Endoluminal Functional Imaging Demonstrates Need for Myotomy During Epiphrenic Diverticulectomy

Epiphrenic diverticulum develops when elevated esophageal intraluminal pressure causes herniation of the mucosa and submucosa through an area weakness in muscularis layer. Treatment must address both underlying dysmotility. The endoluminal functional lumen imaging probe allows measurement lower sphincter pressures to achieve ideal distensibility that prevents postoperative gastroesophageal reflux disease as well recurrence. We present case a 60-year-old woman with epiphrenic who underwent robot-assisted laparoscopic diverticulectomy Heller myotomy Dor fundoplication. was used for intraoperative monitoring. has incidence approximately 1 500,000 individuals per year.1Kilic A. Schuchert M.J. Awais O. Luketich J.D. Landreneau R.J. Surgical management diverticula minimally invasive era.JSLS. 2009; 13: 160-164PubMed Google Scholar These are categorized false or pseudodiverticula they do not involve all 3 layers esophagus. most commonly develop (LES) dysfunction dysmotility elevates pressure, causing They found within 10 cm junction (GEJ). If left untreated, may enlarge, resulting worsening dysphagia, disease, pain, and, severe cases, fistulization nearby structures.2Thomas M.L. Anthony A.A. Fosh B.G. Finch J.G. Maddern G.J. Oesophageal diverticula.Br J Surg. 2001; 88: 629-642Crossref PubMed Scopus (113) long-standing history managed proton pump inhibitor H2 receptor blocker. She also reported progressively belching, halitosis, heartburn. Barium esophagography demonstrated mild dilation esophagus, mildly decreased motility, 2.5-cm right-sided (Figure 1A) confirmed on esophagogastroduodenoscopy. patient elected undergo diverticulectomy, myotomy, fundoplication (Video). An 8-cm (FLIP, 325N) impedance planimetry at each stage operation. FLIP uses balloon catheter collect real-time cross-sectional (mm2) manometry data (mm Hg). Distensibility index (DI; mm2/mm Hg) is calculated by dividing given level esophagus median intraballoon using predetermined filling volume. Before any surgical intervention, patient’s DI be 0.4 Hg 30 mL (which had adequate pressure), consistent LES 2A). <0.8 need myotomy. crura diaphragm were dissected, followed circumferential dissection obtain length fully dissect 3A). Care taken preserve anterior posterior vagus nerves. A performed Harmonic scalpel (Ethicon), longitudinal circular muscle total 6 above 2 below GEJ while leaving intact 3B). placed endoscope ensure narrowed resected white loads robotic stapler 3C). after 2.3 Hg, thus demonstrating 2B). (180° wrap) prevent 3D). final 1.8 2C), which too tight.Figure 3Intraoperative images. (A) Dissection preservation left/anterior nerve. (B) myotomy; propria layer divided bipolar instrument submucosal (C) (two 45-mm loads). (D) fundoplication; greater curvature stomach sutured right crus diaphragm.View Large Image Figure ViewerDownload Hi-res image Download (PPT) did postoperatively. Postoperative resolution without evidence extravasation contrast material 1B). have normal motility distensibility. Clear liquids initiated day 1. discharged full liquid diet weeks. By week 4, she tolerating regular her dysphagia symptoms. Final pathologic examination absent propria, diagnosis diverticulum. At 18 months operation, symptoms dysphagia. In this case, we real-time, objective manometric demonstrate tight setting subsequent abnormality Furthermore, guide decision-making, ensuring adequacy tight. ability perform advantageous it confirmation achalasia.3Law Y.Y. Nguyen D.T. Meisenbach L.M. et al.Intraoperative treatment achalasia EndoFLIP during fundoplication.Surg Endosc. 2022; 36: 2365-2372Crossref (2) study evaluating measurements patients hiatal hernia, >99% probability having values can monitor how compliance changes procedure result intrinsic (ie, before transection layer) extrinsic compression fundoplication) factors. Operations tailored individual basis provided avoid iatrogenic narrowing GEJ. use robot operation incurs additional costs compared operation; however, discovered there significantly fewer technical complications fundoplication.4Ali A.B. Khan N.A. al.Robotic per-oral endoscopic myotomy.Surg 2020; 34: 3191-3196Crossref (20) Thus, improves clinical outcomes, adding value despite cost. supports presenting helps tailor creation Further investigation still needed determine optimal differing degrees impaired dysfunction. Video viewed online version article [https://doi.org/10.1016/j.atssr.2023.04.008] http://www.annalsthoracicsurgery.org. authors no funding sources disclose.