What is the role of myotomy in treatment of diverticula associated with esophageal motor disorders ?
EH. Ellis Jr (Boston)
The need for cricopharyngeal myotomy in the management of all patients with pharyngoesophageal diverticulum has already been stated. These comments will be directed solely toward the role of myotomy in the treatment of patients with epiphrenic diverticula. Although some evidence exists that a motility disorder may be involved in some midesophageal traction diverticula , the need for operation in these instances is so uncommon that it does not warrant our attention here.
Kay  was the first to point out the association of thickened distal esophageal musculature with a variety of esophageal disorders, including epiphrenic diverticula. Several years later, Effler and associates  emphasized these findings as specifically related to a small group of patients with epiphrenic diverticula and recommended that esophagomyotomy be performed in all such patients.
In a discussion of that paper presented at the Central Surgical Association meeting, I pointed out that by using esophageal motility, patients who needed a myotomy could be identified. I recommended avoiding its use in patients without an underlying esophageal motor disorder, a view that I still hold. Although esophageal manometry was not available to Effler and associates  at the time of their report, Cross and associates , employing motility and cinefluorography, subsequently identified a variety of motor disorders that were present in patients with epiphrenic diverticula.
The need for an associated esophagomyotomy became clear from a comparison of two series of patients operated on at the Mayo Clinic . Postoperative
complications developed in 6 of 24 patients treated by diverticulectomy alone. Five patients had leakage from the suture line, resulting in the development of empyema in four patients and one death. A recurrent diverticulum developed in four patients. Of a subsequent group of 17 patients undergoing diverticulectomy, 10 patients also had myotomy with minimal morbidity and no recurrent diverticula.
The most recent report  from the Mayo Clinic on 18 patients undergoing diverticulectomy, 17 of whom also had myotomy, showed that their results were equally satisfactory. The authors now urge that an esophagomyotomy be performed at the time of diverticulectomy in all patients. Other recent recommendations include diverticulectomy with myotomy and Nissen fundoplication , diverticulectomy with myotomy and Belsey Mark IV fundoplication , and esophagomyotomy alone, particularly for small diverticula .
My preference is for diverticulectomy with myotomy employed concomitantly only in patients in whom preoperative esophageal motility studies identify abnormal esophageal function. A hiatus hernia, when present, should be repaired anatomically when gastroesophageal reflux (GER) is absent. In the presence of reflux symptoms and documented GER. partial fundoplication as in the Belsey Mark IV procedure should also be employed rather than complete wrap with its potential for postoperative dysphagia in a patient whose esophageal peristaltic activity has been rendered ineffective by the myotomy. Diverticulectomy is employed in practically all patients unless the diverticulum is exceedingly small (2 cm or less).
In the past 20 years, I have operated on 12 patients with epiphrenic diverticula at the Lahey Clinic. In the same period of time, 28 patients were operated on for Zenker's diverticulum, resulting in a 24 p. cent incidence (12 of 50 patients) of epiphrenic diverticula. Only a few patients with midesophageal traction diverticula were encountered during this time interval, none of whom required operation.
Nine of the 12 patients, two of whom had multiple (two) diverticula, proved to have an underlying motility disorder. Five patients had esophageal achalasia, and two patients had diffuse esophageal spasm (DES). One patient had DES with a hypertensive lower esophageal sphincter (LES). One of three patients without an associated motor disorder of the esophagus had a sliding esophageal hiatus hernia with GER.
Only one postoperative complication, an esophageal leakage, was treated successfully by drainage. Follow-up symptomatic evaluation was possible in 11 of 12 patients, the median follow-up interval being 7 years. Ten of the 11 patients followed up were asymptomatic as far as the esophagus was concerned.
In the patient with DES and hypertensive LES, reflux esophagitis with stricture developed and was managed medically.