Evolving Options in Management of Minimally Invasive Diverticular Disease: A Single Surgeon's Experience and Review of the Literature

Abstract

Background:

Esophageal thoracic diverticular disease is a rare condition resulting from multiple etiologies. Surgical management is recommended when symptomatic. Traditionally, a thoracotomy was considered the standard approach; however, the use of minimally invasive approaches has been associated with improved outcomes.

Methods:

We retrospectively reviewed a single surgeon's experience with minimally invasive esophageal diverticulectomy.

Results:

Fifteen patients with symptomatic esophageal diverticular disease underwent minimally invasive diverticulectomy between 2005 and 2018. Most patients (86.7%) had epiphrenic diverticula and 53.3% underwent a video-assisted thoracoscopic surgery approach. All patients had a diverticulectomy, while 14 patients (93.3%) also had an esophageal myotomy. Three patients (20%) underwent an extended myotomy, 4 patients (26.7%) underwent a concomitant fundoplication, and 2 patients (13.3%) underwent a concomitant paraesophageal hernia repair. Median length of hospital stay was 2 days (range, 1–16 days). There were no mortalities. Two patients (13.3%) were readmitted with delayed esophageal leaks. Median follow-up was 10.7 months (range, 10 days to 6.3 years). One patient presented with recurrent disease 5 years after his initial operation.

Conclusions:

In experienced hands, a minimally invasive diverticulectomy is safe, effective, and associated with excellent patient outcomes. A minimally invasive approach should be performed when possible and should be tailored to the individual patient's disease and preoperative workup.

Background

Esophageal diverticula are mucosal herniations through a weak point in the muscle layers of the esophagus. This condition is encountered in less than 1% of upper gastrointestinal studies and accounts for less than 3% of patients with dysphagia.¹ Midesophageal and epiphrenic diverticula are the result of increased intraluminal pressure secondary to a functional or mechanical esophageal obstruction.² Epiphrenic diverticula, in particular, have been increasingly associated with a wide spectrum of esophageal motility disorders.^3–5

Most patients with esophageal diverticula are asymptomatic and do not require treatment.^1,2,4,5 Symptoms vary among different types of diverticula, yet the most common clinical presentations include dysphagia, regurgitation, unintentional weight loss, chest pain, and aspiration.⁶ Surgical treatment is recommended for symptomatic patients.⁷ Traditionally, a right thoracotomy was the approach for midesophageal diverticula and left thoracotomy for distal diverticula.^5,8 However, many surgeons have moved away from an open approach with the introduction of minimally invasive surgery, which carries a reduced morbidity and better outcomes.^8,9 The objective of this study is to review a single surgeon's experience with the surgical management of esophageal diverticula using minimally invasive approaches and to review the current literature.

Methods

Patients

A retrospective review was conducted of a prospectively maintained database of all esophageal diverticulectomies performed by a single surgeon (M.B.M.) at MedStar Georgetown University Hospital from 2005 to 2018. Patients included in the study underwent a minimally invasive esophageal diverticulectomy. Medical records were reviewed for patient demographics, comorbidities, operative characteristics, and perioperative outcomes. In-hospital mortality and 90-day perioperative morbidity were reviewed. This study was reviewed and approved by the Institutional Review Board.

Preoperative evaluation and investigations

Patients deemed appropriate surgical candidates underwent a complete history and physical examination. Preoperative investigations performed included barium esophagogram, esophagogastroduodenoscopy, and esophageal manometry. Functional disorders of the esophagus were identified before surgery.

Operative technique

The surgical approach was tailored to the location of the diverticulum and other associated pathology. We typically used four port sites, traditional thoracoscopic and laparoscopic instruments, as well as a 5 mm 30-degree camera. We performed flexible esophagoscopy to confirm the location of the diverticulum and evaluate any pathologic esophageal abnormality. The esophageal diverticulum was dissected away from the surrounding structures down to the neck of the diverticulum, being careful not to perforate into the lumen. The myotomy was started at the neck of the diverticulum and continued distally. The diverticulum was transected using a linear endo-GIA stapler (Ethicon, Sumerville, NJ). The overlying muscle and pleura are then reapproximated. A laparoscopic partial fundoplication is performed when the myotomy is extended down to the lower esophageal sphincter. At the completion of the procedure, a chest tube is left in place if a thoracoscopic approach was performed.

Postoperative follow-up

In the postoperative period, patients were observed in the hospital on average for 2 days. Chest tubes were pulled on postoperative day 1. Patients were routinely followed up in the outpatient setting for evaluation of symptoms.

