Modern Management of Esophageal Diverticula

Armando Rosales-velderrain, MD, Steven P Bowers, MD, Ross F Goldberg, MD, Tatyan M Clarke, MD, Lauren M Olsen, Mauricia A Buchanan, RN, John A Stauffer, MD, Horacio J Asbun, MD, C D Smith, MD. Mayo Clinic in Florida

Introduction: Esophageal diverticula are rare, with the largest series in the literature including less than 25 patients. Esophageal diverticula (ED) are typically characterized as either pulsion diverticula (PD), which result from an increased intraesophageal pressure, or traction diverticula (TD) that are associated to periesophageal chronic inflammation. Typically PD are epiphrenic, and TD midthoracic, but each can occur variably in location. When ED are large and/or symptomatic surgical management is indicated. Herein we report our experience with the surgical management of ED since applying minimally invasive surgical (MIS) approaches to this condition, which to the authors’ knowledge this represents the largest case series.

Methods: Between 1997 and 2011, 36 patients underwent surgical management of symptomatic ED [17 men and 19 women, aged 67 ± 12 years, BMI 27 ± 4 kg/m²]. We retrospectively reviewed these patients’ records specifically looking operative approach, perioperative and long-term outcomes. Of the 36 patients, 31 had a PD (29 epiphrenic and 2 midthoracic), and 5 had a TD (1 epiphrenic and 4 midthoracic). Eleven patients had undergone a prior foregut operation for GERD or hiatal hernia (6), esophageal diverticulectomy (3), closure of an esophagobronchial fistula (1), and gastrojejunostomy with vagotomy (1). An esophageal motility disorder was present in 22 patients (PD, 21 and TD, 1). Three patients with a PD had an esophageal stricture.
 

Results: A MIS approach was attempted in 29 patients, and completed in 26 patients [laparoscopic (Lap); 20 PD and 1 TD, video assisted thoracoscopy (VATS); 1 PD and 1 TD or (VATS-Lap); 2 PD and 1 TD]. Three patients were converted to an open approach, and another 7 patients underwent a primary open approach. Stapled diverticulectomy was performed in 30 patients (MIS, 21 and open, 9), 4 patients with PD underwent a diverticulum imbrication. An esophagogastric myotomy was performed in 29 patients (PD, 26 and TD, 3), and fundoplication in 23 patients (PD, 21 and TD, 2). During intraoperative endoscopy two staple line leaks were detected and oversewn. Perioperatively 6 patients developed complications, with 4 staple line leaks. None were in patients who had leaks identified intraoperatively. In 2 patients with postoperative leaks no myotomy was performed. The median hospital stay was 3 and 6 days for the MIS and open procedure, respectively. There were no perioperative deaths. During a median follow-up of 4 weeks (2-35), 2 patients developed recurrent diverticula; 1 had not undergone a myotomy. Only 1 patient who underwent resection and myotomy with fundoplication remained symptomatic.
 

Conclusions: This large series of esophageal diverticula managed by MIS approach(s) confirms that the procedure is safe and relieves symptoms in the majority of patients. Leaks can occur and when found intraoperatively can be managed. Postoperative leaks were associated with prior diverticulectomy and not performing a myotomy at the time of diverticulectomy. An MIS approach should be offered when appropriate.
 

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