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Ann Thorac Surg 2005;80:2076-2080
© 2005 The Society of Thoracic Surgeons

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Original article: General thoracic

Minimally Invasive Operation for Esophageal Diverticula

Division of Thoracic and Foregut Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Accepted for publication June 3, 2005.

^_* Address correspondence to Dr Fernando, Cardiothoracic Surgery, Boston Medical Center, 88 East Newton Street, Robinson B402, Boston, MA 02118 (Email: hiran.fernando{at}bmc.org).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment References

 
BACKGROUND: Mid and lower esophageal diverticula are rare entities usually managed by open operation. Morbidity can be significant with these complex procedures. This study evaluates our results of minimally invasive surgery for esophageal diverticula.

METHODS: Over a 5-year period, 20 patients underwent operation for esophageal diverticula. Median age was 70.5 years. There were 16 epiphrenic and 4 midesophageal diverticula with a median size of 7.5 cm (range, 2-11 cm). Symptoms included dysphagia (14), regurgitation (12), weight loss (8), heartburn (4), aspiration pneumonia (3), chest pain (2), and vomiting (2). Dysphagia scores (1 = none, 5 = severe) were recorded before and after operation.

RESULTS: Surgical approaches were laparoscopy (10), video-assisted thoracic surgery (VATS) (7), laparoscopic/VATS (2), and laparoscopic/thoracotomy (1). The most common operation performed was a diverticulectomy, myotomy, and partial fundoplication (12). Complications occurred in 9 (45%) patients and included 4 (20%) esophageal leaks. Three leak patients had successful outcomes; the fourth patient died 61 days after operation. Median hospital stay was 5.0 (1–61) days. Detailed follow-up was available in 18 patients at a median of 15 (1–70) months. Dysphagia scores improved significantly (p < 0.001) from 2.3 to 1.3 postoperatively. Symptomatic improvement was excellent in 13 (72%), good in 2 (11%), fair in 1 (6%), and poor in 2 (11%) patients.

CONCLUSIONS: Minimally invasive operations for esophageal diverticula are feasible but also challenging. The potential for morbidity is significant. Patients should be selected and evaluated carefully before undertaking repair. Open surgery should remain the standard except in centers experienced with minimally invasive esophageal surgery.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment References

 
Esophageal diverticula (ED) are rare entities that are categorized primarily by anatomic location and etiology. Epiphrenic diverticula are mucosal outpouchings that usually occur in the distal third of the esophagus. These are pulsion diverticula, which are thought to develop secondary to increased intraesophageal pressure usually associated with motility disorders [1–4]. Midesophageal diverticula, on the other hand, are usually traction diverticula that occur secondary to mediastinal inflammation [5].

The clinical manifestations of epiphrenic and mid-ED are variable, with little correlation between the severity of symptoms and the size of the diverticulum. Distinguishing between symptoms of the diverticulum and those caused by the underlying motility disorder can also be difficult. Controversy exists regarding the management of these patients primarily due to our incomplete understanding of the pathophysiology and the risks associated with operation. In the past, operative treatment was favored for symptomatic patients only, although some authors have advocated operative intervention on all patients with thoracic diverticula regardless of symptoms [6]. The extent of the esophageal myotomy and the need for an antireflux procedure are also issues of contention. Since the introduction of laparoscopic fundoplication in 1991 [7], a variety of esophageal diseases have been approached using minimally invasive techniques. These include the management of giant hiatal hernia [8], achalasia [9], reoperative antireflux surgery [10], and esophageal cancer [11]. Although ED are rarely seen in most clinical practices, these patients are now being referred and repaired with increasing frequency in those centers performing minimally invasive esophageal surgery. A number of authors have reported their limited experiences with laparoscopy and video-assisted thoracic surgery for ED [12–16], with most involving isolated case reports. We have been using a minimally invasive approach for ED for about 5 years. This study reviews our experience and examines our treatment outcomes with minimally invasive surgery (MIS) for ED.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment References

