The 79-year-old, nonsmoking, Asian female presented to our hospital with a persisting cough and signs of aspiration pneumonia that lasted more than 1 year. The patient had a history of pulmonary tuberculosis about 50 years ago. Chest computed tomography showed a fibrotic change in the right lower lobe basal segment and suspicious finding of the nearby esophageal diverticulum. Water-soluble contrast esophagography showed a BEF at right side wall of mid to lower esophagus (Figure 2A). Esophagogastroduodenoscopy confirmed BEF in the esophageal diverticulum at 30 cm from the incisors (Figure 1).
The patient underwent uniportal VATS under general anesthesia with one-lung ventilation. An incision was made in the sixth intercostal space of the mid axillary line. The soft tissue and intercostal muscles were retracted with an X-small wound retractor (Alexis; Applied Medical) to secure the intercostal space. A 5-mm, 30  video thoracoscope and endoscope instrument were used. Dissection of the diverticulum and the fistulous tract was done with Ligasure (Valleylab, Covidien), and fistulectomy and diverticulectomy was done with endoscopic linear staplers. The muscular layer of esophagus was approximated with interrupted sutures. There was no bronchial and esophageal defect. The parietal pleural flap was interposed between bronchial and esophageal ends of the divided fistula. At the end of the surgical procedure, a chest tube (24 Fr) was inserted through a single incision (Figure 3). The postoperative course was uneventful. On postoperative day 5, esophagography was performed to detect any esophageal leakage. There was no evidence of contrast leakage (Figure 2B). The patient resumed diet and discharged on postoperative day 6. No recurrence has been observed during 3 months follow-up in the outpatient clinic to date.