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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 defined, 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 results of surgical therapy carried out following physiopath- ological criteria.

Out of 49 patients seen with esophageal diverticular disease, 18 had cervical diverticula, 9 had epibronchial diverticula, and 22 had epiphrenic diverticula. Thirty-one patients had an operation performed: 15 had a diverticulectomy only, 13 had a diverticulectomy with subdiverticular myotomy, and 3 had a subdiverticular or Heller myotomy plus a Nissen procedure. There was no operative mortality. 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 procedure for esophageal diverticula is to be chosen for each patient 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 diverticulopexy and was based on the theory that the diverticulum was (with the exception of epibronchial traction diverticulum) a mucosal hernia

Reprint requests: Dott. Carlo De Marchi, Via G. Papini 36, 00137 Rome, Italy.

through a weakness of the muscular wall. The weakness was considered anatomical in the pharynx, while in an epiphrenic focus it was considered 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 diverticula, 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 etiopathogenetic factors that are responsible. There- fore, procedures such as subdiverticular myotomy (with correction of the spasm) and antireflux procedure (if reflux is present) are performed in association with a diverticulectomy by many authors [3-6]. Others have continued to perform diverticulectomy alone based on their previous results [7, 8]. The merit of this new surgical approach is, therefore, 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 treatment of esophageal diverticula based on the functional-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 ( l l 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 patients pH-manometric, esophagoscopic, and radi- ologic studies were performed.

A short-term pH determination was performed utilizing the standard acid reflux test and the results 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 according to standard criteria [10]. From 1977 the manometry 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 esophageal alterations associated with diverticular disease, in particular, motility disturbances of the tract underlying the diverticulum primary or secondary 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 cervical, and in 10 of 22 patients with epiphrenic diverticula. In Table 1 are reported the disorders seen associated with diverticular disease in the 49 patients observed. In some cases, these associated disorders would account for the motility disturbance 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 present; 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 patients with small diverticula and minimal symptomatology refused surgical treatment.

Of the 9 patients with epibronchial diverticula, only 2, who complained of severe dysphagia because of a large diverticulum, underwent surgery. In both cases only a diverticulectomy was performed.

Patients with epiphrenic diverticula presented a somewhat different problem. Motility disturbance or other esophageal disorders are frequently associated with such diverticula. This accounts for the variety of surgical techniques that we have em- ployed. Of the 14 patients with epiphrenic diverticula subjected to operation, only 1 was treated with a diverticulectomy alone. In 9 cases, a myotomy (8 cases) or a Heller myotomy (l case) was also performed. In another case a transthoracic fundusplication was performed in addition to subdiverticular myotomy. In 3 cases, using the ab- dominal approach, either a subdiverticular myotomy (2 cases) or a Heller myotomy (1 case) associated with fundusplication, was performed. The diverticula were not resected because of their small dimension.

S u r g i c a l T e c h n i q u e s

Cervical Diverticula

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 retracted 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 [11] is represented by the wedge-shaped section of the inferior con-


\ \ \

, , '~ ........

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 myotomy, while maintaining the muscular plane.

Epibronchial Diverticula

A right posterolateral thoracotomy is performed at the sixth intercostal space. The mediastinal pleura is cut and the azygos vein found and dissected. The diverticulum is identified and the dissection of its adhesions to neighboring lymph nodes is performed (Fig. 3). The diverticulum is then resected, the mucosa is sutured, and the overlying muscular layer reconstructed.

Epiphrenic Diverticula

A left posterolateral thoracotomy at the level of the eighth intercostal space usually is the opening incision. If the diverticulum protrudes into the right posterior thorax, the incision would be a right thoracotomy. The pulmonary ligament is divided and the mediastinal pleura opened. The esophagus should be isolated above and below the level of the diverticulum and traction exerted on it by means of a ribbon. The diverticulum is then corrected either by diverticulopexy (Fig. 4A) or diverticular resection (Fig. 4B, C). Once the overlying muscular plane is reconstructed, a longitudinal extramucosal myotomy is done lateral to the suture, extending some 5-6 cm inferiorly (Fig. 5). If the myotomy has included the cardia or if the patient complained of


Fig. 3. Epibronchial diverticulum. Dissection of the adhesions.

B

g

Fig. 4. Epiphrenic diverticulum. Surgical possibilities in the treatment of the diverticulum. A. Pexis. B. Section C. Automatic suture.

gas t roesophageal reflux, t ransthoracic fundoplication through a diaphragmatic opening is performed (Fig. 6).

Results

All patients in this study who underwent surgical correct ion of esophageal diverticula f rom 1972 to 1981 were evaluated. The follow-up consisted of a 6- and 12-month clinical, radiographic, endoscopic, and pH-manomet r i c evaluations; each year after this only clinical and radiographic studies were made. All patients had a minimum follow-up of 1

Fig. 5. Epiphrenic diverticulum. Subdiverticular myotomy after diverticulectomy.