 
A retrospective analysis was performed of 20 consecutive patients who underwent minimally invasive repair of epiphrenic or mid-ED between January 8, 1997 and September 7, 2002. There were 12 males and 8 females with a mean age of 70.5 years (range, 27 to 96). All patients were symptomatic with a median duration of symptoms of 3 years (range, 3 months to 20 years). The most common presenting symptoms were dysphagia (14), regurgitation (12), weight loss (8), heartburn (4), aspiration pneumonia (3), chest pain (2), and vomiting (2). Six patients had previous esophageal surgery, endoscopic procedures, or both.

Preoperative workup included barium swallow and upper gastrointestinal endoscopy in all patients. The diverticulum was identified in 19 (95%) patients on both barium swallow and endoscopy. A small incidental epiphrenic diverticulum was identified intraoperatively in one patient who presented with heartburn and had previously undergone a Nissen fundoplication through a left thoracotomy. There were 4 mid-ED and 16 epiphrenic diverticula. Mid-esophageal diverticula and epiphrenic diverticula were defined as diverticula in the middle third (22 to 30 cm from the incisors on endoscopy) and distal third of the esophagus, respectively. The median size of the diverticulum was 7.5 cm (range, 2 to 11 cm). Functional disorders of the esophagus were identified in 18 (90%) patients. Eight patients (40%) had achalasia, 7 (35%) had nonspecific esophageal motor disorder, and 3 (15%) others had gastroesophageal reflux with large hiatal hernias. Only 2 (10%) patients appeared to have normal esophageal function.

The indication for surgery in all patients was severe symptoms. The operative approaches included laparoscopy only (n = 10), video-assisted thoracic surgery (VATS) only (n = 7), combined laparoscopy and VATS (n = 2), and laparoscopy with left thoracotomy (n = 1).

The most common operation performed was diverticulectomy, myotomy, and partial fundoplication (n = 12). Four patients had a diverticulectomy and myotomy using a right VATS approach and two patients had a VATS diverticulectomy alone. Two patients with recurrent hiatal hernias after previous antireflux surgery, and normal esophageal motility, underwent laparoscopic diverticulectomy with a Collis gastroplasty and Nissen fundoplication.

Our standard operative technique includes an initial esophagoscopy with the endoscope left in the esophagus during the procedure. For laparoscopic diverticulectomy and myotomy the patient is supine with the surgeon on the patient's right and one assistant on the left. Five laparoscopic ports are used with one 10-mm port and four 5-mm ports. Our preference is to use ultrasonic coagulating shears (US Surgical, Norwalk, CT) for the major portion of the dissection. Limited division of the short gastric vessels is performed so there will be adequate mobility of the gastric fundus to allow creation of a tension-free wrap. The anterior fat pad is dissected from the gastroesophageal junction to clearly identify this junction and optimize the length and location of the myotomy. The epiphrenic diverticulum is then dissected out with careful identification of the entire neck. The diverticulum is then resected with an Endo GIA stapler (US Surgical, Norwalk, Ct.). Since the diverticulum is a mucosal outpouching without a muscular covering, we initially used this as the proximal site of our myotomy, extending the myotomy distally from the diverticulum onto the stomach. However, because of leaks seen in the earlier part of our series, we now close the overlying esophageal muscle layer using the Endo Stitch (US Surgical, Norwalk, CT) with intracorporeal knot tying after excising the diverticulum. The myotomy is then performed on the opposite side of the diverticulum extending from the level of the diverticulum down onto the first 1 to 2 centimeters of the stomach. The myotomy is performed using a combination of sharp dissection with ultrasonic shears (US Surgical, Norwalk, CT) and blunt dissection with "Endo-peanut" dissectors (US Surgical, Norwalk, CT). Epinephrine (1 mL of 1;1,000 in 20 mL normal saline) is injected into the muscular layers of the anterior esophagus and stomach to improve hemostasis and facilitate the myotomy. The endoscope is used to assess the completeness of the myotomy and to check for mucosal perforations. We routinely include a posterior partial fundoplication (Toupet) with the laparoscopic approach. The combined laparoscopic and VATS approach is used only when the epiphrenic diverticula cannot be safely resected transhiatally due to its proximal location and/or significant mediastinal adhesions.