Results

Patient characteristics

Fifteen patients with symptomatic esophageal diverticula underwent minimally invasive diverticulectomy by a single surgeon and were included in the study. There were 5 males (33.3%) and 10 females (66.7%) with a median age of 65 years (range, 36 to 71 years). The most common presenting symptom was dysphagia (80%; Table 1). Most patients (13 of 15 [86.7%]) had epiphrenic diverticula (Table 1). Three patients (20%) had multiple diverticula and 1 patient had three diverticula (Fig. 1). Preoperative workup included upper endoscopy and esophagogram; manometry was attempted in 5 patients. The median diverticulum size was 4.75 cm (range, 3 to 20 cm). Achalasia was identified as the most frequent functional disorder (9 of 15 [60%]; Table 1).

FIG. 1.

Barium esophagogram of a patient with three diverticula.

Table 1.

Patient Characteristics

Patient demographics
Female, n (%)	10 (66.7)
Male, n (%)	5 (33.3)
Age, years, median (range)	65 (36–71)
Presenting symptoms, n (%)
Dysphagia	12 (80)
Regurgitation	7 (46.7)
Reflux	3 (20)
Respiratory complications	4 (26.7)
Diverticula location, n (%)
Midesophageal	1 (6.7)
Epiphrenic	13 (86.7)
Midesophageal+epiphrenic	1 (6.7)
Multiple diverticula, n (%)	3 (20)
Maximum diverticulum size, cm, median (range)	4.75 (3–20)
Functional disorders identified, n (%)
Achalasia	9 (60)
Nonspecific motility disorder	4 (26.7)
Diffuse esophageal spasm	2 (13.3)

Operative approaches and procedures

Most patients underwent a video-assisted thoracoscopic surgery (VATS) approach (8 of 15, [53.3%]; Table 2). There were 3 (20%) laparoscopic approaches, 3 (20%) robotic approaches, and 1 (6.7%) combined laparoscopic and VATS approach. One case was converted to a right thoracotomy for a patient with dense adhesions from a prior esophageal leiomyoma excision by another surgeon.

Table 2.

Operative Characteristics

Surgical approach, n (%)
VATS	8 (53.3)
Laparoscopic	3 (20)
VATS/laparoscopic	1 (6.7)
Robotic	3 (20)
Conversion to open	1 (6.7)
Procedures performed, n (%)
Diverticulectomy	1 (6.7)
Diverticulectomy/myotomy	5 (33.3)
Diverticulectomy/extended myotomy	3 (20)
Diverticulectomy/myotomy/fundoplication	4 (26.7)
Diverticulectomy/myotomy/paraesophageal hernia repair	2 (13.3)

VATS, video-assisted thoracoscopic surgery.

All patients underwent a diverticulectomy and 14 patients (93.3%) underwent an esophageal myotomy (Table 2). One patient, without a motility disorder, who had a myotomy for leiomyoma resection, underwent diverticulectomy alone with oversewing of the staple line. Additional procedures included extended myotomy in 3 patients (20%), fundoplication in 4 patients (26.7%), and paraesophageal hernia repair in 2 patients (13.3%).

Perioperative outcomes

The median length of hospital stay was 2 days (range, 1 to 16 days; Table 3). Total postoperative morbidity was 20% (3 of 15). The 90-day mortality and in-hospital mortality were 0%. Two patients (13.3%) were readmitted within 30 days of surgery with delayed leaks presenting on day 9 and 11 after discharge on a soft diet (Table 3). Both patients were managed with a combination of endoscopic treatment and a drainage procedure for the chest.

Table 3.

Postoperative Outcomes

Length of stay, days, median (range)	2 (1–16)
30-day readmission, n (%)	2 (13.3)
Morbidity, n (%)
Esophageal leak	2 (13.3)
Pleural effusion	1 (6.7)
90-day mortality, n (%)	0 (0)
Recurrence, n (%)	1 (6.7)

All patients had resolution of their symptoms postoperatively. Median follow-up was 10.7 months (range, 10 days to 6.3 years). One patient who underwent a VATS diverticulectomy of three diverticula with extended myotomy and Dor fundoplication presented 18 months after her initial procedure with progressive esophageal dysfunction. She underwent minimally invasive transhiatal esophagectomy. One patient presented with recurrent disease. He had a laparoscopic diverticulectomy with extended myotomy and Dor fundoplication and presented 5 years later with dysphagia and reflux. His recurrent diverticulum was likely related to inadequate myotomy. He subsequently underwent a laparoscopic takedown of the wrap and a repeat diverticulectomy by VATS with myotomy, and is well on last follow-up.

