Robotic-assisted diverticulectomy offers a successful management of a large thoracic esophageal diverticulum: a case report

Introduction

Esophageal diverticulum is a rare condition that occurs as a result of herniation of the esophageal lining through a weakened area of the muscular wall of the esophagus. Since esophageal diverticula may not cause symptoms in many cases, hence do not present to medical attention, the true incidence and prevalence cannot be accurately determined. Nevertheless, the prevalence of esophageal diverticula has been reported to be 0.015–2% (1,2). Based on the pathogenic mechanism, esophageal diverticula are classified into pulsion or traction diverticula. As per localization of esophageal diverticula development, three classifications are raised: superior (pharyngoesophageal or Zenker’s diverticulum), midthoracic or midesophageal, or inferior (epiphrenic diverticulum) (1).

Common symptoms of esophageal diverticula include dysphagia, heartburn, halitosis, and vomiting. However, incidental diagnosis of esophageal diverticula is also common since many are asymptomatic (3,4). Although asymptomatic small diverticula may be managed conservatively, the mainstay of treatment of large asymptomatic or symptomatic esophageal diverticula is surgical correction (2). Initially, surgical correction via thoracotomy, laparotomy, or thoracoabdominal approach was performed. However, these procedures, though effective, carried considerable surgical risks, necessitating the development of novel approaches that convey similar efficacy yet improved safety (4). This led to the shift of open surgical management of esophageal diverticula towards minimally invasive and robotic-assisted techniques. Although it is not the standard of care to proceed with a robotic-assisted approach, it might be considered in complex cases with difficult anatomy, as it offers higher visual abilities and better technical maneuvers. Herein, we report a case of a large symptomatic esophageal diverticulum in a 57-year-old patient that was successfully managed via robotic-assisted surgery. We present this article in accordance with the CARE reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-22/rc).

Case presentation

A 57-year-old male who is known to have diabetes, hypertension, esophageal diverticulum, and severe mitral valve regurgitation, which was repaired surgically in January 2024, was referred to our service as a case of large esophageal diverticulum; at the time, he was complaining of heartburn, regurgitation, and halitosis. Physical examination revealed no abnormality.

Essential preoperative workup was done for the patient. An upper gastrointestinal (GI) barium study showed a large, well-circumscribed esophageal diverticulum arising from the right lateral thoracic esophagus measuring 6.5 cm × 7.5 cm, with no obvious stricture or contrast holdup (Figure 1). A computed tomography (CT) scan of the chest redemonstrates the large diverticula with approximately the same measurements, distant around 5 cm from the cricopharyngeus muscle, with no evidence of intrathoracic lymphadenopathy (Figure 2). Esophagoscopy was performed, showing a large diverticulum located around 20 cm from the incisors with remnants of food particles within the diverticulum (Figure 3), passing through the esophagus down to the stomach with no other abnormality identified. Manometry was not available at that time in our hospital. Although the standard of care is to utilize minimally invasive video-assisted thoracoscopic surgery (VATS), we decided to proceed with robotic-assisted diverticulectomy and myotomy, due to the complex nature and difficult anatomy of this case, which this approach will overcome. Clearance from anesthesia was obtained, and the patient was scheduled for robotic esophagus diverticulectomy and myotomy.

Figure 1 Preoperative upper GI study. A large, well-circumscribed esophageal diverticulum originating from the right lateral thoracic esophagus, measuring 6.5 cm × 7.5 cm. Neither contrast holdup nor contrast stricture was observed. GI, gastrointestinal.

Figure 2 Preoperative CT scan of the chest. A large diverticulum was observed originating at 5 cm distant from the cricopharyngeus muscle. Intrathoracic lymphadenopathy was not observed. CT, computed tomography.

Figure 3 Upper GI endoscopy. This is a picture of the esophagus. A represents the true lumen, and B represents the diverticulum. GI, gastrointestinal.

On the 5th of August 2024, the patient underwent robotic esophageal diverticulectomy with myotomy. After induction of general anesthesia, a double-lumen intubation was done with successful isolation of the right lung. The procedure was done in the left lateral decubitus position. After prepping and draping, four ports were inserted, starting with the 5th intercostal space port at the anterior axilla line, an 8 mm port as a camera port. Another port was inserted at the 3rd intercostal space at the anterior axillary line, and then two more ports were placed at the 7th intercostal space at the mid-axillary line and anterior axillary line. After robotic docking and clutching the arms, the operation was started by retracting the lung anteriorly. After complete isolation and applying the suction, the lung deflated successfully. The diverticulum was identified, and at the paratracheal area just above the azygos vein level; it was estimated to be around 9 cm × 8 cm. Dissection of the pleura that was covering the mediastinum over that diverticulum at the supra-azygos level was carried out until reaching the cervical esophagus. Followed by separating the azygos vein away and medially from the diverticulum, separation of the diverticulum from the trachea and from the right innominate artery was done. Dissection was continued posteriorly to separate the diverticulum from the vertebrae to free the diverticulum circumferentially. Myotomy incision was done superiorly and inferiorly. The diverticulum was measured at approximately 5 cm × 8 cm (Figure 4).

Figure 4 Resected diverticulum. A large esophageal diverticulum measuring at approximately 5 cm × 8 cm was excised.

