One patient had an intraoperative myocardial infarction and died. Two patients had persistent mild dysphagia after surgery. The remaining patients had complete relief of their primary symptoms. CONCLUSIONS: There is a high prevalence of named motility disorders in patients with epiphrenic diverticula, and this condition is associated with the potential for lethal aspiration. Twenty-four-hour ambulatory motility testing can be helpful if the results of the stationary examination are normal or indefinite. Resection of the diverticula and a surgical myotomy of the manometrically defined abnormal segment results in relief of symptoms and protection from aspiration. SN - 0003-4932 UR - https://www.unboundmedicine.com/medline/citation/11882756/Physiologic_basis_for_the_treatment_of_epiphrenic_diverticulum_ L2 - http://Insights.ovid.com/pubmed?pmid=11882756 DB - PRIME DP - Unbound Medicine ER -