“Functional approach” to esophageal body diverticula

Esophageal diverticula should be considered as epiphenomena of an esophageal motility disorder, thus a targeted approach should be taken into consideration when a treatment is indicated. Conventional surgical management consists in diverticulectomy or diverticulopexys, associated or not with a myotomy and/or fundoplication on the basis of the underlying motor disorder. A thorough endoscopic evaluation of the diverticulum, associated with a functional assessment of the esophageal motility is mandatory before the treatment. Surgical management of epiphrenic diverticula is often more challenging due to the long operation time and high postoperative complication and mortality rates, and reserved to referral centres. To date, despite the fact that diagnostic workup is now codified, there is not a solid consensus about the management of the diverticula, including the use of routine versus selective myotomy and whether or not a fundoplication should be included. Beyond its classical indications, recently the POEM technique has been applied for the performance of an endoscopic diverticulectomy by mean the submucosal myotomy of the diverticular septum. No literature data about the comparison between these different approaches are reported, so we reviewed literature data about the treatment modalities of diverticula of the esophageal body (mid-esophageal and epiphrenic), to highlight how to best address the choice.