Mastery of Cardiothoracic Surgery
2nd Edition

22
Excision of Esophageal Diverticula
Philip A. Rascoe
W. Roy Smythe
Diverticula of the esophagus are uncommon disorders that are usually classified according to their location (cervical, thoracic, or epiphrenic), their pathogenesis (pulsion or traction), and their morphology (true or false).
The great majority of esophageal diverticula are acquired lesions that occur predominantly in elderly adults. Pulsion, or false, diverticula are the most commonly encountered type of esophageal diverticula. These localized outpouchings lack a muscular coat, and their wall is formed entirely by mucosa and submucosa. Almost all are the result of a functional obstruction to the advancing peristaltic wave, usually caused by an abnormal upper or lower esophageal sphincter. Occasionally, impedance to peristaltic progression may be the result of peptic strictures or localized motility disorders such as spasm. Pulsion diverticula thus occur most commonly at the level of the cricopharyngeus where there is a weak area of the crossing muscle fibers in Killian’s triangle or the distal 10 cm of the thoracic esophagus between the inferior pulmonary vein and the diaphragm (epiphrenic location); however, they may also occur within the midthoracic esophagus.
True, or traction, diverticula are usually seen in the middle one third of the thoracic esophagus in a peribronchial location. These diverticula are the result of paraesophageal granulomatous mediastinal lymphadenitis secondary to disorders such as tuberculosis or histoplasmosis. The ensuing desmoplastic reaction tents the full thickness of the esophageal wall, producing a conical, wide-mouthed true diverticulum. They most frequently project to the right because subcarinal lymph nodes in this area are closely associated with the right anterior wall of the esophagus. These outpouchings are rarely seen in the Western world and are usually of little or no clinical significance except in rare instances when ongoing mediastinal inflammation results in a fistulous communication with the airway or other intrathoracic structures.
Zenker’s Diverticulum
The British surgeon Abraham Ludlow is credited with the original description of a pharyngoesophageal diverticulum from an autopsy specimen that remains on display at the Royal Infirmary Pathology Museum in Glasgow, Scotland. Almost a century later, the German pathologist Zenker provided a complete clinical and pathologic description of 34 cases. The pathogenesis of this lesion was first suggested in 1926 by Jackson, who proposed that the tonically contracting upper esophageal sphincter (UES) impeded the progress of the swallowed bolus. A localized increase in intraluminal pressure forces the mucosa to herniate through the posterior midline of the inferior pharyngeal constrictor in the anatomically bare area (Killian’s triangle) between the oblique fibers of the thyropharyngeus and the horizontal fibers of the cricopharyngeus. The diverticulum deviates away from the rigid vertebrae and usually presents on the left side. The exact nature of this cricopharyngeal motor dysfunction remains unclear, but most commonly an incomplete or incoordinated opening of the UES is present.
Clinical Presentation
Zenker’s diverticulum is primarily a condition of the elderly and is twice as common in men. Dysphagia for solid food and regurgitation of undigested food are the most common symptoms and are typically present. Halitosis, noisy swallowing or “gurgling” after deglutition, and globus sensation are also common. Aspiration may also result from this condition, and it may manifest as a mild nocturnal cough, morning hoarseness, or new adult bronchospasm caused by repeated laryngeal penetration and irritation and, on rare occasion, present as chronic lower respiratory tract infection or even lung abscess. Despite the association among hiatal hernia, gastroesophageal reflux, and Zenker’s diverticulum, only a few patients present with severe heartburn and rarely do they require surgical correction of their reflux.
Diagnosis
A barium esophagogram using a lateral or oblique projection usually demonstrates the diverticulum, which can be large and may protrude well into the superior mediastinum (Fig. 22-1). Esophageal manometry adds little information and should not be routinely performed. Endoscopy can be considered, but often adds little to the diagnosis. Perforation of the diverticulum can result from aggressive endoscopic examination because the flexible endoscope often enters the diverticulum rather than the true esophageal lumen. Malignant change is possible but is exceedingly rare in these diverticula, with squamous cell carcinoma having been reported in no more than 0.5% of patients. If diverticulopexy or endoscopic management is planned, the diverticulum should be palpated to rule out a nodular density in the wall, and a preoperative endoscopic examination should be considered to evaluate the interior of the sac because there will be no pathologic specimen.
Figure 22-1. Barium esophagram demonstrating a large Zenker’s diverticulum.