Discussion and Review of the Literature

Esophageal diverticula are relatively rare, consistent with the few cases encountered in this series. The true incidence is unknown as only a small percentage of patients are symptomatic, while most other cases are diagnosed incidentally. Pulsion diverticula are the result of increased intraluminal pressure causing an outpouching of the mucosa and submucosa through the muscle layers of the esophagus. When symptomatic, surgery is recommended.^10–13 This series supports the understanding that most patients with esophageal diverticular disease have an underlying functional or mechanical esophageal disorder. We demonstrate that a minimally invasive approach is safe, effective, and is associated with an acceptable morbidity and no mortality.

Historically, a transthoracic approach through a left thoracotomy allowed optimal visualization and access to distal diverticula and a right thoracotomy was utilized for the management of midesophageal diverticula.^{3,10,11,14–17} In the last decade, a minimally invasive approach has been shown to be as effective as an open repair in providing symptom relief with less morbidity.^18,19 However, because of the rarity of occurrence, not many surgeons have a robust experience. More recently, a transhiatal approach has been performed by some.^9,20 This facilitates a myotomy well onto the gastric wall, a Toupet or Dor fundoplication, and avoids single-lung ventilation without the need for a chest tube at the completion of the procedure. We have found this approach beneficial in patients with a concurrent paraesophageal hernia as well as those with distal diverticuli. A VATS approach combined with laparoscopy may be suitable in cases of a large diverticulum, a long distance between the diverticulum and the hiatus, or dense mediastinal adhesions.^8,21 Recently, there has been an increasing interest in robotic-assisted esophageal diverticulectomy.^19,22,23 In comparison to a VATS or laparoscopic approach, the robot provides the surgeon with high-definition visualization and improves the technique for mobilizing the gastroesophageal junction, inferior esophagus and the diverticular sac from the mediastinal structures in the presence of adhesive disease or large diverticula.²⁴ However, larger case series are needed as most of the literature in this area is composed of small case reports. We determine the ideal individualized operative approach based on patient factors, such as location of the diverticulum, number of diverticula, existence of additional surgical pathology, combined with imaging and functional studies, and the patient's operative history.

A point of contention in the literature is the routine versus selective performance of a myotomy at the time of diverticulectomy. Previously reported high leak rates in the absence of a myotomy at the time of diverticulectomy have likely contributed to routine myotomy.²⁵ Other authors favor more selective performance of a myotomy when a motility disorder is identified preoperatively.^12,26,27 A recent systematic review and meta-analysis of the literature on esophageal diverticular repair revealed that staple line leaks were less common after a myotomy compared with no myotomy.²⁸ The likely reason there is no consensus, however, is because there is significant variation in the reported rates of motility disorders identified in this group of patients. This issue might be related to the suspected intermittent nature of certain motility disorders. Therefore, manometry may not always detect a motility disorder and it may be inaccurate for measuring high pressures at the lower esophageal sphincter (LES) as a large diverticulum can accommodate a fair amount of volume and offset the pressure readings. We believe that surgical management of patients with diverticular disease must consist of a diverticulectomy and esophageal myotomy to adequately address the anatomic and functional defects that may sometimes go unrecognized in the preoperative workup. A myotomy can alleviate dysphagia related to dysmotility and, most importantly, reduce intraluminal pressure that can lead to complications at the diverticulectomy site.

Many also argue for a routine myotomy extended onto the gastric wall in the management of patients with diverticular pathology, regardless of whether an underlying motility disorder is identified.^10,15,17 However, this view is not supported by all. Some favor sparing the lower esophageal sphincter and thus only performing a myotomy in the area of the motor abnormality as detected by manometry.¹⁶ In our practice, the preoperative workup consists of an esophagogram, manometry, and we routinely perform esophagoscopy to evaluate the LES endoscopically. In addition, one can get a sense of the pathology in the muscle of the esophagus, while performing the myotomy. In patients where the muscle caliber returns to normal before the LES, it may not be necessary to perform a myotomy that extends onto the LES. An extended myotomy should be an individualized approach and should be performed judiciously to prevent unnecessary postoperative reflux symptoms.