Right VATS is our approach of choice to the thoracic esophagus with mid-ED or after failed laparoscopic resection of epiphrenic diverticula. The patient is positioned in the full left lateral decubitus with the right lung deflated. The surgeon stands on the right side of the table, the assistant on the left. Three 10-mm ports and one 5-mm port are used. A single retracting suture in the central tendon can facilitate exposure of the distal esophagus. A fan retractor is used to retract the lung anteriorly and division of the azygous vein is often advantageous. The esophagus is mobilized and the diverticulum identified and its entire neck exposed. An Endo-GIA stapler is used to divide the neck of the diverticulum and the overlying muscle layer closed over the staple line.

In addition to standard outcomes, dysphagia scores and heartburn severity scores were measured as part of an on-going Institutional Review Board approved outcomes study. The dysphagia scores range on a scale from 1 (no dysphagia) to 5 (severe dysphagia). These scores were recorded preoperatively and postoperatively. Since heartburn is often reported after myotomy, heartburn severity was measured using the gastroesophageal reflux disease health-related quality of life scale (HRQOL) [17]. This instrument involves 9 questions with each response rated from 0 to 5. The best possible score is 0 (no heartburn) and the worst possible score is 45 (severe heartburn). The HRQOL was administered postoperatively.

	Results

Top Abstract Introduction Patients and Methods Results Comment References

 
Nineteen complications occurred in nine (45%) patients. These are outlined in Table 1. There were no differences in complications between laparoscopic, VATS or combined approaches, location of diverticulum, or associated motility disorder. There were four postoperative esophageal leaks (20%) of which three were successfully managed with good outcomes. All four leak patients had associated motility disorders and had myotomies performed. Two patients required reoperation. The first patient developed a leak from the staple line after resection of the diverticulum. Her initial operation was performed laparoscopically. This leak area was also part of the esophageal myotomy. Laparoscopic repair over a 12-French esophageal T-tube was performed with placement of a Jackson-Pratt drain adjacent to the repair. A feeding jejunostomy was also placed at the same time. She was taking liquids by mouth at the time of her discharge 40 days later. Her drains were eventually removed and she was able to resume a normal diet as an outpatient. The second patient underwent a thoracoscopic esophageal diverticulectomy and myotomy. On the seventh postoperative day a leak from the myotomy site was noted. This was repaired by thoracotomy using an intercostal muscle flap to buttress the repair. He did well after this. The third patient developed a leak 2 days after laparoscopic myotomy and fundoplication. Thoracotomy and repair over a T-tube was performed. This patient continued to do poorly, developing renal failure and failure to thrive, and expired 61 days after her operation. Although there were no 30-day mortalities, this patient was the only hospital mortality (5%) in our series. The fourth leak patient underwent VATS resection of a midesophageal diverticulum. Although no leak could be identified by barium swallow, this was suspected clinically. The patient was taken to the operating room on the fourteenth postoperative day, and a small leak identified by esophagoscopy. The leak was drained by placing a lateral pharyngostomy tube on the left side of the neck and then advancing this down the esophagus using the endoscope, through the leak site into the abscess cavity. A laparoscopic jejunostomy was also performed to provide nutrition. His leak eventually healed and he was able to resume a diet 17 days later. In addition to the postoperative leaks, there was one intraoperative mucosal perforation in a patient who underwent right VATS resection of a midesophageal diverticulum with a limited myotomy. This was repaired intraoperatively with no further problems.

