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

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.