Treatment of epiphrenic and mid-esophageal diverticula

Abstract

Thoracic esophageal diverticula are uncommon. They account for less than 30% of esophageal diverticula. The majority of patients are asymptomatic or have minimal symptoms. About one third of patients present with severe symptoms. Occasionally, pulmonary symptoms can be the sole manifestation of the disease and can be life threatening. Dysphagia, food regurgitation, chest pain, weight loss, and reflux symptoms are the most commonly encountered gastrointestinal symptoms. Malignancy is a rare complication of esophageal diverticula; therefore, patients should be educated regarding this complication. Appropriate diagnostic tests should be arranged promptly if alarming symptoms develop. Esophageal motor disorders are found in the majority of patients and need to be taken into account when planning therapy. Medical and endoscopic therapies have limited roles in treatment. Surgery is the standard of care for patients with pulmonary or incapacitating symptoms related to an epiphrenic diverticulum, and myotomy is the cornerstone of surgery. To ensure complete relief of the obstruction, the myotomy should extend distally at least 1.5 to 2 cm into the stomach and proximally at least to the neck of diverticulum. Adding a nonobstructing entireflux procedure is recommended to prevent the development of gastroesophageal reflux disease. Occasionally, a specific treatment such as a diverticulectomy or diverticulopexy needs to be directed to the diverticulum. Preliminary treatment results from minimally invasive surgery, especially laparoscopy, have been promising. In the future with increased experience, minimally invasive surgery may become the standard of care.

Mid-Esophageal Diverticulum Mimicking an Aortic Aneurysm on Chest Radiography

“…Surgery generally involves diverticulectomy and myotomy in symptomatic large diverticula, with esophagectomy performed in patients with nonfunctional esophagus or cases complicated by malignancy [11]. …”

Minimally invasive approach to a symptomatic giant mid esophageal diverticulum

“…They commonly occur in the 6th to 7 th decade with a male preponderance. 4 The incidence of true diverticula containing all the layers of the esophageal wall is on the decline. These were commonly associated with mediastinal inflammation and scarring due to tuberculosis and histoplasmosis.…”

“…Patients with a diverticulum 5 cm or greater in width and those with preferential filling of the diverticulum with barium on swallowing studies are more likely to develop symptoms. 4 Commonly encountered symptoms include regurgitation, dysphagia, weight loss, retrosternal chest pain, halitosis. Pulmonary complications related to aspiration of regurgitated food contents can occur in 24% to 45% of these patients.…”

An uncommon source of upper gastrointestinal bleeding: epiphrenic esophageal diverticulum

“…Epiphrenic esophageal diverticula are located 10 cm from the gastroesophageal junction and account for about 15% of all esophageal diverticulae; the majority are false diverticula, containing the mucosal and submucosal layers without the muscularis propria [ 6 ]. Epiphrenic esophageal diverticula more commonly occur on the right side, perhaps because the aorta and the heart inhibit the enlargement of diverticula on the left side [ 7 , 8 ]. The mechanism of formation of epiphrenic esophageal diverticula is most commonly attributed to pulsion forces associated with esophageal dysmotility, functional or mechanical obstruction, and local wall weakness leading to mucosal herniation at the segment of maximal luminal pressure and least wall resistance [ 6 ].…”