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Treatment
Once a diagnosis is made, treatment is suggested because these diverticula will often enlarge over time and can lead to the more bothersome complications such as aspiration. The gold standard for the surgical treatment of Zenker’s diverticulum is cricopharyngeal myotomy combined with either diverticulectomy or diverticulopexy via an open transcervical approach. However, advances in instrumentation for minimally invasive surgery now allow for the management of Zenker’s diverticula via a transoral endoscopic creation of a stapled esophagodiverticulostomy in many patients. This procedure creates a cricopharyngeal myotomy while bringing together the lumina of the pouch and esophagus. Carefully selected patients may be offered endoscopic management with the caveat that conversion to an open procedure may be necessary should the minimally invasive approach prove technically unfeasible intraoperatively.
Preoperative Management
Endoscopic management is not the preferred procedure in some patients due to anatomic constraints. Difficulty in placing the diverticuloscope may be encountered in patients with retrognathia, limited jaw mobility, prominent incisors, or rigid cervical kyphosis that limits neck extension. In addition, the size of the diverticulum on barium esophagogram should be assessed because small diverticula (<2 cm) are generally not amenable to stapling. A small pouch limits access of the stapler head and prohibits adequate length of myotomy. Diverticula >6 cm should also be managed with an open approach because endoscopic stapling results in a large pharyngeal cavity that does not empty completely. This information is helpful in preoperative discussions with the patient concerning the likelihood of conversion to an open procedure. All patients should be prepared and give consent for an open procedure in the event that endoscopic instrumentation proves unfeasible or a complication is encountered. Patients are instructed to limit their diet to clear liquids the day before surgery.
Although many cervical operative procedures are now performed under local anesthesia, a general endotracheal anesthetic is suggested for this procedure, along with the usual preincision antibiotic prophylaxis.
Endoscopic Surgical Technique
After induction of general anesthesia, a shoulder roll is placed to achieve neck extension in the standard position for rigid esophagoscopy. An upper jaw dental guard is placed. Direct endoscopy is performed using a lighted suspension laryngoscope. The esophageal lumen, diverticular lumen, and their common wall are visualized. The distal blades are opened slightly to enter the esophagus anteriorly and the diverticular lumen posteriorly. The distal blades of the scope are opened, keeping the common wall between the esophagus and diverticulum centered in the scope’s aperture. The proximal scope is then widened, and the laryngoscope is attached to a suspension system to allow for bimanual instrumentation during the stapling procedure. A 0-degree bronchoscope telescope attached to an endoscopic camera is then inserted laterally through the laryngoscope. The pouch is examined to exclude malignancy and to assess the depth of the pouch and length of the septum. A 30-mm linear stapler is then introduced through the laryngoscope, and its jaws are positioned on the common wall with the longer end containing the staple cartilage within the esophageal lumen. The position of the jaws is confirmed using the telescope. If the position of the jaws is in question, the stapler is opened and the device reapplied. If necessary, traction sutures can be placed laterally in the common wall using an Endosuture device and used to help pull the common wall into the jaws of the stapler. If proper positioning of the stapler cannot be confirmed before firing, the minimally invasive approach cannot safely be performed and should be abandoned in favor of an open procedure. Once proper position is confirmed, the stapler is fired and removed. The stapler divides the common wall, including the cricopharyngeus muscle, between the diverticulum and esophagus and closes the wound edges with a triple row of staples on each side. The divided edges of the septum should retract laterally revealing an open esophageal lumen. The cut edges should be inspected to ensure hemostasis. Should a significant septum and diverticular sac still be present, a second stapler application should be performed in a similar fashion. Once the septum is completely divided and hemostasis is confirmed, the procedure is terminated. Patients are offered a liquid diet the following day, and if fluids are tolerated, they are advanced to a soft diet and discharged on the second postoperative day. All patients should have a chest x-ray postoperatively to exclude air in the retropharyngeal space or mediastinum.
