M L Thomas1, A A Anthony, B G Fosh, J G Finch, G J Maddern. 1. University of Adelaide Department of Surgery, Queen Elizabeth Hospital, Woodville Road, Woodville, Adelaide, South Australia 5011, Australia.
Abstract
BACKGROUND: Oesophageal pulsion diverticula, excluding pharyngeal types, are uncommon sequelae of oesophageal dysmotility. Current opinion favours myotomy as effective therapy, but the role of diverticulectomy, myotomy selection and placement, and the need for fundoplication remain unresolved. METHODS: A Medline search and review of references identified relevant English language articles. Data on epidemiology, aetiology, oesophageal motility, pathology, symptomatology, investigations, surgical management and outcome were examined. RESULTS: Data were largely retrospective. Significant morbidity and mortality were associated with pulmonary aspiration and diverticulectomy site leaks. Surgical outcome was similar whether or not a diverticulectomy was added to a myotomy, but a myotomy clearly reduced the risk of leaks. Fundoplication reduced the incidence of postcardiomyotomy reflux symptoms. Results from minimally invasive techniques were similar to those of open surgery. CONCLUSION: Surgery should be reserved for symptomatic patients; asymptomatic patients may benefit from surveillance. Pulmonary aspiration mandates surgical intervention. Myotomy remains the mainstay of treatment and an adequate subdiverticular extension is crucial in relieving obstruction. A partial fundoplication is preferred in selected patients. Minimally invasive techniques should become the routine approach for oesophageal pulsion diverticula.
BACKGROUND:Oesophageal pulsion diverticula, excluding pharyngeal types, are uncommon sequelae of oesophageal dysmotility. Current opinion favours myotomy as effective therapy, but the role of diverticulectomy, myotomy selection and placement, and the need for fundoplication remain unresolved. METHODS: A Medline search and review of references identified relevant English language articles. Data on epidemiology, aetiology, oesophageal motility, pathology, symptomatology, investigations, surgical management and outcome were examined. RESULTS: Data were largely retrospective. Significant morbidity and mortality were associated with pulmonary aspiration and diverticulectomy site leaks. Surgical outcome was similar whether or not a diverticulectomy was added to a myotomy, but a myotomy clearly reduced the risk of leaks. Fundoplication reduced the incidence of postcardiomyotomy reflux symptoms. Results from minimally invasive techniques were similar to those of open surgery. CONCLUSION: Surgery should be reserved for symptomatic patients; asymptomatic patients may benefit from surveillance. Pulmonary aspiration mandates surgical intervention. Myotomy remains the mainstay of treatment and an adequate subdiverticular extension is crucial in relieving obstruction. A partial fundoplication is preferred in selected patients. Minimally invasive techniques should become the routine approach for oesophageal pulsion diverticula.
Authors: Lora Melman; Jessica Quinlan; Brian Robertson; L M Brunt; Valerie J Halpin; J C Eagon; Margaret M Frisella; Brent D Matthews Journal: Surg Endosc Date: 2008-09-24 Impact factor: 4.584