Video-Assisted Thoracoscopic Surgery Resection of a Large Esophageal Diverticulum With Esophageal Myotomy

Introduction

Esophageal diverticulum is a rare condition characterized by protrusion of the esophageal mucosa through an area of weakness in the surrounding muscular layers. Generally, esophageal diverticula can be categorized as pulsion or traction. The former constitutes a false diverticulum, as the mucosa is the only protruding layer (1). Traction diverticula, on the other hand, include all muscular layers of the esophagus and tend to occur as a result of mediastinal inflammation (1, 2). Midesophageal, also known as parabronchial, diverticula account for only 15-30% of all esophageal diverticula (2, 3). They are characterized by their location in the middle third of the esophagus and are typically associated with mediastinal inflammation (4).

Surgery is generally undertaken for patients who present with large complex diverticula causing moderate to severe symptoms (aspiration, reflux, regurgitation, or dysphagia) (5). In recent years, thoracoscopic and laparoscopic techniques for the management of esophageal diverticula have become increasingly common. These minimally invasive techniques have reduced the risk of operative mortality while maintaining the benefits of symptom relief seen with open surgery (6, 7). The authors present a right video-assisted thoracoscopic approach for resection of a distal esophageal diverticulum.

Tips and Tricks

This procedure may be performed by any surgeon familiar with video-assisted thoracoscopic surgical techniques. The authors have the following suggestions for increasing the chances of success when performing this procedure:

1. Intraoperative esophagogastroduodenoscopy (EGD) should be performed prior to manipulation of the diverticulum to clean the space and to correctly identify the neck of the defect. EGD should also be performed following the procedure to ensure adequate stapling.
2. A diaphragmatic suture should be placed to improve exposure for large diverticula.
3. It is necessary to completely dissect and remove the diverticulum at its true base in order to prevent recurrence.
4. Diverticulectomy and esophageal myotomy should be performed over a bougie dilator to reduce the risk of iatrogenic stenosis.
5. Following the diverticulectomy and myotomy, the esophagus should be completely submerged in sterile water and insufflated to perform an intraoperative leak test.
6. The diverticulectomy staple line should be covered by soft tissue to reduce the risk of fistula formation.
7. A drain should be left close to, but not directly in contact with, the diverticulectomy site. This allows for monitoring of leak in the postoperative period.
8. A postoperative upper gastrointestinal or computed tomography contrast swallow study should be performed prior to advancing the patient’s diet.
9. These patients are typically ready to go home on postoperative day two to four, and they should remain on a full liquid diet until the first postoperative clinic visit.

References

1. Ballehaninna UK, Shaw JP, Brichkov I. Traction esophageal diverticulum: a rare cause of gastro-intestinal bleeding. Springerplus. 2012;1(1):50.
2. Sonbare DJ. Pulsion diverticulum of the oesophagus: more than just an out pouch. Indian J Surg. 2015;77(1):44-48.
3. Palanivelu C, Vij A, Rajapandian S, Palanisamy S, Ahluwalliah JS, Palanivelu P. Laparoendoscopic single site oesophageal diverticulectomy. J Minim Access Surg. 2013;9(3):128-131.
4. Fernando HC, Luketich JD, Samphire J, et al. Minimally invasive operation for esophageal diverticula. Ann Thorac Surg. 2005;80(6):2076-2080.
5. Caronia FP, Fiorelli A, Santini M, Lo Monte AI. Uniportal video-assisted thoracoscopic surgery resection of a giant midesophageal diverticulum. Ann Thorac Surg. 2017;103(4):e365-e367.
6. Kilic A, Schuchert MJ, Awais O, Luketich JD, Landreneau RJ. Surgical management of epiphrenic diverticula in the minimally invasive era. JSLS. 2009;13(2):160-164.
7. Macke RA, Luketich JD, Pennathur A, et al. Thoracic esophageal diverticula: a 15-year experience of minimally invasive surgical management. Ann Thorac Surg. 2015;100(5):1795-1802.