Combined thoracoscopic and laparoscopic surgery for epiphrenic diverticulum with associated gastroesophageal reflux disease: a case report

Abstract

Background: Surgery is indicated for symptomatic epiphrenic esophageal diverticula. Based on the features of a case, thoracoscopic or laparoscopic approaches may be used. Epiphrenic diverticula are often associated with esophageal motility disorders, but cases of reflux esophagitis have rarely been reported. In this report, we describe a case of an epiphrenic esophageal diverticulum with reflux esophagitis, which was successfully treated by thoracoscopic diverticulectomy and laparoscopic fundoplication.

Case presentation: A 69-year-old man visited the hospital with a chief complaint of eructation and hiccup. Upper gastrointestinal endoscopy revealed a diverticulum in the left wall of the esophagus, which was 37-45 cm distal to the incisors. High-resolution manometry (HRM) showed no esophageal motility disorders. Due to the large size of the diverticulum, a thoracoscopic resection of the esophageal diverticulum was performed. Additionally, the patient had reflux esophagitis due to a hiatal hernia. The anti-reflux mechanism would be more impaired during the diverticulectomy; therefore, we decided that anti-reflux surgery should be performed simultaneously. Thoracoscopic esophageal diverticulectomy and laparoscopic Dor fundoplication were performed. The patient had an uncomplicated postoperative course and was discharged on the tenth operative day. He has been symptom-free without acid secretion inhibitors for 21 months after the surgery.

Conclusions: We described a rare case of a large epiphrenic diverticulum with reflux esophagitis. A good surgical outcome was achieved by thoracoscopic resection of the diverticulum and laparoscopic Dor fundoplication.

Keywords: Epiphrenic diverticulum; Reflux esophagitis; Thoracoscopic diverticulectomy.

Fig. 1

Preoperative esophagogastroduodenoscopy. a Multiple erosions and scars in the diverticulum. b The epiphrenic diverticulum is contiguous with the esophageal hiatal hernia. c Close view of the SCJ showing evidence of Barrett’s esophagus and esophageal erosions contiguous with the SCJ. Blue triangles showed the esophagogastric junction. d Esophageal hiatal hernia viewed from the stomach

Fig. 2

Preoperative CT and esophagogram. a CT in the supine position. b CT in the prone position. c 3D-CT of the epiphrenic diverticulum. d: Esophagogram

Fig. 3

Surgical positions and trocar placement. a Prone position with 5 trocars during transthoracic diverticulectomy. b Spine position with 5 trocars and Nathanson retractor during laparoscopic Dor fundoplication

Fig. 4

Surgical findings. Blue triangles showed the diverticulum. a The diverticulum before dissection. b The diverticulum on the left side of the esophagus after dissection. c Resection of the diverticulum. d After resection of the diverticulum. e After suturing the muscular layer and adventitia

Fig. 5

Postoperative upper gastrointestinal series. a Upright position. b Head-down position

Fig. 6

Postoperative esophagogastroduodenoscopy. No findings of reflux esophagitis or diverticular recurrence