Thoracoscopic Diverticulectomy for Epiphrenic Esophageal Diverticulum after Peroral Endoscopic Myotomy: A Report of Four Cases

Abstract

Introduction: An epiphrenic esophageal diverticulum (EED) typically occurs in association with esophageal motility disorders such as esophageal achalasia. Although peroral esophageal myotomy (POEM) is the current standard treatment for esophageal achalasia, laparoscopic diverticulectomy with esophageal myotomy and fundoplication are usually performed for EED. Here, we report four cases of thoracoscopic esophageal diverticulectomy performed for symptomatic EED after POEM for esophageal achalasia.

Case presentation: Between 2022 and March 2024, four patients with EED (average diameter, 68 mm) underwent endoscopic esophageal cleaning prior to surgery. POEM was initially performed in all four cases; however, two patients experienced persistent symptoms, while two experienced progressive EED enlargement over the years, necessitating additional surgery. All operations were performed thoracoscopically with the patient in the left lateral position. After resection of the EED, the mediastinal pleura was sutured. Endoscopy, using an endoscopic balloon, was effective in preventing esophageal strictures. No postoperative complications occurred, and the mean postoperative hospital stay was 5.5 (4-8) days. All patients improved postoperatively and remained relapse-free.

Conclusions: Thoracoscopic esophageal diverticulectomy for large EED can be safely performed with better working space than laparoscopic procedures. Therefore, this technique should be considered a minimally invasive treatment for symptomatic EED cases unresponsive to POEM.

Keywords: epiphrenic esophageal diverticulum; esophageal achalasia; thoracoscopic esophageal diverticulectomy.

Fig. 1. Findings of epiphrenic esophageal diverticulum after peroral esophageal myotomy in patient 4. (A) Contrast study using amidotrizoic acid showing the two esophageal diverticula, which are borderline (black arrow). (B) Endoscopy image showing the cranial segment of the esophageal diverticulum. (C) Endoscopy showing a caudal esophageal diverticulum with ulcerative lesions (white arrow).

Fig. 2. Surgical findings in patient 4. (A) Photograph showing the right esophagus after dissection. (B) Esophageal diverticula are dissected and exposed. Adhesions are observed on the dorsal and ventral sides of the esophagus. (C) Esophageal diverticula are transected using a linear stapler with endoscopic assistance. The light from the endoscope (white arrow) is a landmark of the esophageal wall. (D) A 10-Fr silicone drain is inserted into the mediastinal cavity.

Fig. 3. Postoperative findings in patient 4. (A) Contrast study using amidotrizoic acid demonstrating that the esophageal diverticula had disappeared. (B, C) Endoscopy revealing that both esophageal diverticula improved 1 month postoperatively. (D) Surgical specimen showing two esophageal diverticula.