Laparoscopic diverticulectomy with the aid of intraoperative gastrointestinal endoscopy to treat epiphrenic diverticulum.

OBJECTIVE: Most researchers believe that the presence of large epiphrenic diverticulum (ED) with severe symptoms should lead to the consideration of surgical options. The choice of minimally invasive techniques and whether Heller myotomy with antireflux fundoplication should be employed after diverticulectomy became points of debate. The aim of this study was to describe how to perform laparoscopic transhiatal diverticulectomy (LTD) and oesophagomyotomy with the aid of intraoperative gastrointestinal (GI) endoscopy and how to investigate whether the oesophagomyotomy should be performed routinely after LTD. PATIENTS AND METHODS: From 2008 to 2013, 11 patients with ED underwent LTD with the aid of intraoperative GI endoscopy at our department. Before surgery, 4 patients successfully underwent oesophageal manometry: Oesophageal dysfunction and an increase of the lower oesophageal sphincter pressure (LESP) were found in 2 patients.
RESULTS: There were 2 cases of conversion to an open transthoracic procedure. Six patients underwent LTD, Heller myotomy and Dor fundoplication; and 3 patients underwent only LTD. The dysphagia and regurgitation 11 patients experienced before surgery improved significantly. Motor function studies showed that there was no oesophageal peristalsis in 5 patients during follow-up, while 6 patients showed seemingly normal oesophageal motility. The LESP of 6 patients undergoing LTD, myotomy and Dor fundoplication was 16.7 ± 10.2 mmHg, while the LESPs of 3 patients undergoing only LTD were 26 mmHg, 18 mmHg and 21 mmHg, respectively. In 4 cases experiencing LTD, myotomy and Dor fundoplication, the gastro-oesophageal reflux occurred during the sleep stage.
CONCLUSIONS: LTD constitutes a safe and valid approach for ED patients with severe symptoms. As not all patients with large ED have oesophageal disorders, according to manometric and endoscopic results, surgeons can categorise and decide whether or not myotomy and antireflux surgery after LTD will be conducted.

INTRODUCTION

It is believed that the genesis of epiphrenic diverticulum (ED), a rarely encountered disease, was associated with an oesophageal motor disorder.[1] Failure to diagnose an epiphrenic oesophageal diverticulum may lead to some serious problems, such as gastrointestinal (GI) bleeding, pneumonia or cancer.[2] Most researchers believe that only the presence of large ED with severe symptoms should result in consideration of surgical options.[3] The choice of minimally invasive techniques and whether Heller myotomy with antireflux fundoplication should be employed after diverticulectomy became points of debate.[45] In the following report, the discussion concentrates on our 11-case series of laparoscopic transhiatal diverticulectomy (LTD) operations with the aid of intraoperative GI endoscopy, and investigating when the oesophagomyotomy should be added after LTD.

PATIENTS AND METHODS

Patient population

From 2008 to 2013, 11 patients with ED underwent LTD at our department. There were 4 men and 7 women (ages ranging 45-81 years). The common symptoms included regurgitation, dysphagia, chest pain, and nausea or vomiting. Both preoperative oesophagoscopy and barium oesophagram generally not only confirmed the existence of ED [Figure 1], but they also might rule out malignancy and assess associated oesophageal problems. Because it is difficult for patients with large ED to undergo oesophageal manometry, only 4 patients in our series successfully underwent oesophageal manometry: Oesophageal dysfunction and an increase of the lower oesophageal sphincter pressure (LESP) were found in 2 patients. 7 patients were found to have oesophagitis, 2 having Barrett's oesophagus, 3 showing evidence of oesophageal mucosal ulceration and 3 having strictures of gastro-oesophageal junction (GEJ).

Figure 1

Barium GI study and endoscopy reveal a large ED

For these patients, a high-energy liquid diet was provided 3 days prior to surgery. Patients were warned regarding the potential risks prior to surgery, and signed consent forms.

During follow-up, all patients were evaluated with barium oesophagram, oesophagoscopy, oesophageal manometry and 24-h continuous oesophageal pH monitoring at 6 months after surgery.

Surgical technique

The patient was placed in a supine position with legs spread (20-30°) under general endotracheal anaesthesia. LTD was performed using a 5-port technique. One 10-mm trocar, one 12-mm trocar and three 5-mm trocars were placed. Pneumoperitoneum was established, maintaining a constant abdominal pressure between 12 mmHg and 14 mmHg. The gastrohepatic ligament was opened widely. The dissection then was carried up and down the right and left crura and into the mediastinum. The entire periphery of the abdominal oesophagus was separated. White cotton tape was used to encircle the abdominal oesophagus [Figure 2]. During mobilisation of the oesophagus, care was taken to clearly identify and preserve both the anterior and posterior vagus nerves. The oesophagus was then retracted inferiorly. Adequate mobilisation of the oesophagus was needed to get enough of the oesophagus down into the peritoneal cavity. Generally, the ED is found at the level of the inferior pulmonary vein. The base of the ED was identified first, and then the diverticulum was carefully and completely dissected from all adherent tissue [Figure 3]. At the same time, intraoperative GI endoscopy was performed to facilitate identification of ED and its base, and learn about the GEJ. During performance of GI endoscopy, it is necessary to turn laparoscopic screen brightness down to clearly show the position of endoscopy. The diverticulum at its base is then amputated using an endostapler. The endostapler must be placed parallel to the long axis of the oesophagus [Figure 4]. After performing a diverticulectomy, we decided if a Heller myotomy and Dor fundoplication would be added according to observation of intraoperative GI endoscopy. If the lumen of the abdominal oesophagus narrowed, the myotomy is performed opposite the site of diverticulectomy and should be carried onto the stomach 1-1.5 cm below the GEJ.

