Double Traction Epiphrenic Diverticula in a Nutcracker Esophagus

The Patient

The patient was a seventy-three-year-old man with known epiphrenic diverticula for 13 years. He presented with worsening dysphagia to solid foods, nocturnal coughing, and regurgitation. His relevant past medical history includes achalasia and hiatal hernia. His relevant past surgical history includes esophageal dilations for presumed nonrelaxing sphincter. The patient’s preoperative Eckardt score was three and a preoperative esophagram showed the proximal diverticulum at 7 cm from the GE junction, 4 cm in diameter, and projecting to the right. The distal diverticulum was 3 cm from GE junction, 3.5 cm in diameter, and projecting left.

Based on the number of esophageal wall layers, esophageal diverticula can be true or false. True diverticulum contains all cell layers and false ones only contain mucosa or submucosa. Based on means of formation, they can be classified as pulsion or traction. Based on the location, they can be pharyngeal, midesophageal, or epiphrenic. Epiphrenic diverticula are usually false and pulsion diverticulum. The patient underwent a robotic diverticulectomy from both abdomen and thoracic access with Heller myotomy and Dor fundoplication.

The Surgery

To begin, the patient was placed in a supine position with a 4-8 mm robotic port and a 12 mm assistant port placed as shown in the video. A dual-blade retractor for liver retraction, Cadiere forceps, Maryland bipolar forceps, and a vessel sealer were used in the case.

After entering the lesser sac and dissecting the hiatus, the distal diverticulum was dissected out from the surrounding tissue. A myotomy was performed circumferentially to clear the neck of the diverticulum. It is important to clear the neck of the diverticulum to ensure a clean staple line. A short burst of energy was used to avoid injury to the submucosa.

The myotomy was continued from the base of the diverticulum distally toward the cardia of the stomach. Stapling was completed last to minimize manipulation of the staple line. Keeping the diverticulum intact at this point allowed for proper dissection of the neck of the diverticulum to ensure a clean staple line.

An EGD was then performed. The diverticulum was stapled off, making sure the stapler was flush with the esophagus to prevent redundancy. Care was taken that the elbow of the stapler was not digging into the esophagus to avoid angulation.

An anterior cruroplasty was then performed to close the hiatus using 0-silk sutures. A posterior or lateral cruroplasty can also be performed. Care was taken that the hiatus was not closed too tightly to avoid narrowing or bending of the esophagus, which would lead to dysphagia or poor emptying. At the end, two instruments were able to pass through the hiatus to ensure proper closure.

The second stitch of a three stitch Dor fundoplication was then performed. The first stitch recreated the angle of His. The second stitch created the fundoplication, bringing the fundus to the right side of the right crus. Finally, the third stitch secured the fundus to the crus and elevated the fundus from the myotomy to prevent overcompression of the myotomy.

The abdomen was then closed in a typical fashion. An attempt was previously made to locate the proximal diverticulum from the abdomen before cruroplasty, but it was too proximal, so a thoracic approach was planned.

The patient was then placed in a left lateral decubitus position with 4-8 mm robotic port and a 12 mm assistant port. After entering the chest, the pleura was opened at the level of the right inferior pulmonary vein. A myotomy was performed circumferentially to clear the neck of the diverticulum. The myotomy was also extended distally to the top of the other diverticulum. Once again, a short burst of energy was used to avoid injury to the submucosa and avoid perforation.

An EGD was then performed. Care was taken at this step to not go to the distal staple line. The diverticulum was then stapled off. A leak test was performed and once it was confirmed that there was no leak, the proximal diverticulum staple line was oversewn. The authors do not feel strongly about oversewing the staple line, however, the pleura must be closed to minimize mediastinal contamination.

The patient had an uncomplicated postoperative course and was discharged home on postoperative day four. Upon follow up, his symptoms were resolved and an esophagram showed proper emptying and no leak.

Tips and Tricks

It is important to consider lung isolation strategies such as double lumen tube or bronchial blocker preoperatively in case a thoracic approach is desired or entry into bilateral pleural space is encountered. The approach should be assessed based on the superior aspect of each diverticulum to ensure proper stapling of the diverticulum. A thoracic approach can be considered for easier resection of a significantly proximal diverticulum.

It is important to properly myotomize the diverticulum neck and identify the submucosa to allow for a precise staple line. Endoscopic confirmation should be obtained before stapling to avoid narrowing the esophagus or to avoid leaving residual diverticulum behind. It is also important not to oversew the distal diverticulum staple line, as this increases the risk of stricture and blowout of the proximal staple line. Finally, the authors avoid tan load over purple or thicker load to avoid submucosal bleeding.

References

1. Wlodarczyk J, Smęder T, Obarski P. Surgical treatment of thoracic esophageal diverticula. Kardiochirurgia Torakochirurgia Pol Pol. J Cardio-Thorac Surg. 2023;20(1):1-6. doi:10.5114/kitp.2023.126091
2. Kamboj AK, Chan A, Codipilly DC. Multiple Esophageal Diverticula in Achalasia. Mayo Clin Proc. 2024;99(1):102-103. doi:10.1016/j.mayocp.2023.08.002
3. Uchi Y, Ozawa S, Ando T, Hayashi K, Aoki T, Shimazu M. Combined thoracoscopic and laparoscopic surgery for epiphrenic diverticulum with associated gastroesophageal reflux disease: a case report. Surg Case Rep. 2024;10(1):17. doi:10.1186/s40792-024-01813-0

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