Advertisement

Epiphrenic and Mid-Esophageal Diverticula

  • Lowell S. SuEmail author
  • Jon O. Wee
Chapter

Abstract

Epiphrenic and mid-esophageal diverticula are rare pathologic esophageal diseases. Though they are located in different regions on the esophagus, both pathologic processes are inherently related to esophageal dysmotility. The majority of patients are asymptomatic, and many of these diverticula are diagnosed incidentally on imaging. All symptomatic patients should undergo treatment, and there is growing evidence that treatment should be offered to asymptomatic patients. Ultimately, the treatment for esophageal diverticula is surgical resection and treatment of the underlying dysmotility. The tenets of epiphrenic diverticular surgical treatment are to treat the diverticulum, perform a myotomy, and perform an anti-reflux procedure on the esophagus. Epiphrenic diverticula can be approached laparoscopically or thoracoscopically depending on size and location. The treatment goals for mid-esophageal diverticula are to treat the diverticulum, identify and resect any fistula, and treat the underlying motility disorder. These diverticula are generally approached thoracoscopically, though there are emerging endoscopic treatment modalities that are safe and effective.

Keywords

Epiphrenic diverticula Mid-esophageal diverticula Esophagus Diverticula Diverticulectomy Myotomy 

References

  1. 1.
    Dukes RJ, Strimian CV, Dines DE, et al. Esophageal involvement with mediastinal granuloma. JAMA. 1976;236(20):2313–5.CrossRefGoogle Scholar
  2. 2.
    Zenker FA, von Ziemssen H. Dilatations of the oesophagus. In: Buck AH, Ziemssen H, Peabody GL, editors. Cyclopaedia of the practice of medicine, vol. 3. London: Low, Marston, Searle & Rivington; 1878. p. 46.Google Scholar
  3. 3.
    Hammon JW, Rice RP, Postlethwait RW, et al. Esophageal intramural diverticulosis: a clinical study and pathological survey. Ann Thorac Surg. 1974;17(3):260–7.CrossRefGoogle Scholar
  4. 4.
    Rice TW, Baker ME. Midthoracic esophageal diverticula. Semin Thorac Cardiovasc Surg. 1999;11(4):352–7.CrossRefGoogle Scholar
  5. 5.
    Belsey R. Functional disease of the esophagus. J Thorac Cardiovasc Surg. 1966;52:164–88.PubMedGoogle Scholar
  6. 6.
    Mondiere JT. Notes sur quelques maladies de l’oesophage. Arch Gen Med Paris. 1833;3:28–65.Google Scholar
  7. 7.
    Hirano Y, Takeuchi H, Oyama T, et al. Minimally invasive surgery for esophageal epiphrenic diverticulum: the results of 133 patients in 25 published series and our experience. Surg Today. 2013;43(1):1–7.CrossRefGoogle Scholar
  8. 8.
    Allen TH, Clagett OT. Changing concepts in the surgical treatment of pulsion diverticula in the lower esophagus. J Thorac Cardiovasc Surg. 1965;50(4):455–62.PubMedGoogle Scholar
  9. 9.
    Fasano NC, Levine MS, Rubesin SE, et al. Epiphrenic diverticulum: clinical and radiographic findings in 27 patients. Dysphagia. 2003;18:9–15.CrossRefGoogle Scholar
  10. 10.
    Dodds WJ, Stef JJ, Hogan WJ, et al. Distribution of esophageal peristaltic pressure in normal subjects and patients with esophageal diverticulum. Gastroenterology. 1975;69(3):584–90.PubMedGoogle Scholar
  11. 11.
    Debas HT, Payne WS, Cameron AJ, et al. Pathophysiology of lower esophageal diverticulum and its implications for treatment. Surg Gynecol Obstet. 1980;151(5):593–600.PubMedGoogle Scholar
  12. 12.
    Mercantini P, Virgilio E, Petrucciani N, et al. Giant midthoracic pulsion diverticulum of the esophagus. Am Surg. 2010;76(7):782–4.PubMedGoogle Scholar
