Laparoscopic Heller Myotomy for Symptomatic Epiphrenic Diverticula: A Modern Technique

Epiphrenic diverticula are one of the three types of esophageal diverticula, along with Zenker's and midesophageal, and are extremely rare. They are almost always associated with underlying esophageal motility disorders such as achalasia, diffuse esophageal spasm, and nutcracker esophagus. They are false diverticula and are found slightly above the cardio-esophageal junction on the right side. Symptoms usually appear in the digestive system and include dysphagia, regurgitation, and chest pain, as well as in the respiratory system with the occurrence of chronic cough and aspiration pneumonia. Not all epiphrenic diverticula are symptomatic, and treatment is indicated only when symptoms develop. Imaging methods, such as barium swallow, aid in diagnosing epiphrenic diverticula but should always be combined with endoscopy to exclude malignancy, since, rarely, epiphrenic diverticula are associated with squamous cell carcinoma. Manometry is crucial for confirming the presence of a motility disorder, as well as pH monitoring for symptomatic reflux. The treatment of the pathophysiologic basis of the genesis of the epiphrenic diverticula is the primary concern, and this involves surgical myotomy, as well as endoscopic techniques such as peroral endoscopic myotomy (POEM). The results of symptom remission after the surgical approach are high.