Not Your Average Diverticulum: Massive Esophageal Diverticulum After Laparoscopic Gastric Banding.

CASE REPORT

A 76-year-old woman presented with shortness of breath, dysphagia, nausea, and neck discomfort 1 hour after eating. Her medical history was significant for morbid obesity for which she had undergone laparoscopic adjustable gastric band (LAGB) 17 years before admission. The LAGB was complicated by esophageal dilation, which led to intermittent dysphagia, and the band was removed 4 years before admission.

A noncontrast computed tomography of the chest showed dilated esophagus with a right lateral diverticulum containing an impacted food bolus of size 10 × 7.4 cm (Figure 1). The diverticulum was not apparent on abdominal CT completed 4 years earlier when the LAGB was still in place. The patient underwent endoscopy while intubated with partial removal of the massive food bolus found in the diverticulum. The GIF-190 and GIF-XP scopes could not be advanced into the true esophageal lumen because of compression of the lumen by the diverticulum (Figure 2). The patient was unable to tolerate the entire procedure to completion and was transferred to the medical intensive care unit where she stayed for 1 month because of inability to wean off mechanical ventilation secondary to severe sepsis and acute respiratory distress syndrome. No surgical intervention was pursued. Tracheostomy and surgical gastrostomy tubes were placed. She was discharged to a long-term acute care hospital thereafter.

Figure 1.

Computed tomography of chest at admission showing a massive diverticulum with food impaction postlaparoscopic adjustable gastric band removal.

Figure 2.

Endoscopic view of the massive esophageal diverticulum with food bolus apparent.

The differential diagnosis included achalasia and outflow tract obstruction (mass lesion, paraesophageal hernia, and bariatric procedure), resulting in pseudoachalasia or Zenker diverticulum. Pseudoachalasia can occur secondary to bariatric and antireflux surgical procedures. Although the exact mechanism has not been proven, high esophageal lumen pressure secondary to tight LAGB at the gastroesophageal junction and subsequent esophageal musculature weakness can be the culprit.[1] This likely explains the patient's presentation because she continued to have dysphagia and impactions despite removal of the LAGB without identification of a mass lesion or hernia. Manometry and fluoroscopy were not completed in this patient, making a definitive diagnosis difficult to agree on.

DISCLOSURES

Author contributions: All authors contributed equally to this manuscript. P.K. Paka is the article guarantor.

Financial disclosure: None to report.

Previous presentation: This case was presented at the American College of Gastroenterology Annual Scientific Meeting; October 23-28, 2020; Virtual Meeting.

Informed consent could not be obtained from the patient despite several attempts. All identifying information has been removed from this image report to protect patient privacy.