World J. Surg. 8, 757-765, 1984
Wo lJour l of lr ry 9 1984 by the Soci~t~
lnternationale de Chirurgie
Surgical Management of Esophageal Diverticula
Gianfranco Fegiz, M.D., Antonio Paolini, M.D., Carlo De Marchi, M.D., and Filippo Tosato, M.D.
Fourth Department of Surgery, University of Rome "La Sapienza," Rome, Italy
The therapy of esophageal diverticula has not yet been de- fined, even if our knowledge of the functional alterations involved seems to have clarified the pathogenesis of this disease. The objective of this study was to verify the re- sults of surgical therapy carried out following physiopath- ological criteria.
Out of 49 patients seen with esophageal diverticular dis- ease, 18 had cervical diverticula, 9 had epibronchial diver- ticula, and 22 had epiphrenic diverticula. Thirty-one pa- tients had an operation performed: 15 had a diverticulec- tomy only, 13 had a diverticulectomy with subdiverticular myotomy, and 3 had a subdiverticular or Heller myotomy plus a Nissen procedure. There was no operative mortal- ity. Three patients operated on for epiphrenic diverticula developed an intrathoracic esophageal fistula which healed spontaneously. One patient who had a cervical diverticu. lectomy developed a recurrence.
Long-term results in 29 cases were good. In 2 cases the results could be considered as poor (recurrence, persistent dysphagia).
It is concluded that the most effective surgical proce- dure for esophageal diverticula is to be chosen for each pa- tient on the basis of an accurate preoperative functional study.
The introduction of new instrumental methods to study functional esophageal disease, particularly diverticular disease, has elicited an ever-increasing interest in determining the correct etiology, pathol- ogy, and surgical therapy of this entity.
The treatment of esophageal diverticula, until a few years ago, consisted of surgical resection or di- verticulopexy and was based on the theory that the diverticulum was (with the exception of epibron- chial traction diverticulum) a mucosal hernia
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through a weakness of the muscular wall. The weakness was considered anatomical in the phar- ynx, while in an epiphrenic focus it was consid- ered the result of atrophic alteration or malforma- tion.
Cineradiographic and pH-manometric studies have shown the concurrence of other esophageal disorders with diverticular disease, in particular, spasm or dyskinesia and gastroesophageal reflux. Moreover, these studies have shown the role played by such disorders in the formation of diver- ticula, modifying the previously held anatomo-mor- phologic etiopathogenetic theories and introducing the new functional-dynamic concept.
The problem of the choice of surgical therapy stemming from a number of unsuccessful results following diverticulectomy alone [1, 2] has caused researchers to look for and correct the true etio- pathogenetic factors that are responsible. There- fore, procedures such as subdiverticular myotomy (with correction of the spasm) and antireflux pro- cedure (if reflux is present) are performed in asso- ciation with a diverticulectomy by many authors [3-6]. Others have continued to perform diverticu- lectomy alone based on their previous results [7, 8]. The merit of this new surgical approach is, there- fore, not unanimously accepted at this point, es- pecially in reference to the cervical type.
Through a review of our series of patients, we sought to verify the validity of this surgical treat- ment of esophageal diverticula based on the func- tional-dynamic theory of the pathogenesis of the disease.
Methods and Materials
In the last 10 years we have seen 49 patients, of whom 18 had cervical diverticula (ll males and 7
758 World J. Surg. Vol. 8, No. 5, October 1984
Table 1. Disorders associated with diverticular disease in 49 patients.
Location of diverticula
Epi- Epi- Associated Cervical bronchial phrenic disorders (18 cases) (9 cases) (22 cases)
Other esophageal diverticulum 1
Hiatal hernia Gastroesophageal
reflux 2 Cardial achalasia - Esophageal myoma - Esophageal varices - Duodenal divertic-
ulum Duodenal ulcer
1 4 - 2 - 1 - 1
females, average age 77 years), 9 had epibronchial diverticula (5 males and 4 females, average age 52 years), and 22 had epiphrenic diverticula (12 males and 10 females, average age 53 years). In all pa- tients pH-manometric, esophagoscopic, and radi- ologic studies were performed.