We have summarized the results of the major studies with 10 or more patients who underwent open and minimally invasive surgical management of thoracic esophageal diverticula in Tables 4 and 5, respectively. Morbidity rates for open repair ranged from 6% to 35.5% (pooled rate 20.2%) and leak rates ranged from 3% to 18% (pooled rate 7%).^{3,10,11,14–17,29} Comparable to our series, morbidity rates for minimally invasive diverticulectomy ranged from 7% to 45% (pooled rate 23.5%) and leak rates ranged from 3% to 24% (pooled rate 9.6%).^{8,9,20,21,30–35} Minimally invasive case series reported lower mortality rates than open repair (pooled rates 1.2% versus 4.5%) and shorter length of hospital stay, suggesting an advantage over thoracotomy. A direct comparison between the two groups is challenging, given the retrospective nature of these series and their varying patient populations. Larger minimally invasive case series are needed before concrete conclusions can be drawn. Overall, our results are in agreement with other minimally invasive case series.

Table 4.

Case Series of Open Esophageal Diverticulectomy

Series	n	Approach	Morbidity	Leak	30-day mortality	LOS (days)	Follow-up (months)
Fékéte and Vonns¹⁴	27	Thoracotomy	5 (19%)	2 (7%)	3 (11%)	—	—
Streitz et al.¹⁶	16	Thoracotomy	1 (6%)	1 (6%)	0	—	84
Altorki et al.¹⁰	17	Thoracotomy	—	—	1 (6%)	—	84
Benacci et al.¹¹	33	Thoracotomy	11 (33%)	6 (18%)	3 (9%)	13	82.8
Nehra et al.¹⁵	18	Thoracotomy	2 (11%)	1 (6%)	1 (6%)	—	24
Varghese et al.¹⁷	35	Thoracotomy	5 (14%)	2 (6%)	1 (3%)	7	32.4
D'Journo et al.³	23	Thoracotomy	2 (9%)	0	0	—	61.2
Tapias et al.²⁹	31	Thoracotomy	11 (35.5%)	1 (3%)	0	7	30
Pooled rates	—	—	20.2%	7%	4.5%	—	—

LOS, length of stay.

Table 5.

Case Series of Minimally Invasive Esophageal Diverticulectomy

Series	n	Approach	Morbidity	Leak	30-day mortality	LOS (days)	Follow-up (months)
Macke et al.²⁰	57	VATS 33; laparoscopy 18; VATS/laparoscopy 6	18 (29%)	4 (7%)	0	5	20.8
Rosati et al.⁸	20	Laparoscopy	5 (25%)	1 (5%)	0	7	52
Fernando et al.²¹	20	Laparoscopy 10; VATS 7; VATS/laparoscopy 2; laparoscopy/thoracotomy 1	9 (45%)	4 (20%)	0	5	15
Klaus et al.³¹	11	Laparoscopy 10; VATS 1	2 (18%)	1 (9%)	0	3	26
Soares et al.³³	19	Laparoscopy	5 (26%)	1 (5%)	1 (5%)	3	45
Rossetti et al.³²	21	Laparoscopy	6 (29%)	5 (24%)	1 (5%)	14	78
Palanivelu et al.⁹	12	Laparoscopy 8; VATS 4	3 (25%)	1 (8%)	0	4.5	—
Fumagalli Romario et al.³⁰	30	Laparoscopy	2 (7%)	1 (3%)	0	6.5	52
Achim et al.³⁴	17	Laparoscopy 9; VATS 3; VATS/laparoscopy 5	4 (23.5%)	3 (17.6%)	1 (5.8%)	—	20
Brandeis et al.³⁵	27	Laparoscopy 22; VATS 3; VATS/laparoscopy 2	3 (11%)	1 (4%)	0	5	33.1
Current series	15	VATS 8; laparoscopy 3; robotic 3; VATS/laparoscopy 1; VATS/thoracotomy 1	3 (20%)	2 (13.3%)	0	2	10.7
Pooled rates	—	—	23.5%	9.6%	1.2%	—	—

LOS, length of stay; VATS, video-assisted thoracoscopic surgery.

There are several limitations to this study. This is a small case series, which makes it difficult to draw larger conclusions applicable to most patients. The rare nature of symptomatic diverticular disease makes a larger case series challenging. In addition, we had a relatively short follow-up. Longer follow-up is required to better understand patient outcomes. Finally, the retrospective nature of this study has its inherent limitations.

In conclusion, we demonstrate a single surgeon's experience with minimally invasive esophageal diverticulectomy for symptomatic diverticular disease. In experienced hands, a minimally invasive approach is safe, effective, and associated with excellent patient outcomes. Ultimately, the approach and procedure performed should be tailored to the individual patient's disease and preoperative workup.

Footnotes

Disclosure Statement

No competing financial interests exist.

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