Figure 2

White cotton tape is used to encircle the oesophagus to facilitate the dissection

Figure 3

The diverticulum and its base are carefully dissected from the adjacent tissue

Figure 4

The diverticulum at its base was amputated using an endostapler placed parallel to the long axis of the oesophagus

Usually, a clear liquid diet was permitted after a successful GI iodolography 7 days after surgery, and then, is advanced gradually to a normal diet within 5 days.

RESULTS

There were no operation-related deaths. There were 2 cases of conversion to an open transthoracic procedure with diverticulectomy, Heller myotomy and Dor fundoplication, due to tight adhesion surrounding the diverticulum. Six patients underwent LTD, Heller myotomy and Dor fundoplication, and 3 only undergoing LTD. Mean operative time averaged 199 ± 15 min and mean intraoperative blood loss was 152 ± 32 mL. All patients were routinely treated with antacid medical therapy (20 mg of famotidine, twice a day) for at least 1 month after surgery. There were no operation-related complications occurring within 1 month after surgery.

The median follow-up was 26 (range 10-56) months. There was no diverticular recurrence. Eleven patients experiencing dysphagia and regurgitation before surgery improved significantly and the improvement persisted over time. Motor function studies showed that there was no oesophageal peristalsis in 5 patients during follow-up, while 6 patients showed seemingly normal oesophageal motility. The LESP of 6 patients undergoing LTD, myotomy and Dor fundoplication was 16.7 ± 10.2 mmHg, while the LESPs of 3 patients undergoing only LTD were 26 mmHg, 18 mmHg and 21 mmHg. In 4 cases undergoing LTD, myotomy and Dor fundoplication, gastro-oesophageal reflux occurred during the sleep stage. On endoscopic examination it was found that there were 2 patients with oesophagitis and 1 with ulcer. For 6 patients undergoing LTD, Heller myotomy and Dor fundoplication, the post-operative barium oesophagogram demonstrated that the lumen of the distal oesophagus was widening unevenly [Figure 5].

Figure 5

Two years after LTD, Heller myotomy and Dor fundoplication, oesophagoscopy and barium oesophagram showed that the lumen of the distal oesophagus was widening unevenly

DISCUSSION

ED is a kind of rarely encountered disease. It may be an innate defect of the distal oesophagus. In a review by the Mayo Clinic, 63.4% (71/112) of untreated patients with ED were successfully followed without symptom progression.[3] In Benacci's study, none of 71 patients having an ED with minimal symptoms had clinically significant progression of symptoms.[6] As a result, some experts claimed that only the presence of large diverticulum with severe symptoms should lead to the consideration of surgical options.[78]

Traditionally, diverticulectomy has been performed through a thoracotomy. In the era of minimally invasive surgery, a few surgeons reported having surgically managed large ED by thoracoscopy or laparoscopy.[49] Generally, EDs occur less than 10 cm from the GEJ. The majority of the reported cases have preferred to undergo laparoscopy. The main advantages of laparoscopy over thoracoscopy include the fact that laparoscopy may provide better exposure to the distal oesophagus and that it is relatively easy to perform myotomy and antireflux surgery with laparoscopy.

In fact, it is controversial whether the oesophagomyotomy should be performed after LTD. It has long been believed that ED is a kind of pulsion diverticula usually resulting from an oesophageal motility disorder.[1] In some articles, most of which were case reports, most researchers preferred performing diverticulectomy, myotomy and fundoplication.[4510] There are other studies which hold a different opinion. In Benacci's study,[6] he found that among 33 patients with big ED undergoing surgery, 24.2% had achalasia, 9.1% had diffuse oesophageal spasms and 21.2% had non-specific motor abnormalities of the oesophageal body. Diverticulectomy and oesophagomyotomy were performed in 22 patients, and diverticulectomy alone in 7. Benacci obtained a relatively good long-term result. In our studies, we also discovered that not all ED with severe symptoms were associated with an oesophageal motor disorder. Because the presence of ED made it difficult for the oesophageal manometry probe to pass through the distal oesophagus, in our series 4 patients successfully received oesophageal manometry before surgery, and oesophageal dysfunction was found only in 2 patients,. Besides, only 5 out of 11 cases, accounting for 45.5% (5/11) showed postoperative oesophageal dysfunction. Thus we support the notion that not all big ED cases have oesophageal motility disorder.

According to the analysis mentioned above, we think that there are two kinds of big ED which need surgery: For some big ED associated with some kinds of oesophageal motility disorder, such as achalsia, myotomy is mandatory after diverticulectomy;[1112] for other big ED without oesophageal motility disorder, pressing the distal oesophagus leading to symptoms, there is no need for patients to undergo myotomy in addition to diverticulectomy. The main drawback of myotomy after diverticulectomy is post-operative gastro-oesophageal reflux. Even if Dor fundoplication was performed, 4 in 6 cases undergoing LTD, myotomy and Dor fundoplication experienced nocturnal gastro-oesophageal reflux. Among them, 2 patients had oesophagitis and 1 had ulcer. Accurate preoperative recognition of oesophageal disorders is helpful in determining how to perform surgery for big ED. Although preoperative oesophageal manometry is often difficult to perform, extra efforts, such as guiding by GI endoscopy, should be made to obtain manometric diagnoses. Associated with observation by GI endoscopy, manometric diagnoses will allow surgeons to confidently categorise before surgery and direct surgical procedures.

CONCLUSION

In conclusion, LTD represents a safe and valid approach for ED patients with severe symptoms. Because not all patients with large ED have oesophageal disorders, according to manometric and endoscopic results, surgeons can categorise and decide beforehand whether or not myotomy and antireflux surgery after LTD will be conducted.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.