Open Surgical Technique
After general anesthesia is induced, a shoulder roll is placed and the neck is extended
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with the head turned slightly to the right. An incision is made along the anterior border of the left sternocleidomastoid muscle down to near the suprasternal notch. The subcutaneous tissue and platysma are subsequently divided. A superficial cervical cutaneous nerve is present in the upper one third of the field and should be protected if possible to prevent postoperative dysesthesia of the submandibular skin. The incision is deepened through the cervical fascia medial to the sternocleidomastoid muscle. The fascia overlying the omohyoid muscle is incised, and the muscle is divided. The prethyroid muscles are retracted medially to reveal the thyroid gland, the jugular vein, and the carotid artery. The middle thyroid vein is ligated and divided, and the larynx is retracted medially. The inferior thyroid artery is ligated and divided as laterally as possible to protect the recurrent laryngeal nerve, which is located immediately beneath its branches in the tracheoesophageal groove behind the thyroid. The thyroid and cricoid cartilage are rotated medially while retracting the carotid sheath and its contents laterally, and the use of manual retraction is preferred to self-retaining devices to prevent a traction or direct compression injury to the recurrent laryngeal nerve. With the use of blunt dissection, the prevertebral fascial plane is entered posterior to the esophagus and diverticulum, and further rotation of the larynx then everts the lateral posterior pharyngoesophageal junction. The diverticulum can usually be visualized adherent within its filmy attachments to the posterior aspect of the cervical esophagus at or below the level of the cricoid cartilage. The adventitial tissues are gently dissected in the posterior midline to free up the pouch. The tip of the diverticulum is grasped with an atraumatic Babcock or similar type of clamp and is dissected away from the esophagus using a combination of sharp and blunt dissection (Fig. 22-2). The sac is elevated until its neck is clearly defined, and this may require some additional sharp dissection from the known surface of the diverticular sac toward the investing muscle fibers and scar tissue, if present. Once the neck is displayed, a cricopharyngeal myotomy is created starting at the inferior border of the diverticulum on the left posterolateral or posterior aspect of the esophagus. The muscle is separated from the underlying submucosa bluntly using a small right-angled clamp. The myotomy should be extended inferiorly for approximately 3 cm (Fig. 22-3). The submucosa will bulge between the edges of the sectioned muscle. With the myotomy completed, small diverticula (<1 cm) will often
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disappear when released into the bulging submucosa, and thus myotomy alone is sufficient. Those that do not spontaneously resolve should be further treated with either diverticulopexy or excision. Diverticula <5 cm in length are amenable to diverticulopexy, which is a simpler and faster procedure that does not require opening the esophageal lumen. After myotomy, the tip of the diverticulum may be suspended either to the posterior wall of the pharynx or to the prevertebral fascia with two to four simple 3-0 silk sutures (Fig. 22-4). Care should be taken not to transfix the sac to avoid any contamination of the surgical field. Diverticula >5 cm are too large to be suspended and should usually be resected. After myotomy, a large bougie (40 F or larger, depending on patient size) is inserted into the cervical esophagus to prevent an excessive mucosal resection. If possible, a linear stapling device is applied transversally across the neck of the sac, and the sac is transected distal to the staple line. In the rare cases in which a stapler cannot be applied, the sac may be resected and the defect repaired using interrupted sutures. Care must be taken here to not remove an excessive amount of submucosa with the resection. It is better to have more than needed because tissue can be gathered into the suture line to make the lumen an appropriate size. Before closure, a nasogastric tube is passed into the proximal esophagus, and the mucosal integrity is tested by air insufflation by placing saline in the incision and compressing the distal esophagus below the nasogastric tube with a tonsil sponge on a ring forceps. The nasogastric tube is subsequently removed, and after hemostasis is ensured, the wound is closed in two layers without drainage. If the ends of the omohyoid are large enough, they may be reapproximated using a figure-of-eight suture technique. Patients are allowed a clear liquid diet the morning after surgery and advanced to a soft diet the following day in most cases. Most patients are discharged on the second or third postoperative day. A postoperative barium swallow is not routinely required before discharge. When at home, a soft diet may be suggested for the first week following surgery.
Figure 22-2. Exposure of Zenker’s diverticulum. The sac is grasped with an atraumatic clamp and dissected away from the esophagus.
Figure 22-3. The esophageal muscle is incised from 2 cm to 3 cm below the diverticulum and extended toward the cricopharyngeus.
Figure 22-4. Once the myotomy is completed, the diverticulum should be resected or sutured superiorly to the prevertebral fascia.
Surgical Results
There have been no randomized, controlled trials comparing the different open surgical approaches, nor have there been randomized studies comparing endoscopic stapled esophagodiverticulostomy with open surgical techniques. Several case series describing endoscopic techniques have reported satisfactory outcomes in at least 90% of patients, with both morbidity and recurrence rates <10%. These figures closely approximate those reported in series of open surgical techniques. Complications are similar after both techniques and most commonly include hemorrhage, transient vocal cord paralysis, and perforation resulting in mediastinitis. Reported advantages of the minimally invasive approach include shorter anesthetic time, earlier resumption of normal diet, and shorter hospital stay. The endoscopic stapling technique is an effective procedure that is likely to find increasing application. However, follow-up data regarding recurrences are limited to 2 years. Therefore, conventional open techniques should be considered gold standard therapy at present.
