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Laparoscopic management of epiphrenic diverticula

FERNANDO MIER AND JOHN G. HUNTER

Esophageal epiphrenic diverticula are pulsion diverticula located in the distal 10 cm of the esophagus. They represent the protrusion of the mucosa and submucosa through the muscular layers of the esophageal wall. (See Figure 45.1.)

They are quite rare findings but the true incidence is unknown, as only 15%-20% are symptomatic, with the majority of cases diagnosed incidentally during a radiographic or endoscopic examination performed for other reasons. The pathophysiology of this rare disease is still uncertain. Many authors believe that the diverticulum is not a primary problem; rather, it is secondary to an underlying esophageal motility disorder that results in increased intraluminal pressure against a distal functional or mechanical obstruction leading to herniation of the esophageal mucosa. This is a critical concept because it mandates the need for a myotomy at the time of surgical resection. The most common treatment of symptomatic epiphrenic diverticula is myotomy, surgical resection, and the antireflux procedure. The approach has evolved from a thoracotomy (see Chapter 43, “Left thoracic approach to esophageal diverticula”) to a laparoscopic transhiatal approach (as discussed in this chapter), or video-assisted thoracic surgery (refer to Chapter 44, “Thoracoscopic management of esophageal diverticula”).

CLINICAL PRESENTATION

A large number of patients with epiphrenic diverticula are asymptomatic and the diverticulum is found incidentally as part of a work-up for other reasons. These patients do not require treatment. In the symptomatic patient, the most common presenting complaints are dysphagia and regurgitation of undigested food, but halitosis, chest pain, and unintentional weight loss are also common. Respiratory complaints such as chronic nocturnal cough and laryngitis are due to episodes of aspiration, and may be the only presenting symptoms in some patients. Generally, symptoms correlate with the degree of esophageal dysmotility and not with the size of the diverticulum. Complications such as bleeding perforation or malignant transformation are rarely seen.

WORK-UP AND TREATMENT

Barium swallow, endoscopy, and esophageal manometry

All patients with esophageal epiphrenic diverticula should be evaluated with the same diagnostic imaging and physiologic studies as any patient with any other gastroesophageal pathology. The barium esophagogram should be the first test performed, as it is essential for operative planning and helps the endoscopist identify the diverticulum. This diagnostic test defines the size of the diverticulum, size of its neck, location, and distance from the gastroesophageal junction. In 70% of the patients, the diverticulum is on the right side and 15% of patients may have two or more diverticula. Upper endoscopy should also be performed in all patients with dysphagia and epiphrenic diverticula, mainly to rule out any neoplastic process. Furthermore, the use of endoscopy can also be used to identify the side of the opening of the diverticulum, size of its neck, and distance to the gastroesophageal junction. Finally, either stationary or ambulatory esophageal manometry should be performed to determine the underlying motility disorder. Several studies have shown that the prevalence of primary esophageal motility disorders in patients with esophageal epiphrenic diverticula ranges from 85% to 100%, with achalasia being the most common.

OPERATIVE TECHNIQUE

PREOPERATIVE CONSIDERATIONS AND PATIENT POSITION

The patient is positioned on the operative table, pneumatic compression stockings are used for deep vein thrombosis prophylaxis, and preoperative antibiotics are used prior to skin incision. A rapid sequence induction is always performed to prevent aspiration of undigested food. Endoscopy to remove all food from the diverticulum is performed the day before surgery or on the operating table after the induction of anesthesia. A Foley catheter is placed and the patient’s lower extremities are abducted and taped to the operating table. Once the abdomen is prepped and draped, the patient is positioned in steep reverse Trendelenburg.

PORT PLACEMENT

Our typical laparoscopic approach uses five ports placed in the same places we use for any surgery in the gastroesophageal junction or the hiatus (see Figure 45.2).

GASTROESOPHAGEAL JUNCTION DISSECTION, ESOPHAGEAL MOBILIZATION AND MEDIASTINAL DISSECTION, AND DIVERTICULECTOMY

The operation starts with opening the lesser omentum through the pars flaccida. Then the phrenoesophageal ligament is divided anteriorly from the apex of the right crus to the apex of the left crus, and the anterior vagus is identified and preserved. A window is then created posteriorly to the esophagus with identification of the posterior vagus. This will expose the rest of the diaphragmatic crura. At this point, a Penrose drain can be passed around the esophagus to enable retraction. We then proceed to the posterior mediastinal dissection. Most of the dissection can be done bluntly or with a Harmonic scalpel. The diverticulum is identified in the posterior mediastinum. If difficulty is encountered in identifying the diverticulum, intraoperative endoscopy is indicated at this point. Once identified, the diverticulum is bluntly dissected free of the surrounding tissues. Care must be taken not to injure the pleura, especially in cases where inflammatory tissue is encountered. If the pleura is breached, a chest tube may be required at the end of the case. The diverticulum should be dissected entirely from the mediastinal connective tissue until the neck is clearly isolated. A 56 Fr bougie is placed into the esophagus, to prevent narrowing, and the diverticulum is divided with a laparoscopic stapler. We usually use a laparoscopic stapler with a 2.5 mm vascular load but a thickened or inflamed diverticulum may require the use of longer staples. The staple line should be oriented longitudinally. The bougie is removed. (See Figure 45.3.)

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