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Surgical Science, 2024, 15, 1-6
https://www.scirp.org/journal/ss
ISSN Online: 2157-9415
ISSN Print: 2157-9407
DOI:
10.4236/ss.2024.151001 Jan. 16, 2024 1 Surgical Science
Robotic Surgery: An Effective Treatment Option
for Epiphrenic Diverticulum Associated with
Nutcracker Esophagus
Augusto Tinoco, Gilberto Carvalho, Leonardo Tinoco, Ana Paula Quintão
Department of Digestive Surgery, Hospital São José do Avaí, Itaperuna, Brazil
Abstract
Background: Epiphrenic Diverticulum is frequently associated with esopha-
geal motility disorders, such as nutcrackers esophagus. The diagnosis is usual
ly
made using imaging studies such as a Barium esophagogram, and esophageal
manometry. Surgical treatment options for epiphrenic diverticulum and EN
include diverticulectomy and wide myotomy. Aim: The resection of three epi-
phrenic diverticula and extensive myotomy were performed by robotic tho-
racoscopy uneventfully. Case presentation: A 65-year-
old female complaining
of dysphagia for solid foods, Chest pain and regurgitation. Esophagogastro-
duodenoscopy (EDG) with difficulty in advancing the endoscope at 25
cm and
demonstrating an ED, no hiatal hernia and normal stomach and duodenum.
Barium Esophagogram showed multiple diverticula and tortuosity through-
out the esophagus. Conclusion:
With robotic surgery, surgeons can perform
highly precise operations with enh
anced 3D vision and control. Through this
cutting-edge approach, the treatment of ED associated with EN can be dras-
tically changed, promising better outcomes for patients.
Keywords
Robotic Surgery, Myotomy, Nutcracker Esophagus, Epiphrenic Diverticulum
1. Introduction
The prevalence of epiphrenic diverticulum (ED) associated with nutcracker
esophagus (NE) remains unknown due to the rarity of these conditions [1].
NE, also known as hypertensive peristalsis or hypercontractile esophagus af-
fects 2% to 3% of the population [2]. The true incidence is thought to be much
higher since it is often misdiagnosed as acid reflux. ED is associated with eso-
How to cite this paper:
Tinoco, A.,
Car
valho, G., Tinoco, L. and Quintão, A.P.
(20
24) Robotic Surgery: An Effective Treat-
ment Option for Epiphrenic Diverticulum
Associated with Nutcracker Esophagus.
Surgical Science
,
15
, 1-6.
https://doi.org/10.4236/ss.2024.151001
Received:
November 28, 2023
Accepted:
January 13, 2024
Published:
January 16, 2024
Copyright © 20
24 by author(s) and
Scientific
Research Publishing Inc.
This work is licensed under the Creative
Commons Attribution International
License (CC BY
4.0).
http://creativecommons.org/licenses/by/4.0/
Open Access
A. Tinoco et al.
DOI:
10.4236/ss.2024.151001 2 Surgical Science
phageal motility disorder in 60% of patients, the most frequent being achalasia
and diffuse esophageal spasm (DES). It is rarely reported with NE [3]. Unlike
achalasia, NE have no well-defined pathology.
Recently, esophageal diverticula have been associated with motor abnormali-
ties being characterized by high-pressure contractions in the esophagus, making
swallowing difficult [4] [5]. There are non-surgical options such as lifestyle
changes (avoiding certain foods and eating slowly) and medication which often
end up being a temporary solution and not a long-term treatment. They may
provide temporary relief, but they are not the definitive answer for all patients
[6].
The treatment of esophageal motility disorders is a complex and evolving
field, and the optimal management of patients with ED and DES remains con-
troversial.
The key to successful treatment of DES and NE is to resecting the diverticu-
lum and to perform a complete myotomy to prevent disease recurrence.
Robotic surgery has emerged as a promising approach for the treatment of ED
associated with NE, offering greater precision and visualization, avoiding mu-
cosal perforations during myotomy, when comparing to traditional surgical
technique approaches. Despite the complexity of these conditions, advances in
robotic surgery have paved the way for innovative solutions [7] [8]. By harness-
ing the power of technology, surgeons can perform highly accurate operations
with precise movement of robotic arms, endowrist technology and enhanced 3D
vision control.
The objective of this report is to demonstrate that performing resection of the
epiphrenic diverticulum with extensive myotomy robotically to treat NE is feasi-
ble and safe, this method has not yet been reported in the literature.
2. Case Presentation
A 65-year-old female complains of dysphagia for solid foods, Chest pain and re-
gurgitation. esophagogastroduodenoscopy (EDG) with difficulty in advancing
the endoscope at 25 cm and demonstrating an ED, no hiatal hernia and normal
stomach and duodenum. Barium esophagogram showed multiple diverticula
and tortuosity throughout the esophagus (Figure 1). Manometry was not possi-
ble due to the difficulty in passing the probe through the esophagus.
Under general anesthesia, a single-lumen endotracheal intubation was used.