Thoracic Diverticula
Diverticula of the thoracic esophagus are relatively uncommon and typically account for <30% of all esophageal diverticula. As stated earlier, their classification according to location or pathogenesis is probably unnecessary because midesophageal traction diverticula are now a rarity in the Western hemisphere. Almost all thoracic esophageal diverticula are associated with and perhaps caused by an esophageal motor disorder, most commonly achalasia, diffuse esophageal spasm, hypertensive lower esophageal sphincter, and nonspecific motor disorders. Using cinefluorography and manometry, Cross et al. concluded that in 150 patients with esophageal disorders, esophageal diverticula were the result of excessive intraluminal pressures. This segmental increase in pressure, caused by increased esophageal tone or a delay in sphincteric opening, acts on weakened areas of the esophagus and results in outpouching of the mucosa.
Clinical Presentation
Most patients are >60 years of age, and many are asymptomatic or have only minimal and often vague symptoms. There is usually no correlation between diverticular size and the presence of symptoms. Many vague symptoms may be attributable to the underlying motility disorder rather than the diverticulum. Symptoms include dysphagia, postural regurgitation, belching, retrosternal pain, heartburn, and epigastric pain. As in pharyngoesophageal diverticula, pulmonary symptoms are often present but underestimated. These symptoms range from mild nocturnal cough to life-threatening massive aspiration.
Diagnosis
The diagnosis is suggested by a posterior mediastinal air-fluid level on chest roentgenogram and is almost always confirmed by a barium esophagogram. The presence of an associated hiatal hernia or carcinoma within the diverticulum (both
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uncommon occurrences) can be assessed by endoscopic examination, which should be performed in every case. Esophageal manometry is not essential for the diagnosis but may help to define the nature and the extent of the underlying motor disorder. Manometry may require directed passage of the catheter beyond the diverticulum if difficulty is encountered.
Indications for Surgery
Most would agree that surgical intervention is necessary in symptomatic patients, those with large diverticula, and those with established complications such as bronchopulmonary infection (Fig. 22-5). The indication for surgery in asymptomatic or minimally symptomatic patients is less clearly defined by the literature, and yearly surveillance for patients with an asymptomatic thoracic esophageal diverticulum is often the most prudent option.
The basic elements of the operation are resection of the diverticulum and a myotomy to alleviate the underlying motor disorder. Although some authors advocate that a myotomy be done only if a documented underlying motor disorder is present, this is a hazardous proposition because it risks the integrity of the diverticulectomy staple line in the postoperative period and a possible recurrence of the diverticulum later. Another point of controversy is the length of the myotomy. Although a limited myotomy may be satisfactory in many situations, a long myotomy from the level of the aortic arch down to the first 1 cm to 2 cm of the stomach adds little to the duration of the operation and essentially eliminates the need for reoperation. Naturally, once the cardia is mobilized, a nonobstructive type of antireflux repair must be added to avoid the almost certainly ensuing gastroesophageal reflux, which the aperistaltic esophagus cannot adequately clear.
Surgical Procedure
All patients receive a preoperative dose of ampicillin/sulbactam, and this antibiotic is continued for 24 hours postoperatively. Patients with large diverticula should have the contents of the sac evacuated by a large tube preoperatively. Rapid sequence induction of general anesthesia is necessary to secure rapid control and protection of the airway against aspiration.
Notwithstanding that most diverticula project into the right side of the chest, the preferred approach is through a left thoracotomy, which permits excellent exposure of the lower half of the thoracic esophagus, the diverticulum, and the cardia should an antireflux repair be necessary. The patient is placed in the right lateral decubitus position, and the left chest is entered through the sixth intercostal space. The use of a double-lumen endotracheal tube with deflation of the left lung greatly improves the exposure. The mediastinal pleura is incised over the esophagus, the incision extending from the aortic arch to the esophageal hiatus. The esophagus is mobilized at some distance away from the diverticulum and encircled proximally and distally with Penrose drains including both vagus nerves (Fig. 22-6). The sac is freed from the surrounding mediastinal structures with blunt and sharp dissection. Occasionally, the sac is firmly adherent to the right lung or the right mainstem bronchus (in midesophageal diverticula), and upward traction on the esophagus allows a careful dissection of the sac from those attachments.
