Large Epiphrenic Diverticula: A Rare Case Presentation

Abstract

A 70-year old female was admitted to hospital with heartburn and chronic halitosis since 5 years. She was on proton pump inhibitors for the same. Her complaints worsened during the last one-year. Workup comprising of esophago-gastro-duodenoscopy, esophageal manometry, 3D computed tomography scan showed right-sided epiphrenic diverticula measuring 10x10 cm with wide mouth about 5 cm with hypertensive lower esophageal sphincter. Patient underwent a video assisted thoracoscopic surgery for esophageal diverticulectomy using two 45 mm staplers. On day 5, the patient developed leak, which was managed by a covered esophageal stent placement. Patient started on oral feeds from day 3 and the esophageal leak healed completely within 2 weeks. Literature suggests that esophageal leaks treated conservatively took approximately 30-40 days on an average for healing. Literature search did not reveal esophageal leak managed by stent with faster recovery (2 weeks). This is one of the largest epiphrenic diverticuli reported in literature.

Keywords: Epiphrenic diverticulum; achalasia; leak; stent.

Figure 1.

A) High resolution computed tomography (CT) scan of thorax showing right sided epiphrenic diverticulum (arrow); B) 3D CT scan of thorax revealed a right-sided epiphrenic diverticula measuring 10x10x5.0 cm with maximum wall thickness being 3 mm.

Figure 2.

Esophago-gastro-duodenoscopic picture showing esophageal opening and diverticulum.

Figure 3.

A) Intra-operative picture showing stapling of the diverticulum being done; B) intra-operative esophago-gastro-duodenoscopic view showing stapling of the diverticulum being done.

Figure 4.

A) Esophago-gastro-duodenoscopic (OGD) picture showing post operative leak through lowermost part of the staple line (arrow); B) OGD view of the esophagus showing stent placement done to seal off the leak site post operatively (arrow).