Two patients developed recurrent diverticula postoperatively. Both patients had mid-ED of similar size (6 and 8 cm) managed with a right VATS approach. Both patients had normal esophageal manometry. One patient had a diverticulectomy, while the other had a diverticulectomy and myotomy which extended to, but did not include, the lower esophageal sphincter. Both diverticula are small (2 to 3 cm) and have remained stable in size (for 3 to 4 years). Both patients experienced relief of their original preoperative symptoms but have experienced slowly progressive dysphagia to solids and intermittent regurgitation over the last year. Since these patients are minimally symptomatic, with only small diverticula seen on barium swallow, reoperation has not been performed. The question of underlying motility disorders as an etiology for the ED certainly exists in these two patients. No patient in the study group underwent further operative intervention for recurrence of the diverticulum or symptoms.

Detailed outcome follow-up was available in 18 (90%) patients at a median of 15 months (range, 1 to 70 months). Thirteen patients (72%) had an excellent result with complete relief of symptoms with no recurrence. Two patients (11%) had a good result with only mild well-tolerated symptoms. One patient (6%) had a fair result with occasional symptoms requiring therapy, and two patients (11%) had a poor result. The dysphagia scores were improved in all but one patient, with the mean dysphagia score decreasing significantly from 2.3 before the operation to 1.3 postoperatively (p < 0.001). Acid regurgitation was reported in 2 (11%) patients. The mean HRQOL score was 17.5 in these patients compared with 3.5 in the other patients who denied significant reflux.

	Comment

Top Abstract Introduction Patients and Methods Results Comment References

 
Epiphrenic and mid-ED are classically distinguished by their location within the esophagus and the underlying pathophysiology. Although mid-ED are generally considered to be traction diverticula, some authors believe that in the Western world most will be pulsion diverticula secondary to distal esophageal motility disorders [18]. In our study, 2 patients with mid-ED had normal manometry with small but adherent lymph nodes; no granulomatous inflammation was identified on pathology in either case. In the other 2 patients with mid-ED, one had a nonspecific esophageal motility disorder and the other had a 6-cm sliding hiatus hernia with no manometry performed. It appears that the two with adherent lymph nodes may have had weakening of the esophageal wall due to the traction of the inflammatory nodes, followed by subsequent enlargement of the diverticulum. The other cases likely represent pulsion rather than traction diverticula.

The exact association between esophageal diverticula and esophageal motility disorders is unclear. Motility disorders have been identified in 43% to 100% of patients with epiphrenic diverticula [3, 4, 6, 19, 20]. This inconsistency in identifying a motility disorder in patients with a diverticulum has not been explained. One problem with confirming an associated motility disorder is the technical difficulty often encountered while attempting passage of the manometry catheter. Nehra and colleagues (from the University of Southern California) [4] addressed the issue of associated motility disorders by performing endoscopic guidance of the manometric catheter and 24-hour ambulatory motility studies. In their cohort of 21 patients, motility abnormalities were found in 100% of cases.

There continues to be debate over the indications for surgery for patients with epiphrenic and mid-ED. At our institution operative management is reserved for those with major symptoms, but large diverticulum may also warrant surgical consideration. The mortality rates for open surgery for ED are not insignificant, and range from 0 to 11% [3, 4, 6, 19, 20]. Postoperative esophageal leak rates range from 6% to 18% (3, 4, 19–21). The Mayo Clinic experience represents one of the largest series of open operations for ED [3]. After repair in 33 patients, mortality was reported in 9.1%. Morbidity occurred in 33% of patients and included an 18% leak rate. Excellent or good results were reported in 75.8% of their patients. The potential advantages of minimally invasive surgery include decreased morbidity, less pain, decreased hospital stay, and quicker return to normal activity. In our study the median length of stay was 5 days, which is considerably less than the 13 days reported with an open approach [6]. Operations for ED, however, are challenging even with an open approach. The high leak rate of 20% in our series suggests that these patients should be approached with caution. In the last 12 months another experienced laparoscopic center published their results [22] on 13 patients undergoing minimally invasive repair of ED. These authors also experienced a high leak rate of 23.1% and one perioperative death (7.7%). Although it is possible that with increasing experience the leak rates will decrease, we do not recommend operation (using open or MIS techniques) for those patients with minimal symptoms and small diverticula.

