VA03.3. Laparoscopic Treatment of Intramural Diverticulum in Type III Achalasia

Abstract

Benign Disease: Esophageal Surgery Achalasia is a primary esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and absent peristalsis. Chronic functional obstruction may lead to structural complications, including esophageal dilation and, rarely, diverticulum formation. The coexistence of achalasia and esophageal diverticulum presents diagnostic and therapeutic challenges. We present a video of a 67-year-old female presenting with dysphagia, regurgitation and episodes of food impaction. Barium esophagogram demonstrated delayed esophageal emptying, spastic contractions and two esophageal diverticula. High-resolution manometry confirmed the diagnosis of type III achalasia (Chicago Classification) and upper endoscopy showed a small diverticulum in the middle esophagus and a larger one 3cm proximal to the gastroesophageal junction. The video shows the intra operative finding of a distal diverticulum that was still covered by all muscular layers of the esophageal wall, posing a challenge for dissection. A long myotomy was performed, the diverticulum was resected and covered with a partial fundoplication. Distal esophageal diverticula are typically associated with underlying esophageal motility disorders, as observed in our patient with type III achalasia. Concomitant management is essential for optimal outcomes. We report a case where the key challenge was recognizing that the diverticulum remained covered by the esophageal muscular layers and carefully isolating it prior to proceeding with resection. We present a video of a 67-year-old female presenting with dysphagia, regurgitation and episodes of food impaction. Barium esophagogram demonstrated delayed esophageal emptying, spastic contractions and two esophageal diverticula. High-resolution manometry confirmed the diagnosis of type III achalasia (Chicago Classification) and upper endoscopy showed a small diverticulum in the middle esophagus and a larger one 3cm proximal to the gastroesophageal junction. The video shows that the diverticulum remained covered by all muscular layers of the esophageal wall, posing a challenge for dissection. A long myotomy was performed, the diverticulum was resected and covered with a partial fundoplication.