Laparoscopic transhiatal oesophageal diverticulectomy: An experience of large epiphrenic oesophageal diverticulum and review literature

Abstract

Epiphrenic diverticulum is a rare abnormality of the distal oesophagus. Both thoracic and abdominal approaches are suitable for this diverticulum. A 46-year-old male presented with complaints of regurgitation and chest pain for 2 years. Contrast-enhanced computed tomography of the neck, thorax, abdomen and oesophageal endoscopy revealed 12 cm × 10 cm size large intrathoracic oesophageal diverticulum. He underwent an elective laparoscopic transabdominal oesophageal diverticulectomy. Gastrograffin study on the first post-operative day did not reveal any leak. In this case report, we are sharing our experience in the management of large epiphrenic oesophageal diverticulum through a laparoscopic approach. The benefits of the laparoscopic approach include decreased morbidity because we can avoid large thoracotomy or laparotomy incision.

INTRODUCTION

Epiphrenic diverticulum is a rare anatomical as well as functional abnormality of the distal oesophagus. Multiple factors affect this disease process, but functional incoordination in between the pharyngeal and oesophageal sphincter is the most important factor for weakness and outpouching of the distal oesophagus. According to the previous reports, the actual incidence is not known, but the prevalence in the different parts of the world is 0.015%–2%.[1]

CASE REPORT

A 46-year-oldmale presented with complaints of dysphagia, regurgitation, vomiting and epigastric pain for the last 2 years. The pain was localised to the epigastric region and used to get aggravated after having food with no relieving factors. There was no history of similar complaints in the family or any other medical or surgical illness. All routine blood investigations and echocardiogram were normal. Contrast-enhanced computed tomography of the neck, thorax and abdomen revealed a large outpouching with size 12 cm × 10 cm arising from the left posterolateral wall of the oesophagus just proximal to oesophagogastric junction, containing an air-fluid level suggestive of epiphrenic diverticulum [Figure 1a]. The neck of the diverticulum measured 3.3 cm in diameter. The diverticulum was abutting the left dome of the diaphragm and indenting on the fundus of the stomach. The entire oesophagus was dilated and showed air-fluid levels. Both lungs showed the signs of chronic aspiration. The upper gastrointestinal endoscopy confirmed the diagnosis of a large epiphrenic oesophageal diverticulum. The contrast study showed the irregular shape of contrast collection with air-fluid level in the lower part of the oesophagus [Figure 1b and c].

Figure 1.

Contrast-enhanced computed tomography of the thorax finding revealed a large outpouching of size 12 cm × 10 cm arising from the left posterolateral wall of the oesophagus (a) The gastrograffin study showed the irregular shape of contrast collection with air-fluid level in the lower part of the oesophagus (b and c)

The patient underwent elective laparoscopic transabdominal oesophageal diverticulectomy. He was positioned in reverse Trendelenburg with spread legs. The gastrohepatic ligament was divided by ultrasonic dissection [Figure 2a]. The gastro-esophageal junction was mobilised and encircled with umbilical tape [Figure 2b]. The epiphrenic diverticulum was mobilised and pulled into the abdominal cavity [Figure 2c]. An endo-GI stapler was fired across the neck of the oesophageal diverticulum [Figure 2d]. Haemostasis was ensured, and a leak test was performed using methylene blue, which was negative. Heller's myotomy followed by anti-reflux surgery was done.

Figure 2.

Intraoperative image: Division of gastro-hepatic ligament (a) Mobilization of gastro-esophageal junction and encircled with umbilical tape (b) Mobilization of epiphrenic diverticulum and pulled into abdominal cavity (c) An endo GI stapler was fired across the neck of esophageal diverticulum (d)

On postoperative day 1, gastrograffin study revealed no leak from the stapler line, and the patient was allowed liquid orally. The patient was discharged on the third post-operative day in the satisfactory condition. Histopathology revealed no evidence of malignancy in the specimen. The patient is being regularly follow-up for a period of 6 months and is doing well.

DISCUSSION

Epiphrenic diverticula are usually asymptomatic. Most patients are incidentally diagnosed in imaging done for abdomen pain, chest pain or chronic cough. Few large case series suggested myotomy and anti-reflux surgery after diverticulectomy due to association of some form of oesophageal motor disorder and regurgitation in most of the patients.[1,2,3] Therefore, the patient underwent a successful laparoscopic diverticulectomy with additional procedures. Tapias et al. case series of 31 patients showed no clear difference in the same procedure with or without the antireflux procedure.[4] Open transthoracic surgery represents the traditional approach for the treatment of symptomatic oesophageal diverticula.[4,5] Left thoracotomy or thoracoabdominal approach is a morbid procedure for the patients. However, the laparoscopic transhiatal approach has also been reported with success. Post-operative pain, drain output management, chest complications and long hospital stay are the major sequelae after thoracotomy. Other conventional procedures such as laparotomy also have complications related to wound infection which cause increased hospital stay and cost of treatment.

The thoracic approach has more chances of stapler site leak and abscess formation. The average hospital stay was longer (5–211 days) in thoracic and (5–18 days) in the abdominal case, but our case was discharged on post-operative day 3.[5] Few studies suggested that leakage rate was 12%–16% in thoracic case and very little chance or no leakage in abdominal surgery which is also observed with our case report.[3,4,5] Most literature reported the average size of epiphrenic oesophageal diverticulum is 7.4 cm and its ostium diameter up to 2 cm.[6] In our case, diverticulum size was 12 cm × 10 cm and ostium diameter was 3.3 cm size.

We are sharing our experience of a giant oesophageal diverticulum and successfully treated through a laparoscopic approach. A giant epiphrenic oesophageal diverticulum is a rare entity in the oesophagus. The laparoscopic transhiatal oesophageal diverticulectomy is more convenient, feasible and beneficial for the patients in terms of reduced hospital stay as well as post-operative complications.

Declaration of patient consent

The authors certify that they have obtained allappropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in thejournal. The patients understand that their names and initial s will not be published and due efforts will bemade to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.