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Herbella et al. Mini-invasive Surg 2020;4:82 I http://dx.doi.org/10.20517/2574-1225.2020.84 Page 5 of 7

Figure 3. Schematic treatment selection tree diagram for epiphrenic diverticula

Some authors opt for treatment irrespective of symptoms due to the fear of aspiration of the contents of the
[25]
diverticulum. Symptoms of nocturnal intermittent aspiration are frequent ; however, cases of pneumonia
are rare [26,27] .

The risk of malignant transformation is negligible and does not justify an operation in asymptomatic
[13]
patients .

CONCLUSION
[18]
ED treatment may be associated to high morbidity and mortality in up to 4% of cases . Thus, these
patients should be preferably treated in centers with a high volume and expertise in esophageal surgery.
A conservative nonoperative approach is acceptable in asymptomatic or oligosymptomatic patients since
the risk for severe aspiration and cancer is exceptionally low. When surgery is indicated, the laparoscopic
approach should be favored as results are similar to the thoracoscopy approach, but it allows the
performance of a partial fundoplication to prevent pathologic reflux. Treatment of the underlying motor
[17]
disorder is imperative to relieve symptoms and prevent leaks when a diverticulectomy is performed ,
but the resection of the diverticulum may not to be necessary when they are small or very high up in the
mediastinum. A treatment selection tree diagram is provided in Figure 3. Endoscopic therapy is waiting a
careful evaluation but seems to be a promising alternative.

DECLARATIONS
Authors’ contributions
Conception and design, acquisition of data, analysis and interpretation of data, drafting the article: Herbella
FAM