Current status of minimally invasive surgery for thoracic esophageal diverticula: systematic review and meta-analysis.

Abstract

Introduction: Thoracic esophageal diverticula, including epiphrenic and parabronchial types, are rare clinical entities representing about 30% of all esophageal diverticula. Thoracic diverticula of the pulsion type have traditionally been associated with motility disorders and treated by stapled diverticulectomy with or without myotomy/fundoplication in patients experiencing disabling symptoms of dysphagia, regurgitation or pulmonary aspiration. Purpose of this study was to review the existing literature and estimate outcomes of minimally invasive surgery.

Methods: Systematic review and meta-analysis. PubMed, MEDLINE, Scopus, Web of Science, Cochrane Central Library, and ClinicalTrials.gov were queried. The search was last updated on April 20, 2026. Outcomes were staple-line leak, overall complications, in-hospital mortality, and symptoms improvement.

Results: Twenty-one observational studies including 390 patients were analyzed. The age of the patients ranged from 23 to 83 years. Dysphagia (86%), regurgitation (73.4%), and respiratory symptoms (31.2%) were common indications for surgery. The size of the diverticula ranged from 2 to 11 cm. Preoperative use of standard or high-resolution esophageal manometry was reported in 18 studies. Achalasia (49.2%) was the most commonly associated motility disorder. Laparoscopic (61.9%), thoracoscopic (30.6%), or combined (6.7%) minimally invasive approaches were described. Adjunctive procedures were esophagomyotomy (87%) and Dor (34.6%) or Toupet (17.7%) fundoplication. The estimated pooled prevalence of staple-line leak was 9.8% (95% CrI 7.1-13.4%; I² = 0.0). Exploratory unadjusted subgroup analyses did not identify statistically supported differences in staple-line leak according to myotomy (RR = 0.67; 95% CrI 0.17-3.52) or surgical approach (RR = 0.72; 95% CrI 0.22-3.39). The estimated pooled prevalence of overall complications, in-hospital mortality, and study-reported symptom resolution/improvement was 21.6% (95% CrI 16.1-28.4%), 1.3% (95% CrI 0.5-2.9%), and 92.1% (95% CrI 87.7-95%), respectively.

Conclusions: Current evidence reporting outcome for minimally invasive midesophageal and epiphrenic diverticulectomy is limited by study design and treatment heterogeneity. Future well-designed multicenter studies are required to assess the effect of surgical approach and esophageal myotomy on short-term morbidity, symptomatic outcomes, and recurrence rate.