AB017. 94. Case report: surgical management of a large epiphrenic diverticulum

Abstract: Oesophageal diverticula are classified by location (pharyngeal, parabronchial or epiphrenic), by pathophysiology (traction or propulsion) and histopathology (true or false diverticula). Epiphrenic diverticula are pulsion diverticula that occur in the distal 10 cm of oesophagus and are associated with oesophageal motility disorders. Oesophageal mucosa and submucosa herniate through the muscular layers resulting in dysphagia, food regurgitation and even aspiration pneumonia. A 63-year-old man was referred with a 1-year history of progressive dysphagia to solids, food regurgitation and halitosis and a recent in-hospital admission with right middle lobe pneumonia. Investigations included a barium swallow, upper endoscopy, and high resolution impedance manometry (HRiM) which diagnosed a right sided epiphrenic diverticulum. HRiM confirmed an oesophagogastric junction (OGJ) outflow obstruction. A thoracoscopic diverticulectomy was performed. In the left lateral decubitus position a 5-port thoracoscopy was performed. Dissection begun by dividing the mediastinal pleura over the oesophagus. The diverticulum was mobilized and the neck of the diverticulum isolated. A 54-Fr bougie was placed into the oesophagus over a guidewire. A longitudinal myotomy was performed distal to the diverticulum to the OGJ to relieve the distal obstruction and prevent recurrence. Once haemostasis was achieved a 16-Fr chest drain and Jackson-Pratt drain were placed and incisions closed in layers. This patient underwent a thoracoscopic diverticulectomy and longitudinal myotomy without complication. A gastrografin swallow on day 3 confirmed an intact staple line and a straight oesophagus.

Keywords: Diverticulum; oesophagus; diverticulectomy; thoracoscopic; myotomy