Multiple huge epiphrenic esophageal diverticula with motility disease treated with video-assisted thoracoscopic and hand-assisted laparoscopic esophagectomy: a case report

Abstract

Background: Epiphrenic esophageal diverticulum is a rare condition that is often associated with a concomitant esophageal motor disorder. Some patients have the chief complaints of swallowing difficulty and gastroesophageal reflux; traditionally, such diverticula have been resected via right thoracotomy. Here, we describe a case with huge multiple epiphrenic diverticula with motility disorder, which were successfully resected using a video-assisted thoracic and laparoscopic procedure.

Case presentation: A 63-year-old man was admitted due to dysphagia, heartburn, and vomiting. An esophagogram demonstrated an S-shaped lower esophagus with multiple epiphrenic diverticula (75 × 55 mm and 30 × 30 mm) and obstruction by the lower esophageal sphincter (LES). Esophageal manometry showed normal peristaltic contractions in the esophageal body, whereas the LES pressure was high (98.6 mmHg). The pressure vector volume of LES was 23,972 mmHg² cm. Based on these findings, we diagnosed huge multiple epiphrenic diverticula with a hypertensive lower esophageal sphincter and judged that resection might be required. We performed lower esophagectomy with gastric conduit reconstruction using a video-assisted thoracic and hand-assisted laparoscopic procedure. The postoperative course was uneventful, and the esophagogram demonstrated good passage, with no leakage, stenosis, or diverticula.

Conclusions: The most common causes of mid-esophageal and epiphrenic diverticula are motility disorders of the esophageal body; appropriate treatment should be considered based on the morphological and motility findings.

Keywords: Epiphrenic esophageal diverticulum; Esophageal motility; Hypertensive lower esophageal sphincter; Video-assisted thoracic surgery.

Fig. 1

Preoperative imaging findings. a An upper gastrointestinal contrast study demonstrates dilatation of the esophagus and epiphrenic diverticula. b Upper gastrointestinal endoscopy shows a huge diverticulum in the lower esophagus (asterisk). c Endoscopic examination showed that the rosette-like esophageal folds appeared in the lower esophagus. d, e Chest computed tomography demonstrates dilatation of the esophagus and the epiphrenic diverticula of 50 × 40 mm and 25 × 25 mm in size. Arrows indicate the diverticula

Fig. 2

Preoperative esophageal manometry findings. a Intra-esophageal pressure measurement showing a high lower esophageal sphincter pressure and normal peristaltic waves. b The vector volume is very high (23,972 mmHg² cm)

Fig. 3

Operative findings and resected specimen. a The skin incision and the trocar placement (two 12-mm trocars and one 5-mm trocar in the abdomen and one 12-mm trocar in the chest). b Peeling of the hiatus. c Taping the huge right-sided diverticulum. d Resected specimen showing no abnormalities on its mucosal surface