Figure 22-5. Large epiphrenic pulsion diverticulum associated with pain and intermittent regurgitation of undigested food.
The sac may be invested in an inflammatory rind of tissue, and this must be carefully removed to expose the submucosal wall. The neck of the diverticulum is sharply dissected from the surrounding esophageal muscle and residual scar if present, and the submucosal layer should be separated from the surrounding overlying muscle at its margins so that the true neck is obvious for later division. The vagus nerves may be very adherent to the sac, and can be embedded in the inflammatory tissue surrounding it. Care must be taken not to injure the nerves during this part of the procedure.
Dissection then proceeds caudally to mobilize the gastric cardia. The phrenoesophageal membrane is sharply divided, and the hiatus is manually dilated. The mobilization of the cardia is completed by dividing the posterior attachments between the two vagi and entering the lesser sac, followed by complete excision of the fat pad just superior to the cardia in this region. The posterior attachments here may harbor an enlarged arterial branch emanating from the left gastric artery, and failure to recognize this can result in hemorrhage.
At this time, a 44-F or larger bougie is placed by the anesthesiologist with manual guidance by the surgeon past the diverticular opening. The diverticulum is then brought into view by grasping its fundus with an atraumatic clamp and rotating the diverticulum and the esophagus anteriorly and then to the left (Fig. 22-7). If possible, a diverticulectomy is now performed by excising the sac about 5 mm from its neck using a linear stapling device. If this is not possible due to the size of the neck or necrosis at its junction at the esophageal wall, it can be sharply excised after placement of stay sutures on the cranial and caudal extents of the neck. This can then be repaired using interrupted 3-0 absorbable sutures. A nasogastric tube is passed, and the stapled closure is tested for leak by air insufflation under water with distal esophageal compression. The muscle layer is then approximated over the mucosal closure with interrupted 3-0 silk sutures (Fig. 22-8). On occasion, the muscular layer may be too edematous
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or attenuated for a good second-layer closure. If this is the case, an intercostal muscle flap may be mobilized and approximated to the linear repair using interrupted small silk sutures on the muscular margins. If this is necessary, placing it around the esophagus posteriorly and then onto the left anterior surface will facilitate comfortable position when the esophagus is rotated back to the right. A long myotomy is then performed on the left lateral aspect of the esophagus 180 degrees from the excised diverticulum. The muscle is divided at least 2 cm proximal to the diverticular repair, and if feasible from just below the aortic arch and carried across the gastroesophageal junction onto the stomach for approximately 1 cm. The edge of muscle is gently dissected off the underlying mucosa for several millimeters on either side to preclude premature healing of the myotomy. A nonobstructive antireflux repair should then be performed to prevent reflux sequelae. The repair of choice is the Belsey Mark IV partial fundoplication, with sutures placed on either side of the myotomy in the muscular layer. Once the second layer of sutures is placed, the cardia is gently repositioned into the abdomen and the second layer of sutures is tied. The crura are reapproximated with large nonabsorbable suture so that it will accommodate the tip of the operator’s index finger, and the nasogastric tube is advanced into the stomach.
Figure 22-6. Mobilization of the esophagus for thoracic diverticulum. Penrose drains are used to encircle the esophagus proximal and distal to the diverticulum, including vagus nerves. (n. = nerve.)
Figure 22-7. The esophagus is rotated to the left and anteriorly to expose the diverticulum, which is most often located on the right side. (n. = nerve.)
Minimally invasive treatment of thoracic esophageal diverticula has been performed, but the laparoscopic approach should not be used for those diverticula that are positioned higher near the inferior pulmonary vein. When this approach is feasible, a Dorr fundoplication is the preferred procedure after resection of the diverticulum and myotomy. Thoracoscopic approaches have also been reported, and the components of the operation are no different from the open procedure described previously, with the caveat that very large diverticuli may be difficult to dissect and rotate into the field adequately. These minimally invasive techniques are attractive, although the relatively rare nature of these lesions as symptomatic or very large lesions at presentation has precluded systematic study of this approach.
Surgical Complications and Postoperative Care
Retention of the nasogastric tube is encouraged for 3 to 4 days, at which time a barium esophagram is performed to rule out leak at the repair or myotomy or mechanical obstruction. If no leak is present, a clear liquid diet is begun and is rapidly advanced to a soft mechanical diet with discharge typical on the sixth or seventh postoperative day. Although success rates are very high, there has been moderate morbidity reported and a mortality of up to 9% in some series, substantiating the recommendation that small or asymptomatic diverticula should be observed. Causes of death are more frequently mediastinitis as a result of esophageal leakage and aspiration pneumonia. Morbidity and mortality are obviously negatively influenced by the advanced age of many candidates.
