Laparoscopic Transhiatal Resection of an Esophageal Diverticulum in a Patient With Systemic Lupus Erythematosus: A Case Report

Esophageal diverticula are relatively uncommon, especially supradiaphragmatic diverticula. Esophageal diverticula are normally managed by observation; however, surgical treatment is sometimes indicated for large diverticula or diverticula in highly symptomatic patients. Surgical approaches for esophageal diverticula include thoracoscopic or laparoscopic resection; however, consensus has not yet been reached on the optimal approach. Here, we report a case of safe laparoscopic transhiatal esophageal diverticulectomy in a patient with a giant esophageal diverticulum with severe coexisting disease. The patient was a 63-year-old woman with a 17-year history of systemic lupus erythematosus (SLE) who was managed by outpatient therapy with steroids and immunosuppressive drugs. She had a history of SLEassociated renal dysfunction and SLE-associated pulmonary artery thromboembolism, and she was receiving anticoagulation therapy. During an outpatient visit, the patient experienced pericardial discomfort, and upper gastrointestinal endoscopy and computed tomography revealed the presence of a diaphragmatic diverticulum with a diameter of 3 cm. She subsequently developed aspiration pneumonia, which was thought to be caused in part by food stagnation in the diverticulum. However, due to the risks associated with systemic complications, she was initially managed by observation. One year later, the diverticulum had expanded to 6 cm in diameter, and it was determined that the risk of esophageal perforation and aspiration pneumonia was high. Surgery was performed under a laparoscope, and the diverticulum was resected with surgical staplers under an extremely good visual field by dissecting the area around the esophageal hiatus. Postoperative pathology confirmed that the diverticulum was a pseudodiverticulum. The patient's postoperative course was initially good, and she was discharged 10 days after surgery. However, the day after discharge, a hematoma infection occurred near the suture site, requiring re-hospitalization and drainage surgery. After reoperation, she recovered without complications and was discharged 14 days later. Subsequent follow-up showed no diverticulum or pneumonia recurrence. The laparoscopic approach is a minimally invasive approach for patients with diverticula who are at high surgical risk. With an adequate view from the abdominal cavity, even a patient with a fairly large diverticulum can be safely resected.