S4185 Atypical Presentation of Mid-Esophageal Diverticulum With Esophageal Fistula: Experience From a Public Hospital in Central America

Introduction: Mid-esophageal diverticulum is the rarest of all known esophageal diverticula. This case report describes its clinical presentation in a resource-limited setting in Guatemala, Central America, highlighting the challenges faced and strategies employed. Case Description/Methods: A 47-year-old man with no reported medical history presented to our public hospital with a 3-month history of dysphagia, weight loss, and regurgitation. Upon admission, the patient was stable with unremarkable physical examination. Laboratory tests ruled out pulmonary tuberculosis and HIV infection. An upper endoscopy showed, at 24 cm from the dental arch, the diverticular septum, the ostium of the diverticular sac, and the esophageal lumen, along with a distal fistulous opening from the sac into the esophagus. A barium esophagram revealed a posterior saccular image in the proximal third of the esophagus, filling with contrast, measuring 18 mm in length and 34 mm in diameter, with delayed passage of contrast from the sac to the distal esophagus. A thoracic computed tomography scan showed a filiform saccular image at the T1 level, posterior to the esophagus, extending posterolaterally to the T4 projection, with a transverse diameter of 8.1 mm, and recommunication with the main esophageal lumen. Due to limited resources, endoscopic treatment was not available. The patient was referred to thoracic surgery for esophagectomy. Discussion: Mid-esophageal diverticulum is a rare condition. Risk factors such as esophageal motility disorders, mediastinal inflammatory processes, and chronic inflammation should be ruled out. Treatment depends on the diverticulum’s size and the patient's symptoms and may include surgical resection or diverticular peroral endoscopic myotomy (D-POEM), the latter associated with fewer risks and complications. In resource-limited settings, the management of mid-esophageal diverticulum relies heavily on the availability of diagnostic and therapeutic tools, as illustrated in our case, which ultimately impacts patient outcomes.