Epiphrenic esophageal diverticulum

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Epiphrenic esophageal diverticulum

Elias Jirjoss Ilias^I; Paulo Kassab^II

^IColégio Brasileiro de Cirurgiões, São Paulo, SP, Brazil

^IIFaculdade de Ciências Médicas da Santa Casa Misericórdia de São Paulo, São Paulo, SP, Brazil

^{Corresponding author at}

Case presentation

Female patient, 40 years of age, presented to the surgical outpatient clinic complaining of dysphagia and halitosis. She had a medical history of HIV-positive asymptomatic disease. She was submitted to an upper endoscopy procedure that showed protrusion of a sac in the distal esophagus, compatible with epiphrenic esophageal diverticulum.

A contrast X-ray was performed, which showed a large diverticulum in the distal esophagus, protruding from the right side of the thorax (Figure 1); the computed tomography assessment showed a distal esophageal diverticulum with air-fluid level in the right hemithorax (Figure 2).

The patient underwent a right thoracotomy with diverticulum resection and simple suture of its base, with good postoperative outcome. The patient showed resolution of dysphagia symptoms, and has remained asymptomatic during the follow-up.

Discussion

Esophageal diverticula are epithelialized mucosal sacs that protrude from the esophageal lumen. They can be classified based on the place of occurrence; the epiphrenic type emerges from 10 cm distal to the esophagus (supradiaphragmatic). The epiphrenic diverticulum occurs more commonly on the right side. The most common symptoms are dysphagia, vomiting, regurgitation, chest and/or epigastric pain, coughing, and halitosis.

The diagnosis method that best defines the diverticulum is contrast X-ray of the esophagus, which also demonstrates the motility disorder. In some cases, the presence of distal esophagus tumors may lead to increased pressure in the organ, which leads to the appearance of the diverticulum. These diverticula are usually acquired and rarely congenital or caused by trauma.

The treatment of these diverticula, when asymptomatic or mildly symptomatic, should be clinical, as the surgical approach has significant morbimortality. In cases of large diverticula (> 3 cm) and very symptomatic patients, surgical resection is necessary through a left or right thoracotomy, according to the diverticulum projection. The diverticulum is resected from its base and the walls are sutured. An esophagomyotomy can also be performed, extending it to the stomach. If the patient has concomitant hiatal hernia or gastroesophageal reflux, they should be addressed by reducing the hernia and repairing the anti-reflux valve using Nissen's technique.

Publication Dates

• Publication in this collection
  07 May 2013
• Date of issue
  Apr 2013