Fig. 13.1
Typical epiphrenic diverticulum in association with achalasia
It is estimated that fewer than 10 % of patients develop symptoms or complications of their diverticula in the absence of additional motility abnormalities such as achalasia [3]. Patients with a diverticulum and an associated motility disorder that requires therapy should be offered surgery for management of both problems. Although dysphagia and regurgitation are the most common symptoms, patients should also be routinely asked about pain, weight loss and respiratory complaints [4]. The association of diverticulum size with symptoms is inconsistent and should not be used as a criterion for surgery [5]. The diameter of the neck of the diverticulum is related to the severity of symptoms in many patients. Those with a narrow-necked diverticulum experience more delayed regurgitation and risk of aspiration, whereas patients with a wide-necked diverticulum tend to empty their pouches readily and with less regurgitation.
A recent interesting study compared outcomes in patients with achalasia and epiphrenic diverticulum who underwent diverticulectomy to those who did not undergo diverticulectomy (small size or due to technical reasons – high sac or adhesions) with their laparoscopic myotomy and Dor fundoplication. Interestingly, the diverticula were larger in the group who did not undergo excision for technical reasons, the neck diameters were similar, and patients in both groups went from an average Eckardt score of 6.5 preoperatively to 0 postoperatively [6]. These findings suggest, at least in patients with achalasia, that treating the motor disorder may be all that is required and, subjecting these patients to the risk of leak associated with diverticulectomy may be unnecessary.
Dysplastic or neoplastic processes may affect the diverticulum in rare instances, and also may coincidentally occur in conjunction with a diverticulum resulting in spurious attribution of obstructive symptoms to the diverticulum. Thus, upper endoscopy should be part of the routine pre-operative work-up. Barium swallow and possibly computed tomography of the chest are the most important tests for preoperative planning. They define the size of the diverticulum, its radial location, the width of its neck, and the distance from the gastro-esophageal junction.
Operative Procedure
The patient is intubated with a double lumen endotracheal tube for single lung ventilation and positioned in the right lateral decubitus position with the left side up. After left lung isolation, four thoracoscopic ports are placed (Fig. 13.2). The camera port (5 mm) is placed in the seventh or eighth intercostal space in the center line of the chest. A 5 mm port is placed at the eighth or ninth intercostal space posteriorly for the surgeon’s left hand. A 5 mm port is placed medial to the tip of the scapula for the surgeon’s right hand, and a 5 mm port is placed in the fourth intercostal space anterior to the latissimus dorsi for retraction and counter-traction during the esophageal dissection. At least one of the ports will need upsizing for passage of sutures, an endo-stitch device, and a stapler. The decision regarding which port to upsize is made intraoperatively.
Fig. 13.2
Port placement for thoracoscopic diverticulectomy and esophagomyotomy
A 0 silk stitch is placed in the central tendon of the diaphragm and brought out of the anterior chest wall through a 3-mm skin nick at the level of the costophrenic sulcus using the endo-close device. This traction suture allows downward deflection of the diaphragm without the need for a retractor and gives good exposure of the distal esophagus.
The diverticulum most often presents to the patient’s right. The pulmonary ligament is divided to the level of the inferior pulmonary vein. The mediastinal pleura is divided laterally along the esophagus from the hiatus to the aortic arch. The esophagus is dissected circumferentially from several centimeters proximal to the diverticulum to several centimeters distal to the diverticulum. A tape or Penrose drain is placed around the esophagus for use in retraction.
The diverticulum is freed from its mediastinal attachments and the esophagus is rotated 180° to enable visualization of its neck. The tip of the diverticulum is grasped and the overlying connective tissues are dissected free to clearly identify the neck of the diverticulum arising between the muscular fibers (Fig. 13.3). A 50 French bougie is guided down the esophagus and into the stomach while carefully retracting the diverticulum to aid with maintaining esophageal lumen diameter during the diverticulectomy.
Fig. 13.3
The diverticulum is dissected of overlying soft tissues to the level of its neck
An articulating endoscopic stapling device is placed parallel to the esophagus at the base of the diverticulum, through the port which provides the best angle of approach. There should be minimal traction on the diverticulum to avoid compromising the subsequent esophageal lumen. The stapler is fired (Fig. 13.4) and the diverticulum is removed. Esophagoscopy is performed to ensure that no mucosal leak is present. The esophagoscope is left in place. The esophageal muscle layers are closed over the stump with a running suture (Fig. 13.5).