/ / /

Fig. 6. Epiphrenic diverticulum. doplication.

Transthoracic fun-

Table 2. Results in the surgical treatment of cervical esophageal diverticula.

Divertic- Diverticulectomy with ulectomy subdiverticular myotomy (12 cases) (3 cases)

Complications Fistula - - Stenosis - - Recurrence 1 -

Long-term results Optimal 8 3 Fair 3 - Poor 1 -

year. There were no operat ive deaths. We considered the result to be poor when the patient complained of recurrence either of the divert iculum or of the same preoperat ive symptomato logy . A fair


Table 3. Results of surgical treatment of epiphrenic esophageal diverticula.

Diverticulectomy (1 case)

Diverticulectomy with subdiverticular or Heller myotomy (10 cases)

Subdiverticular or Heller myotomy with Nissen fundoplication (3 cases)

Complications Fistula Stenosis Recurrence

Long-term results Optimal 1 Fair Poor

3 m

6 3 1

result was defined by clinical improvement but occasional persistent symptomatology. The result was classificated as optimal when the patient was asymptomatic postoperatively.

None of the 15 patients with cervical diverticula manifested fistulas or transient or persistent vocal cord paralysis (Table 2). Of the 12 patients treated with diverticulectomy alone, ! had poor results because of a symptomatic and radiographic recurrence of the diverticulum 5 months later. Three patients with fair results complained of moderate dysphagia, associated in 1 case with sialorrhea, without recurrence of the diverticulum. In the remaining 8 patients, the results were optimal, as they were in the 3 patients who underwent diverticulectomy and cricopharyngeal myotomy.

In the 2 patients with epibronchial diverticula who underwent a surgical procedure, complications were absent and the clinical results were optimal.

None of the 14 patients treated for epiphrenic esophageal diverticula developed stenosis or recurrence (Table 3). An intrathoracic fistula (which always healed spontaneously) developed in 3 patients who had all been treated by diverticulectomy with subdiverticular myotomy performed from a thoracic approach. The only patient subjected to a simple diverticulectomy had an optimal result. Of the 10 patients treated with both diverticulectomy and subdiverticular or Heller myotomy, one had a poor result because of persistence of dysphagia, the cause of which was not detectable by any diagnostic procedure. Moreover, it is inter- esting to note that the patient's clinical condition was good and she gained 7 kg in 2 years. Fair results were obtained in 3 patients, 2 complaining of intermittent dysphagia and 1 of postprandial acid reflux. The results obtained in the remaining 6 patients were considered optimal.

In the 3 patients treated with a subdiverticular or Heller myotomy plus a Nissen procedure, 2 presented fair results: one because of intermittent

dysphagia, the other due to occasional retrosternal pyrosis. Both conditions were probably due to an imperfect antireflux procedure. The third patient had an optimal result.

Discuss ion

In our opinion, the presence of a cervical diverticulum necessitates its resection. Even if "the fre- quency of recurrences is the same (3 or 4 per cent) amongst cases published in the literature, whether or not the cricopharyngeal muscle is cut" [7], we think, in agreement with others [4, 5, 12, 16], that a motility disturbance of the U.E.S. calls for a subdiverticular myotomy. It is important to rule out its dependence on gastroesophageal reflux, which in some cases is responsible for such motility disturbance [13-15]. The presence of gastroesophageal reflux precludes the possibility of performing a myotomy of the cricopharyngeal sphincter [16] which is the last barrier to aspiration and needs to be corrected with an antireflux procedure. To date we have not been able to confirm, as have others [17], a high incidence of gastroesophageal reflux and/or hiatal hernia, associated with cervical diverticula. This association was detected in only 11% of our patients.

The absence of a motility disturbance of the U.E.S. makes a subdiverticular myotomy un- necessary. Nevertheless, the analysis of our results lets us make few considerations. The fact that 8 of 12 diverticulectomies had optimal results dem- onstrates clearly that diverticulectomy in some cases can be a sufficient procedure. However, the presence of 1 poor and 3 fair results points out that in some cases diverticulectomy alone is not enough. That is probably because we still have some trouble in always detecting the presence of a motility disturbance of the U.E.S. [12].

Most epibronchial diverticula are small, have little tendency to grow, and are not associated with motility disturbances. Therefore, an operation is


rarely indicated, mainly being used in patients in whom the diverticulum is large or there are important symptoms or complications (inflammation, fistula, cancerous transformation). Of course, when it is possible to document a primary motility disturbance, the surgical treatment must be considered according to the criteria followed for epiphrenic diverticula.

