A 67-year-old man presents with dysphagia of two years duration, and his barium swallow is shown. The best treatment is

A. endoscopic pressure-controlled balloon dilatation of the distal esophageal sphincter.
B. esophageal dilatation with Maloney dilators under fluoroscopic guidance.
C. left thoracotomy, resection of the lesion and distal myotomy.
D. right thoracotomy and extended myotomy.
E. thoracoscopic resection of the lesion.

Answer C

The barium swallow shows a large epiphrenic diverticulum. Many such diverticulae develop secondary to dysmotility syndromes. From the aortic arch level down to the esophagogastric junction, tertiary motor activity causes the many visual aspects mentioned in the literature: a corkscrew, a rosary bead, or simple curling of the barium column. Intermittent appearance of a diverticulum may be observed or an epiphrenic diverticulum may be present. Hypermotility disorders have been classified according to manometric criteria: idiopathic diffuse esophageal spasm, hyperperistalsis (nutcracker or supersqueeze esophagus), and hypertensive lower esophageal sphincter (LES). The association of dysphagia (problems swallowing) with odynophagia (painful swallowing), especially with episodes of unexplained chest pain, usually leads to esophageal assessment and a correct diagnosis. 

Endoscopy may also reveal contraction abnormalities or a diverticulum. Esophageal motility studies may show normal function in the upper esophageal sphincter and the proximal third of the esophagus. Tertiary contractions occur in more than 10% but less than 100% of voluntary swallows. The LES is frequently mentioned as normal in patients with diffuse spasm. Hypertensive, poorly relaxing, and incoordinated lower sphincters can be seen in up to 30% of swallows in patients with hypermotility disorders especially with epiphrenic diverticuli. 

Surgical treatment is considered only after full psychological assessment and a trial at medical control of symptoms. 

Significant incapacitation with adverse effects on normal life must be present since results are not as good as for achalasia. For treatment of the hypermotility disorder in a patient with epiphrenic diverticulum, the esophagus is mobilized through a left thoracotomy, and the esophagogastric junction is freed. Once free, the esophagus must be rotated to deliver the diverticulum into the left side of the chest. With a mercury-filled bougie occupying the esophageal lumen to protect its integrity, the diverticulum is resected, and the esophageal wall is closed. Resection of the diverticulum alone ignores the functional motility disturbance causing the diverticulum. A long esophageal myotomy is then carried out contralateral to the site of the diverticulectomy. The length must include the entire area of abnormal motility in the esophageal body, including the LES. If preoperative manometry indicates a hypertensive LES, the myotomy is extended across the LES. A partial fundoplication of the Belsey type may then be added. 

Benacci JC, Deschamps C, Trastek VF, Allen MS, Daly RC, Pairolero PC. Epiphrenic diverticulum: results of surgical treatment. Ann Thorac Surg 1993;55:1109-13.
From 1975 to 1991, 112 patients (64 men and 48 women) were found to have an epiphrenic diverticulum. Symptoms were absent or minimal in 71 patients and incapacitating in 41. All patients with minimal symptoms were managed conservatively; 35 were available for follow-up, which ranged from 1 to 25 years (median, 9 years). None of these 35 patients had clinically significant progression of symptoms. Surgical repair was done in 33 patients with incapacitating symptoms. Achalasia was present in 8 of the surgical patients (24.2%), diffuse esophageal spasm in 3 (9.1%), hypertensive lower esophageal sphincter alone in 1 (3.0%), and nonspecific motor abnormalities of the esophageal body in 7 (21.2%). Diverticulectomy and esophagomyotomy were performed in 22 patients, diverticulectomy alone in 7, esophageal resection in 3, and esophagomyotomy alone in 1. Concomitant hiatal hernia repair was done in 6 patients. Complications occurred in 11 patients; 6 had esophageal leaks. There were three operative deaths (9.1%), all occurring in patients with abnormal manometry. Follow-up was complete in 29 patients and ranged from 4 months to 15 years (median, 6.9 years). Long-term results were excellent in 14 patients (48.2%), good in 8 (27.6%), fair in 5 (17.2%), and poor in 2 (6.9%). We conclude that operation has significant risks and is not warranted in patients with minimal symptoms because progression is unlikely. Surgical treatment, however, is advisable in patients with incapacitating symptoms because most operative survivors will have long-term symptomatic palliation.