The approach and operations performed for epiphrenic and mid-ED are tailored to the location of the diverticulum and the underlying esophageal functional abnormality. Our treatment of choice for epiphrenic diverticula associated with achalasia, hypertensive lower esophageal sphincter (LES), or other motility disorders with abnormal manometry isolated to the distal esophagus is a laparoscopic diverticulectomy, gastroesophageal myotomy, and partial fundoplication (Toupet). The laparoscopic approach has been shown to be associated with a decreased conversion rate, shortened hospital stay, better relief of dysphagia, and less reflux compared with a VATS approach for achalasia [23, 24]. If the epiphrenic diverticulum cannot be resected transhiatally, then a right VATS approach is used for the diverticulectomy. In our series 3 patients required a transthoracic diverticulectomy in combination with laparoscopy. In 2 patients this approach was selected from the outset; in one patient a left thoracotomy was used because of dense mediastinal adhesions adjacent to the epiphrenic diverticulum, preventing adequate exposure and completion of the procedure laparoscopically. There were no other conversions to open procedures in our series. The combined procedures added an average of 1 hour and 45 minutes of operating time to the laparoscopic procedure with no significant increase in morbidity or hospital length of stay.

Patients with mid-ED or epiphrenic diverticula associated with other motility disorders that involve more than distal esophagus should have a long esophagomyotomy with the diverticulectomy. Right VATS is our approach of choice to the thoracic esophagus because the entire length of the esophagus can be well-visualized. The importance of a long esophagomyotomy has been well-demonstrated [2, 25, 26] and should involve all regions of the esophagus with documented abnormal motility. An antireflux procedure should be added if significant gastroesophageal reflux is documented preoperatively, a hiatus hernia is present, or a significant dissection at the level of the gastroesophageal junction is performed. If a laparoscopic antireflux procedure is anticipated, this should be performed prior to the VATS or thoracotomy to prevent loss of the pneumoperitoneum into the pleural space during operation.

The use of diverticulectomy alone and the selective use of LES-sparing myotomy are two controversial management strategies. Diverticulectomy alone has been associated with increased rates of ED recurrence and suture line leakage and should be performed with extreme caution [3, 19, 26]. In our series two patients were treated with diverticulectomy alone. There were no postoperative leaks in these two patients, although one patient developed recurrence of an ED. The other recurrent ED in our series occurred in one of the four patients treated with an esophagomyotomy, sparing the LES. All four patients had manometry, demonstrating a normal pressure LES with complete relaxation. The recurrence of an ED in these patients supports our current preference to perform a complete myotomy extending across the LES in any patient with an epiphrenic diverticulum.

The surgical management of ED is challenging, even with open techniques. Minimally invasive approaches to ED are feasible when performed from a center where there is significant daily exposure to minimally invasive operations for esophageal disorders. In our series good or excellent results were achieved in 83% of patients, with significantly reduced dysphagia scores and minimal occurrence of heartburn. Whether an open or minimally invasive approach is chosen, these patients should be evaluated and selected carefully before undertaking repair. We favor the inclusion of a myotomy extending onto the stomach for all patients with epiphrenic diverticulum, even if normal manometric findings are demonstrated.[21]

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hiran C. Fernando James D. Luketich John Samphire Miguel Alvelo-Rivera Neil A. Christie Percival O. Buenaventura Rodney J. Landreneau Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Fernando, H. C. Articles by Landreneau, R. J. Search for Related Content PubMed PubMed Citation Articles by Fernando, H. C. Articles by Landreneau, R. J. Related Collections Esophagus - other