Laparoscopic Transhiatal Approach for Resection of Midesophageal Diverticula

Benefits of laparoscopic trans-hiatal approach with Heller-Dor surgery in a case of mid-esophageal diverticulum

Compared to the more common epiphrenic diverticula, those located at the central section of the esophagus are quite rare. Minimally invasive approaches for mid-esophageal diverticula have lacked standardization. Certain mid-esophageal diverticula, like epiphrenic diverticula, have been attributed to esophageal motility disorders. Thus, we believe that surgery for esophageal diverticula requires preoperative evaluation of esophageal function, with additional surgery being performed in case of abnormalities. The laparoscopic trans-hiatal approach has been a common technique for managing epiphrenic diverticula but can also be used for mid-esophageal diverticula located far from the esophagogastric junction provided that the port location is carefully considered. Laparoscopic surgery is also preferable given that it is a minimally invasive procedure and allows for diverticulum resection and Heller myotomy and Dor surgery to prevent reflux in the same field of view. Hence, laparoscopic surgery may be a beneficial alternative to the traditional thoracic or thoracoabdominal techniques.

A case report of a midesophageal diverticulum mimicking a fibrovascular esophageal polyp

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Esophageal diverticula and esophageal fibrovascular polyps are uncommon entities.

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These anomalies often present with different symptomatology and may be associated with specific esophageal anatomy.

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We present a case of a midesophageal mass, which was suggestive of a fibrovascular polyp upon diagnostic workup.

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Operative exploration revealed the mass to be an esophageal diverticulum with a leading lipoma.

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Esophageal diverticula may arise in the midesophagus secondary to inflammation or traction, such as a leading lipoma.

Introduction

Esophageal diverticula and esophageal fibrovascular polyps are uncommon clinical entities. While an asymptomatic presentation is possible, symptoms, when present, may be dissimilar in their gastrointestinal or respiratory characteristics. Additionally, these findings typically occur in different segments of the esophagus, with polyps occurring most frequently in the cervical esophagus and the midesophagus being the predominant location of pathologic diverticula.

Presentation of case

We report the case of a 55-year-old patient who presented with a two-year history of progressive dysphagia secondary to a large proximal to midesophageal mass. Workup included esophagography, computed tomography, and endoscopy with ultrasound and was initially consistent with a diagnosis of a large esophageal fibrovascular polyp. Upon operative exploration, the mass was found to be a midesophageal diverticulum associated with a leading lipoma. The patient was successfully treated with transthoracic stapled diverticulectomy. At postoperative follow-up the patient was tolerating oral intake with no symptoms of dysphagia.

Discussion

Esophageal diverticula are typically found in the midesophagus and are thought to arise from radial traction secondary to mediastinal inflammation. Esophageal fibrovascular polyps may result from tracheobronchial compression, and esophagography typically identifies a mobile intraluminal mass.

Conclusion

Esophageal fibrovascular polyps and diverticula are rare, and a high index of suspicion is important in evaluation of these entities.

Laparoscopic transhiatal resection of a large mid-esophageal diverticulum: a case report

This is a description of transhiatal laparoscopic approach for mid-esophageal diverticulum. Traditionally mid-esophageal diverticula are approached by thoracotomy or thoracoscopy, with the laparoscopic technique being reserved for epiphrenic diverticula. A 78-year-old Caucasian female with a secondary dilatative ischemic cardiomyopathy presented with dysphagia, tenderness in the epigastrium and a considerable weight loss. A large mid-esophageal diverticulum was found on barium swallow and confirmed by CT scan. Underlying achalasia was recorded on manometry. The patient underwent diverticulectomy via transhiatal approach, followed by Heller myotomy and Dor fundoplication. Throughout the procedure auxiliary, esophagoscopic image was provided by interventional gastroenterologist due to a very narrow operating field and lack of orientation points. Based on our experience with this case, we propose transhiatal approach as a feasible alternative to thoracoscopy, in particular with patients who suffer from cardiac or pulmonary co-morbidities which make traditional techniques of high risk.

Esophageal strictures and diverticula

Esophageal disease and dysfunction of the lower esophageal sphincter (LES) manifesting as gastroesophageal reflux disease (GERD) particularly, is the most common of all gastrointestinal conditions impacting patients on a day-to-day basis. LES dysfunction can lead to anatomic changes to the distal esophagus, with GERD-mediated changes being benign stricture or progression of GERD to Barrett's esophagus and even esophageal cancer, and LES hypertension impairing esophageal emptying with subsequent development of pulsion esophageal diverticulum. This article details the causes, clinical presentation, workup, and treatment of esophageal stricture and epiphrenic esophageal diverticulum. Other types of esophageal diverticula (Zenker's and midesophageal) are also covered.