The patient was in semi-prone position. A total of four trocars were used on
the right chest. The initial endoscope was placed on port 2 at the 5th intercos-
tal space (ICS), between the mid axillary line (MAL) and anterior axillary line
(AAL). Intrathoracic carbon dioxide (CO2) insufflates with an 8 mmHg pres-
sure. Port 1 was positioned at 8 cm away from port 2 at the 8th ICS space and
port 3 in the 3th ICS, between the MAL and AAL. The 12 mm assist port was
placed at the 6th ICS at AAL. The Da Vinci® cart was docked at the patient left
side.
A. Tinoco et al.
DOI:
10.4236/ss.2024.151001 3 Surgical Science
Figure 1. Barium esophagogram showed multiple diverticula and tortuosity throughout
the esophagus.
Azygos vein dissection was performed with Cadiere forceps at arm 1, and sec-
tioning with scissors with monopolar energy at arm 3. Ligation was done using 4
hemolocks. Proximal and distal dissection was done after the esophageal repair-
ing with an umbilical tape. Three epiphrenic diverticula were identified after
dissection of the esophagus up to the lower esophageal sphincter. After the neck
was fully exposed, a 36-French boogie was inserted into the esophagus to avoid
narrowing the lumen. Through the assistant port, an Endo-GIA stapler (45 mm
length, vascular load; Medtronic, Minneapolis, Minnesota, USA) was inserted to
divide the neck of the diverticulum. During this step, meticulous care was taken
not to perforate the diverticulum. The diverticulum were removed and placed in
an Endo Bag (Cook®). The staple line was examined for any leakage and rein-
forced was done with 3.0 prolene thread, using a running suture and an exten-
sive esophageal myotomy was performed. A thoracic tube was placed into the
right hemithorax (Appendix, Video 1).
An iodine esophagography was performed on the second postoperative day,
demonstrating normal swallowing (Figure 2).
Informed consent was authorized by the patient to report this case.
In the Histopathological study, the following were identified in the macros-
copic visualization: Three irregular fragments of tissue, brownish and elastic,
measuring together 3.5 × 2.2 × 1.3 cm. In conclusion: Epiphrenic Diverticulum.
Patient was discharged from hospital on the third day after the procedure,
presented good clinical evolution, and remains in outpatient follow-up.
3. Discussion
ED is a rare type of esophageal diverticula with a prevalence ranging from
0.015% to 2%. Males show a slightly higher incidence, with a peak age between
the sixth and seventh decades of life [9].
A. Tinoco et al.
DOI:
10.4236/ss.2024.151001 4 Surgical Science
Figure 2. An iodine esophagography was performed on the second postoperative day,
demonstrating normal swallowing.
NE is also a rare esophageal motility disorder characterized by simultaneous,
uncoordinated or rapidly propagated contractions with normal amplitude and
with dysphagia [10].
Esophageal spasms symptoms resemble those of a ED. Chest pain that may
feel like heartburn, dysphagia, retrosternal pain mainly during swallowing, bolus
sensation and regurgitation.
The presented case demonstrated an association of both diseases, with symp-
toms in line with those described in the literature and considering that, up to
60% of patients with ED also present with underlying motility disorders, with
NE being one of them [3]. More recently, esophageal diverticula have been asso-
ciated with motor abnormalities [4] [5].
Surgical treatment for ED and NE is diverticulectomy and wide myotomy of
the esophageal musculature to prevent recurrence [11]. The presented case a
robotic thoracoscopy resection of three diverticula and wide myotomy was done
(Appendix, Video 1).
Surgical treatment for DE and NE has been shown to be effective in improving
symptoms and improving patients’ quality of life. On the other hand, the risks
should be considered including bleeding, leakage, and damage to adjacent or-
gans [12]. Surgical approach can be through conventional surgery or minimally
invasive techniques such as laparoscopy or robotic-assisted surgery.
Controversy persists regarding the extent of the esophagomiotomy, both
proximal and distally. Some authors advocate that should be done myotomy on-
ly in the motor disorder area, sparing the lower esophageal sphincter, unless it is
hypertensive. The goal would be to avoid the need for an additional anti-reflux
repair [13].
Limiting the myotomy may contributed to the recurrence, by not sufficiently
reducing the abnormal contractions and maintaining the symptoms of the NE
[14]. Without myotomy, the incidence of recurrence may reach 20% of the cases
[15]. On the other hand, diverticulectomy with myotomy has been shown in the
literature to have a postoperative leakage in approximately 7.7% - 27.2% la [11]
[16].
A. Tinoco et al.
DOI:
10.4236/ss.2024.151001 5 Surgical Science
Robotic surgery has a high level of precision and accuracy in performing sur-
gical procedures [17] [18], making it possible to reduce morbidity and mortality.
4. Conclusions
In this patient, the robotic approach, with 3D vision, image magnification and
endowrist technology made the operation easier and safer, especially considering
the esophageal dissection, the suture invagination and the extensive myotomy,
with less risk of mucosal injury.
Through this cutting-edge approach, the treatment of ED associated with NE
can be dramatically altered, promising better outcomes for patients.
Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this pa-
per.
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Appendix
Video 1. Final minutes of surgery and an iodine esophagography was performed on the
second postoperative day.
https://drive.google.com/file/d/1OSmQhPADkrP1z9e_BIJFzEWHzTFG-9JD/view?usp=s
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