A short-term pH determination was performed utilizing the standard acid reflux test and the re- sults evaluated according to the usual criteria [9, 10]. Manometric evaluation was performed using a single catheter assembly consisting of 3 fluid- perfused polyethylene tubes bonded together with three 1.5-mm lateral openings, placed 5 cm apart at its distal end. The perfusion rate was 2.1 ml/min. The diagnostic procedure was carried out accord- ing to standard criteria . From 1977 the manom- etry was performed using a catheter with intralumi- nal trasducers (type model 31,S/N 10019, Kulite Semiconductor Products Inc., Ridgefield, New Jer- sey).
Attention was given to the study of the esoph- ageal alterations associated with diverticular dis- ease, in particular, motility disturbances of the tract underlying the diverticulum primary or sec- ondary to an irritative focus. At the cervical level, such alterations consist essentially of a dyskinesia of the cricopharyngeal muscle.
The presence of a zone of spasm underlying the diverticulum was seen in 3 of 18 patients with cervi- cal, and in 10 of 22 patients with epiphrenic diver- ticula. In Table 1 are reported the disorders seen associated with diverticular disease in the 49 pa- tients observed. In some cases, these associated disorders would account for the motility distur- bance mentioned; in others, as in the case of achalasia, they would play a definitive role in the formation of the diverticula. In Fig. 1 are shown the
roentgenograms of some particularly illustrative cases.
Of the 18 patients with a cervical diverticulum, 12 were treated by a diverticulectomy alone. In 2 of these patients, gastroesophageal reflux was pres- ent; nevertheless, a coexistent motility disturbance of the upper esophageal sphincter (U.E.S.) was not revealed. In 3 other patients diverticulectomy was associated with subdiverticular myotomy, on the basis of manometric alteration consisting of hyper- tonia with motor incoordination of the U.E.S. In none of these patients was reflux present. Three pa- tients with small diverticula and minimal symptom- atology refused surgical treatment.
Of the 9 patients with epibronchial diverticula, only 2, who complained of severe dysphagia be- cause of a large diverticulum, underwent surgery. In both cases only a diverticulectomy was per- formed.
Patients with epiphrenic diverticula presented a somewhat different problem. Motility disturbance or other esophageal disorders are frequently asso- ciated with such diverticula. This accounts for the variety of surgical techniques that we have em- ployed. Of the 14 patients with epiphrenic diver- ticula subjected to operation, only 1 was treated with a diverticulectomy alone. In 9 cases, a myot- omy (8 cases) or a Heller myotomy (l case) was also performed. In another case a transthoracic fundusplication was performed in addition to sub- diverticular myotomy. In 3 cases, using the ab- dominal approach, either a subdiverticular my- otomy (2 cases) or a Heller myotomy (1 case) as- sociated with fundusplication, was performed. The diverticula were not resected because of their small dimension.
Surg ica l Techn iques
A left cervical incision is made along the anterior border of the sternocleidomastoid muscle which is retracted laterally. The exposed thyroid is rotated medially. The omohyoid muscle and the inferior thyroid artery are divided, exposing the cervical esophagus. Once identified, the diverticulum is re- tracted superiorly, care being taken to preserve the recurrent nerve (Fig. 2A).
The diverticular neck is then isolated by detach- ing the muscular fibrous layer from the submucosa. The diverticulectomy is performed over a Satinsky clamp placed at the level of the neck (Fig. 2B); the mucosa is then sutured by continuous stitches with chromic catgut. The overlying muscular layer is then sutured (Fig. 2C).
The extramucosal myotomy of the crycopharyn- geal muscle is done anteriorly to the muscular su-
G. Fegiz et al.: Esophageal Diverticula 759
Fig. 1. Radiographic appearance of esophageal diverticula. A. Cervical diverticulum. B. Epibronchial. C. Epiphrenic diverticulum associated with hiatal hernia. D, Epiphrenic diverticulum associated with middle thoracic pouch.
ture (Fig. 2D) and extended inferiorfy for a few cm (3--4). Some surgeons also lengthen the incision su-
periorly. A technical variation  is represented by the wedge-shaped section of the inferior con-
760 World J. Surg. Vol. 8, No. 5, October 1984
Fig. 2A. Cervical diverticulum. Preparation of the diverticular sac. B. Cervical diverticulum. Section over a Satinsky clamp of the neck of the diverticulum. C. Cervical diverticulum. Suture of the overlying muscular layers. D. Cervical diverticulum. Myotomy of the cricopharyngeal sphincter. In A a wedge resection of the sphincter is shown. In B the defect is closed transversely.
strictor of the pharynx and its reconstruction ob- taining a functional result analogous to the myot- omy, while maintaining the muscular plane.
A right posterolateral