Figure 22-8. After removal of the diverticulum, the mucosal and muscular layers are closed with interrupted sutures. The closure may be tested for leak by air insufflation and distal occlusion. (n. = nerve.)
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Suggested Reading
Adams J, Sheppard B, Andersen P, et al. Zenker’s diverticulostomy with cricopharyngeal myotomy: The endoscopic approach. Surg Endosc 2001;15:34.
Allen MS. Treatment of epiphrenic diverticula. Semin Thorac Cardiovasc Surg 1999;11:358.
Aly A, Devitt PG, Jamieson GG. Evolution of surgical treatment for pharyngeal pouch. Br J Surg 2004;91:657.
Bremner CG. Zenker diverticulum. Arch Surg 1998;133:1131.
Rice TW, Baker ME. Midthoracic esophageal diverticula. Semin Thorac Cardiovasc Surg 1999;11:352.
Sen P, Bhattacharyya AK. Endoscopic stapling of pharyngeal pouch. J Laryngol Otol 2004;118:601.
Sideris L, Chen LQ, Ferraro P, et al. The treatment of Zenker’s diverticula: A review. Semin Thorac Cardiovasc Surg 1999;11:337.
White PS, Mountain RE. Endoscopic treatment for Zenker’s diverticulum. Semin Laparosc Surg 1999;6:177.
Editor’s Comments
By far the most common diverticulum of the esophagus is the pharyngoesophageal, or Zenker’s, diverticulum, which, as the authors point out, is not a true diverticulum because it is a mucosal protrusion, not a true full-thickness outpouching of the esophagus. Most commonly these patients present with difficulty swallowing, noisy swallowing, and often signs and symptoms of aspiration, especially at night. Many of these patients are elderly, and many are told they are not operative candidates because of the risk. It is safe to say that the risk is minimal, and it is likely that there is far greater risk to the patient by allowing the diverticulum to remain, especially if the patient has signs of aspiration. If the patient is felt to be at significant risk for general anesthesia, the procedure may be carried out under local anesthesia.
It has been and remains our preference to approach a Zenker’s diverticulum via the open technique. This involves an incision along the anterior border of the left sternocleidomastoid muscle with dissection down to the prevertebral fascia. The left side is used even if the diverticulum protrudes to the right because the esophagus is easily mobilized and the left recurrent nerve is less at risk than the right. The myotomy is begun at the base of the diverticulum and carried well down onto the esophagus taking care to incise both the longitudinal and circular muscle fibers. For all but the largest diverticula I prefer to perform a diverticulopexy, excluding the diverticulum from the flow of material in the esophagus but avoiding a mucosal entry. If a diverticulectomy is to be carried out, a large (50 F) bougie is placed to avoid tenting of the mucosa and excessive excision that could lead to a stenosis. A staple line is placed across the diverticulum, and the patient is not fed for several days. A contrast study assures integrity of the staple line before feeding.
As described by the authors, an endoscopic approach to the treatment of Zenker’s diverticulum has been described. An instrument specifically for this purpose, the Weerda diverticuloscope, should be used for proper visualization of the diverticulum and endoscopic stapler placement. One blade of the stapler must be in the esophageal lumen and the other in the lumen of the diverticulum for the procedure to be successful. This accomplishes obliteration of the “party wall” between the diverticulum and the lumen of the esophagus and accomplishes a myotomy. The long-term results of this procedure have not been well established.
It is critical to recognize that any esophageal diverticulum or pseudodiverticulum represents the manifestation of a motor disorder of the esophagus, which underscores the importance of a complete myotomy. The myotomy is especially important if the diverticulum has been excised to assure the integrity of the staple line. The terms “pulsion” and “traction” diverticula rarely are used in present-day nomenclature. Even the so-called epiphrenic diverticula are manifestations of a motor disorder, and when operation is indicated a myotomy must also be performed. Patients with an epiphrenic diverticulum also are subject to aspiration, but many, if not most, patients with these diverticula do not require operation. Most are asymptomatic and merely represent curiosities on plain chest radiographs or barium contrast studies. The mere presence of a large epiphrenic diverticulum is not an indication for operation, especially because these must be approached via a thoracotomy.
L. R. K.