INDICATIONS/CONTRAINDICATIONS

Indications for surgical intervention for esophageal diverticula include symptoms, large diverticula size, bleeding, and rarely cancer of the diverticulum (Avisar, 2000). Symptoms commonly include chest pain, dysphagia, and regurgitation of food or pills. Some patients are treated primarily for an achalasia pattern of symptoms and likely will need resection of the diverticulum and myotomy. Most patients seen by a surgeon are referred for symptoms, and the decision to operate is fairly straightforward, but in some cases, we have operated on asymptomatic patients depending on the size of the diverticulum and the degree of motor dysfunction that is revealed on workup. If the decision is made not to operate due to absent or minimal symptoms, we recommend follow-up, as it is likely that the epiphrenic diverticulum will enlarge and become symptomatic over time.

Our treatment of choice for diverticula in an epiphrenic location, associated with achalasia, hypertensive lower esophageal sphincter, or other motility disorders with abnormal manometry isolated to the distal esophagus is a right thoracoscopic diverticulectomy and a distal myotomy down onto the stomach. While some surgeons have advocated a laparoscopic approach, it can be quite difficult to retract the diverticulum at a right angle to the esophagus, expose the narrow neck, dissect this away from the musculature, and completely resect the diverticulum at its base laparoscopically. The laparoscopic approach does make the distal portion of the myotomy easier and also facilitates the creation of a partial fundoplication. However, we have seen several patients, both who have been treated exclusively by our practice and who have had a diverticulectomy performed elsewhere and then been referred to us, over the years with incompletely resected epiphrenic diverticula performed laparoscopically. Regardless of the approach, it is essential that a careful myotomy be performed distal and to some degree proximal to the diverticulum to allow adequate exposure of the neck. The larger the diverticulum is, and if there is an extension into the chest, the more compelling the argument to perform these cases via a video-assisted thoracoscopic (VATS) approach. If the VATS approach does not afford the view or access for a complete myotomy onto the stomach, one can always perform a laparoscopy at the end of the VATS portion of the case, complete the myotomy, and perform the anterior fundoplication.

Indications for Diverticulectomy

Dysphagia.

Regurgitation.

Cancer or dysplastic degeneration within the diverticulum.

Weight loss.

Aspiration.

Large diverticula with minimal to no symptoms in low-risk surgical patients.

Considerations for Observation

No symptoms.

Small diverticula (<5 cm) with minimal to no symptoms.

Significant mediastinal adenopathy in patients with midesophageal diverticula. An open approach should be considered. This may have to be determined intraoperatively.

Elderly, high-risk surgical patients with minimal symptoms.

PREOPERATIVE PLANNING

For midthoracic and epiphrenic diverticula, a barium swallow and an upper endoscopy should be performed preoperatively (Fig. 17.1). At some point, the surgeon should also perform his or her own flexible upper endoscopic examination of the patient prior to the procedure to identify the location of the diverticulum and to assess other potential-associated esophagogastric pathology. Ideally, manometry should be performed to assess the degree of esophageal motor dysfunction. This can generally be performed by an experienced esophageal testing center; it may require fluoroscopic or endoscopic guidance.

Patients with epiphrenic diverticula should have a clear liquid diet instituted at least 2 to 3 days before surgery to reduce risk of aspiration related to uncleared/retained esophageal and diverticular debris. This is especially important in patients with large diverticula and when a large diameter esophagus is present in the setting of achalasia. If significant debris is present at the time of the on-table endoscopy, careful clearance of all esophageal contents should also be performed. These interventions and perioperative risks should be discussed with the patient prior to surgery.

SURGERY

In the operating room, the patient is maintained in a supine position, and rapid sequence induction of general anesthesia is performed to minimize aspiration risk. The surgical team should be present at this time to assist with a Sellick maneuver and to alert the entire team to the risk of aspiration.

An esophagogastroduodenoscopy (EGD) should be performed at the start of the procedure to ensure that the esophagus and diverticula are clear of food debris. Esophagoscopy should also be performed after completion of the diverticulectomy during the surgical intervention, regardless of whether a myotomy was performed, to ensure that the mucosa and muscular wall of the esophagus at the area of the diverticulectomy are intact, and that no leak is present.

VATS Approach

The patient is placed in lateral decubitus position after double-lumen endotracheal intubation has been successfully accomplished to establish contralateral single-lung ventilation during the thoracic procedure. Proper endotracheal tube position is assured with bronchoscopic examination.

A right VATS approach can be used for epiphrenic and midesophageal diverticulum with the surgeon standing on the right side of the table (posterior aspect of the patient). In some cases, some surgeons will prefer a left VATS approach to the epiphrenic diverticulum as it may make easier to carry the myotomy down onto the stomach.

In our practice, we have successfully used the right VATS approach for virtually any mid- to distal esophageal diverticulum. In this setting, we place a retraction suture on the diaphragm to gain lower exposure, and put the patient in a moderate reverse Trendelenburg position to allow gravity to facilitate better exposure of the lower esophagus.

A 10-mm port is placed in the seventh or eighth intercostal space (Fig. 17.2) anteriorly for the initial thoracoscopic exploration and direction of subsequent intercostal access sites. Placing the port as low as possible has advantages for exposure of the distal esophagus and, frequently, we place this port right at the costophrenic angle. Posteriorly, we place another 10-mm port near the eighth intercostal space; again, keeping this port lower will facilitate the dissection angles. A 5-mm access site is established near the posterior scapular tip. During resection of true epiphrenic diverticulum, it may be wise to lower this port one interspace, especially in tall patients. Next, another 5-mm port is placed two to three interspaces above the camera port and just medial (toward the sternum) to allow a suction irrigator to keep the plane of dissection bloodless. The final 10-mm port is place higher, medial to the anterior axillary line, to allow placement of a fan-type lung retractor.

The presence of a first and second assistant allows the operation to flow more expeditiously as the first assistant holds the camera and the suction device and the second assistant retracts the lung. Alternately, a self-retaining retractor can be used for the lung retraction.

Division of the azygos vein with a vascular endoscopic stapler is often required to gain clear access/dissection for midesophageal dissection.

The esophagus is mobilized above and below the diverticulum with sharp dissection using autosonic shears, a harmonic scalpel, or similar device.

The diverticulum is identified and completely mobilized, and its neck/base is exposed for subsequent resection (Fig. 17.3). The epiphrenic and the larger midesophageal diverticula are commonly “false diverticula” and the delineation of the submucosa of the diverticula neck will be evident during the course of this dissection.