The epiphrenic diverticulum, because of its different pathogenesis, requires an accurate study of all possible causative factors. Surgical correction of the functional disturbance (subdiverticular spasm, reflux, achalasia, etc.), when present, is impera- tive. Divert iculectomy is always required, except when the diverticulum is small. The value of such a policy is confirmed by our own results and those of others [3, 6, 18, 19]. We feel that in the case of our patient with a poor result, the cause was most likely her emotional instability.

Subdiverticular myotomy with diverticulectomy seems to reduce the number of complications such as esophagopleural fistula which present a high risk of mortality. When the subdiverticular myotomy involves the lower esophageal sphincter an antireflux procedure is required. In this case the fundoplication must be properly calibrated to avoid creating a new sphincter mechanism which, if hypertensive, may lead to dysphagia, or in- competence, with subsequent gastroesophageal reflux.

We point out that no one single surgical treatment is best for diverticular disease. The useful- ness of surgical procedures and mainly of subdiverticular myotomy is not absolute. Each patient must be studied preoperatively with functional investi- gations to allows individualization of surgical therapy.

R6sum6

Le traitement du diverticule oesophagien n 'est pas encore parfaitement 6tabli bien que notre connais- sance des modifications fonctionnelles qui sont impliqu6es dans sa constitution soit plus pr6cise. L 'object i f de cette 6tude fut de d6finir les r6sultats du traitement chirurgical pratiqu6 sur la base de crit6res physio-pathologiques. Les 49 malades pr6sentaient 18 fois un diverticule cervical, 9 fois un diverticule 6pibronchique, 22 fois un diverticule 6piphr6nique. Trente et un malades ont 6t6 op6r6s: 15 ont subi une diverticulectomie, 13 une r6section du diverticule associ6 ~t une myotomie sous-jacen- te et 3 A une myotomie type Heller associ6e avec une fundo-plicature type Nissen. II n 'y eut pas de d~c6s postop6ratoire. Trois malades op6r6s pour diverticule 6piphr6nique pr6sent6rent une fistule oesophagienne intrathoracique qui cicatrisa spon-

tan6ment. Un malade porteur d 'un diverticule oesophagien accusa une r6cidive.

Les r6sultats ~t long terme furent bons dans 29 cas. Darts 2 cas au contraire le r~sultat fut d6cevant (r6cidive, dysphagie persistante).

On peut conclure de ces faits que l 'op6ration ad6quate pour traiter un diverticule oesophagien doit 6tre choisie chez chaque malade en fonction d 'une 6tude fonctionnelle pr6op6ratoire pr6cise.

Resumen

E1 tratamiento de los divertfculos esoffigicos todavfa no estfi totalmente definido, a pesar de que el conocimiento adquirido sobre las alteraciones functionales aparentemente ha venido a aclarar su patogenesis. E1 prop6sito de este estudio fu6 el de verificar los resultados del tratamiento quirfirgico realizado con fundamento en criterios fisiol6gicos.

De 49 pacientes con divertfculos esof~gicos ob- servados, 18 presentaron divertfculos cervicales, 9 epibronquiales y 22 epifr6nicos. Treinta y un pacientes fueron sometidos a operaci6n: 15 tuvieron diverticulectomfa solamente, 13 tuvieron diverticulectomfa combinada con miotomfa subdiverticular y 3 tuvieron una miotomfa subdiverticular o una miotomfa de Heller en combinaci6n con un procedimiento antirreflujo de Nissen. No hubo mortal- idad operatoria. Tres pacientes intervenidos por divertfculos epifr6nicos desarrollaron fistula esof~gica, la cual cicatriz6 espontfineamente. Un paciente sometido a diverticulectomia cervical present6 recurrencia.

Los resultados a largo plazo fueron buenos en 29 casos. En dos casos los resultados pueden ser con- siderados como pobres (recurrencia, disfagia per- sistente).

Se concluye que el procedimiento quirt~rgico m~ts efectivo para el manejo de los divertfculos esoffigicos debe ser seleccionado para cada paciente en particular sobre la base de un preciso estudio funcional preoperatorio.

References

1. Negus, V.E.: Pharyngeal diverticula. Observation on their evolution and treatment. Br. J. Surg. 38:129, 1980

2. Habein, H., Kirklin, J.W., Clagett, O.T., Moersch, J.H.: Surgical treatment of lower esophageal pulsion diverticula. Arch. Surg. 72:1018, 1956

3. Hallen, T.H., Clagett, O.T.: Changing concepts in the surgical treatment of pulsion diverticula of the lower esophagus. J. Thorac. Cardiov. Surg. 50:455, 1965

4. Ellis, F.H., Schlegel, J.F., Lynch, V.P., Payne, W.S.: Cricopharyngeal myotomy for pharyngo-


esophageal diverticulum. Ann. Surg. 170:374, 1969 5. Borrie, J., Wilson, R.: Esophageal diverticula: Prin-

ciples of management and appraisal of classification. Thorax 31:544, 1976

6. Debas, H., Payne, W.S., Cameron, A., Carlson, H.: Physiopathology of lower esophageal diverticulum and its implications for treatment. Surg. Gynecol. Obstet. 151:593, 1980