A 46-French bougie was inserted, and then an endo-GIA stapler was used for the division of the diverticulum. A small part of the pouch at the superior edge was left in order to avoid esophageal stricture (Figure 5). The stapler line was reinforced using fibrin glue and tachoseal sheet. A negative air leak test, repeated three times, confirmed the integrity of the stapler line. After securing hemostasis, a chest tube was placed at the posterior 7th intercostal space. Port sites were closed in layers, leaving small wounds (Figure 6). Two-lung ventilation was done under direct vision before removing the last port (Video 1). The patient was extubated and shifted to recovery in a stable condition. Final histopathology showed squamous mucosa and submucosa with parakeratosis, chronic inflammation, and fibrosis.

Figure 5 Intraoperatively, via an endo-GIA stapler, division of the diverticulum was performed. A small part of the pouch at the superior edge was left in order to avoid esophageal stricture. The stapler line was reinforced using fibrin and tachoseal sheet.

Figure 6 Left lateral decubitus position. Port sites, four incisions, left small wounds. A chest tube was placed at the posterior 7th intercostal space.

Postoperatively, the patient was extubated in the theater and shifted to the recovery bay, then to the surgical ward. The patient was kept for a total of 12 days postoperatively, with no significant postoperative complications. The patient was kept strictly nil per os (NPO) for the first three days, then an upper GI study was obtained, which was concerning for a minor contained leak, so the patient was kept NPO to avoid disruption of the anastomosis and progression to free leak. Antibiotics were escalated to tazocin, and parenteral nutrition was started. Daily monitoring of the patient’s vitals, clinical condition, and laboratory workup was unremarkable. A repeated upper GI study (Figure 7) was done on day 7 post-operative (post-op), which confirms the patency of the staple line with no evidence of contrast leak. Subsequently, oral diet was resumed gradually, starting with sips of water to a clear liquid diet and then to a pureed diet. Pain was controlled with acetaminophen 1 g intravenously (IV) every eight hours and morphine 4 mg subcutaneously (SC) as needed, which the patient was not requiring frequently. Postoperative pneumothorax was followed daily clinically and radiologically by daily chest X-ray; daily improvement was noted till almost complete resolution on day 10 post-op, when the chest tube was removed. An unremarkable chest X-ray was obtained post-removal of the chest tube and the day after; then the patient was discharged. The patient was seen in the clinic a week later; wounds were completely healed, and the patient did not complain of any pain, heartburn, or dysphagia.

Figure 7 Post-operative upper GI study confirms patency of the staple line with no evidence of leak. GI, gastrointestinal.

At follow-up appointments in three, six, and eleven months, the patient reported no residual symptoms or new symptoms. The patient reported complete recovery from halitosis, regurgitation, and dysphagia. Also, the patient started to gain weight and reported improved appetite and compliance with medications. The patient also reports that he is pleased with the operation and its outcome. A summary of the patient’s presentation and management is depicted in Figure 8.

Figure 8 Timeline depicting the patient’s presentation and management.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for publication of this case report, accompanying images, and the video. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

In this paper, we present the case of a 57-year-old male complaining of heartburn, regurgitation, and halitosis. This patient was referred to our care as a case of esophageal diverticulum. CT chest revealed a large diverticulum, measuring 6.5 cm × 7.5 cm, located 5 cm from the cricopharyngeus muscle. Upon endoscopy, 20 cm from the incisors, a large diverticulum containing food particles was encountered. This patient was approached surgically via a robot-assisted diverticulotomy and myotomy.

Traditionally, surgical management of esophageal diverticula through diverticulectomy was achieved via thoracotomy, laparotomy (transhiatal approach), or a combined thoracoabdominal approach (5). These surgical procedures, though efficacious, carried a high-risk. Thus, novel techniques with similar or superior efficacy and improved safety were sought. Since minimally invasive surgical approaches were brought to light, laparoscopic surgery has been adopted due to its added advantages. Recently, a novel minimally invasive procedure was utilized in the management of esophageal diverticula, that is, robot-assisted surgery (4,5).

Robotic approach offers several upsides compared to laparoscopic and open surgery. The high-definition visualization of anatomical structures delivered by the robotic approach is highly valuable, as surgeons are more aware of their surroundings in the surgical field. Further, even in the case of a large diverticulum, such as in our case, or the presence of adhesions, the robotic approach offers smoother dissection and easier mobilization of surrounding structures. Although providing superior technical aspects, the robotic approach is limited due to financial shortcomings. The robotic approach via the da Vinci Surgical System is costly and requires regular maintenance. Due to this, not every center possesses the ability to offer the robotic approach (1). Nevertheless, through the management of our case, several hurdles were overcome via the robotic-assisted approach; namely, the complex nature of the case, the difficult anatomy, and the poor visualization of other minimally invasive procedures.

Conclusions

Studies focusing on the management of such a rare disease as esophageal diverticula via robot-assisted surgery are lacking; hence, further evaluation and investigation of this novel procedure represent a necessity. Since the introduction of robot-assisted surgery in the surgical management of esophageal pathology, only a small number of case reports have reported the use of the robotic approach with no major surgery-related complications, in agreement with our case (1,6-11). These case reports, including this case report, shared a common conclusion, that is, robot-assisted surgery offers successful management for esophageal diverticula. Nevertheless, all are case studies, and, hence, they provide observations that lack comparison to the standard of care and lack generalizability in terms of patient populations and types of diverticula. Therefore, performing studies of a higher level of evidence is crucial to further evaluate the efficacy and safety of this approach.

Acknowledgments

The authors would like to extend their gratitude to the Ministry of National Guard Health Affairs and King Abdulaziz Medical City for their utmost support.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-22/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-22/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-22/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for publication of this case report, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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