Pulsion Diverticulum of the Oesophagus: More than just an Out Pouch

Abstract

Oesophageal diverticulum is divided into two types based on the aetiology: the pulsion and the traction diverticula. Pulsion diverticulum occurs due to increased intraluminal pressure. This can be of three types based on the location along the oesophagus: the Zenker's diverticulum (ZD), the midoesophageal diverticulum (MD) and the epiphrenic diverticulum (ED). A PubMed search was conducted for the words 'pulsion', 'diverticulum' and 'oesophagus' for all studies published from January 1980 to March 2013 in the English language. A total of 31 studies were identified, and out of which, five were not included in the review. The pulsion diverticulum of the oesophagus is an uncommon disorder. Its aetiology is related to the motility disorders of the oesophagus. Patients usually present with chest-related symptoms or oesophageal symptoms, which are related to the underlying motility disorder. Evaluation includes barium studies, gastrointestinal endoscopy, CT scan and oesophageal manometry. Surgery is the treatment of choice for symptomatic and large diverticula, although the outcome in asymptomatic patients is unknown. The surgical options include diverticulectomy or diverticulopexy with an adequate myotomy. Most patients with ZD are now treated by using endoscopic techniques, although no randomised trial has shown its superiority over the open technique. Minimally invasive surgery has also been used for patients with MD and ED. Although isolated case series has shown good improvement in symptoms and reduction in mortality with minimally invasive techniques in patients with ED, its role in thoracic oesophageal diverticulum is debated.

Systematic Review and Meta-analysis of SurgicalTreatment of Non-Zenker’s Oesophageal Diverticula

“…Twenty-four studies6 – 8 , 10 – 13 , 18 – 26 , 28 – 36 reported at least one complication and were included in the overall pooled estimated morbidity rate of 21.1% [95% c.i. (14.4–27.7), p  < 0.001] (Fig.…”

Minimally invasive approach to a symptomatic giant mid esophageal diverticulum

“…8 Earlier myotomy was advocated for all mid esophageal diverticula but with better detection of oesophageal dysmotility, it may be possible to minimise the myotomy by correlating it with the manometric findings. 9 There has also been a recent report of successful management of a midesophageal diverticulum by endoscopic diverticulectomy using a needle knife.…”

Role of Peroral Endoscopic Myotomy (POEM) in the Management of Esophageal Diverticula

“…6 This can be seen in ZD if it is located above the upper esophageal sphincter or in an epiphrenic diverticulum if it is located within 10 cm of the gastroesophageal junction. 7 The traction diverticulum is a true diverticulum. It is an outpouching that involves all three layers: the mucosal, submucosal, and muscular layers.…”