7. Michot, F., Lienhard, P., Maillard, J.N.: La myotomie du cricopharingien est inutile dans la cure chirurgical du diverticule pharingo-oesophagien. Chirur- gie 104:679, 1978

8. Bertelsen, S., Aasted, A.: Results of operative treatment of hyperpharyngeal diverticulum. Thorax 31:544, 1976

9. Kantrowitz, P.A., Corson, J.G., Fleischly, D.G., Skinner, D.B.: Measurement of gastroesophageal reflux. Gastroenterology 56:666, 1969

10. Demeester, T.R., Johnson, L.F., Kent, A.H.: Evalu- ation of current operations for the prevention of gastroesophageal reflux. Ann. Surg. 180:511, 1974

1 l. Silver, C., Fell, C.S.: Repair of pharyngoesophageal diverticulum by resection with myotomy and muscle

closure. Surg. Gynecol. Obstet. 147:599, 1978 12. Orringer, M.B.: Extended cervical esophagomyot-

omy for cricopharyngeal dysfunction. J. Thorac. Cardiovasc. Surg. 80:669, 1980

13. Henderson, R.D., Manyatt, G.: Cricopharyngeal myotomy as a method of treating cricopharingeal dysphagia secondary to g.e.r .J . Thorac. Cardio- vasc. Surg. 74:721, 1977

14. Belsey, R.: Functional disease of the esophagus. Postgrad. Med. J. 39:290, 1963

15. Smiley, T.B., Caves, P.K., Forter, D.C.: Relation- ship between posterior pharyngeal pouch and hiatus hernia. Thorax 25:725, 1970

16. Belsey, R.: Functional disease of the esophagus. J. Thorac. Cardiovasc. Surg. 52:164, 1966

17. Welsh, G.F., Payne, W.S.: The present status of one-stage pharyngoesophageal diverticulectomy. Surg. Clin. North Am. 53:953, 1973

18. Basile, A.: I1 trattamento chirurgico dei diverticoli epifrenici dello esofago. Min. Chir. 32:675, 1977

19. Garcia, J.B.: Epiphrenic diverticula of the esophagus. J. Thorac. Cardiovasc. Surg. 63:114, 1972

Invited Commentary

Ronald Belsey, M.S., F.R.C.S.

Department of Surgery, University of Chicago, Illinois, U.S.A.

The main contribution of this paper is support for the now universally held view that most esophageal diverticula are pulsion "blow-outs" secondary to functional disorders, the correction of which takes priority over any local attack on the diverticula. However, in advocating simple diverticulectomy for pharyngeal (Zenker's) diverticula, the authors are inconsistent. A 33% incidence of less- than-satisfactory results does not support their claim for this therapeutic modality. The cited "minimum follow-up period of 1 year" gives no in- dication as to the mean duration of follow-up, so the reported incidence of satisfactory results can be accepted only with reservation. The authors offer no satisfactory explanation for the development of diverticula other than cricopharyngeal incoordination and support their advocacy of simple diverticulectomy by their inability to demonstrate the functional anomaly. The addition of an upper sphincter myotomy is a technically simple maneuver incur- ring no additional risk. Common sense, which can still play a role in clinical surgery, dictates the rou- tine adoption of this variant.

For primary cricopharyngeal incoordination, the currently accepted treatment is myotomy. Small

pharyngeal diverticula are reversible; larger diverticula are managed by excision or retropharyngeal suspension. When the anomaly is associated with documented gastroesophageal reflux, an antireflux procedure is the recommended first step and may result in complete symptomatic relief. Upper sphincter myotomy and diverticulopexy can be added, synchronously or subsequently, for large diverticula or incomplete symptomatic relief. There is a danger that other surgeons may be encouraged by this report to revert to the "simple diverticulectomy" philosophy.

In discussing the management of epiphrenic diverticula, the authors are on firmer ground and have acknowledged the necessity for correcting the underlying functional anomaly by infradiverticular myotomy. However, their claim that "diverticulectomy is always required" is challenged by an unac ceptable 30% incidence of suture line fistulas which they were lucky to treat without mortality. The al- ternative technique of diverticulopexy in prefer- ence to excision eliminates the risk of this poten- tially lethal complication. The authors fail to stress the importance of extending the myotomy to the full extent indicated by synchronous high pressure contractions recorded by manometry to prevent recurrent "blow-outs" at a higher level.

Their acceptance of the importance of an antireflux procedure following a myotomy involving the lower sphincter is commendable, but the advocacy of a Nissen fundoplication is debatable. A