  13. 13.
    Nehra D, Lord RV, DeMeester TR, et al. Physiologic basis for the treatment of epiphrenic diverticulum. Ann Surg. 2002;235(3):346–54.CrossRefGoogle Scholar
  14. 14.
    Orringer MB. Eiphrenic diverticula: fact and fable. Ann Thorac Surg. 1993;55(5):1067–8.CrossRefGoogle Scholar
  15. 15.
    Altorki NK, Sunagawa M, Skinner DB. Thoracic esophageal diverticula: why is the operation necessary? J Thorac Cardiovasc Surg. 1993;105(2):260–4.PubMedGoogle Scholar
  16. 16.
    Jung JJ, Hsieh CC, Lin SC. Squamous cell carcinoma in a large epiphrenic esophageal diverticulum. Dig Dis Sci. 2009;54(6):1365–8.  https://doi.org/10.1007/s10620-009-0727-2. Epub 2009 Jan 30.CrossRefGoogle Scholar
  17. 17.
    Suzuki I, Oho K, Ariizumi K. A case report of giant esophageal leiomyoma associated with an epiphrenic esophageal diverticulum. Nihon Kyobu Geka Gakkai Zasshi. 1994;42(6):931–5.PubMedGoogle Scholar
  18. 18.
    Hodge GB. Esophageal leiomyoma associated with an epiphrenic diverticulum and hiatus hernia. Am Surg. 1970;36(9):538–43.PubMedGoogle Scholar
  19. 19.
    Eluvanthingal Muttikkal TJ, Shami VM, Jones DR. FDG positron emission tomography and computed tomography demonstration of carcinoma arising in an epiphrenic diverticulum. J Radiol Case Rep. 2014;30(11):42–6.  https://doi.org/10.3941/jrcr.v8i11.2060. eCollection 2014.CrossRefGoogle Scholar
  20. 20.
    Gust L, De Lesquen H, Ouattara M, et al. Open surgical management of oesophageal diverticulum. Multimed Man Cardiothorac Surg. 2015;2015:pii: mmv011.  https://doi.org/10.1093/mmcts/mmv011. Print 2015.CrossRefGoogle Scholar
  21. 21.
    Benacci JC, Deschamps C, Trastek VF, et al. Epiphrenic diverticulum: results of surgical treatment. Ann Thorac Surg. 1993;55(5):1109–13.CrossRefGoogle Scholar
  22. 22.
    Varghese TK, Marshall B, Chang AC, et al. Surgical treatment of epiphrenic diverticula: a 30-year experience. Ann Thorac Surg. 2007;84:1801–9.CrossRefGoogle Scholar
  23. 23.
    Bonavina L, Segalin A, Rosati R. Surgical therapy of esophageal leiomyoma. J Am Coll Surg. 1995;181(3):257–62.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Rosati R, Fumagalli U, Bona S, et al. Diverticulectomy, myotomy, and fundoplication through laparoscopy: a new option to treat epiphrenic esophageal diverticula? Ann Surg. 1998;227(2):174–8.CrossRefGoogle Scholar
  25. 25.
    van der Peet DL, Klinkenberg-Knol EC, Berends FJ, et al. Epiphrenic diverticula: minimal invasive approach and repair in five patients. Dis Esophagus. 2001;14:60–2.CrossRefGoogle Scholar
  26. 26.
    Del Genio A, Rossetti G, Maffetton V, et al. Laparoscopic approach in the treatment of epiphrenic diverticula: long-term results. Surg Endosc. 2004;18:741–5.CrossRefGoogle Scholar
  27. 27.
    Rosati R, Fumagalli U, Bona S, et al. Laparoscopic treatment of epiphrenic diverticula. J Laparoendosc Adv Surg Tech A. 2001;11:371–5.CrossRefGoogle Scholar
  28. 28.
    Neoral C, Aujeský R, Bohanes T, et al. Laparoscopic transhiatal resection of epiphrenic diverticulum. Dis Esophagus. 2002;15:323–5.Google Scholar
  29. 29.
    Macke RA, Luketich JD, Pennathur MD, et al. Thoracic esophageal diverticula: a 15-year experience of minimally invasive surgical management. Ann Thorac Surg. 2015;100:1795–803.CrossRefGoogle Scholar
  30. 30.
    Kilic A, Schuchert MJ, Awais O, et al. Surgical management of epiphrenic diverticula in the minimally invasive era. JSLS. 2009;13(2):160–4.PubMedPubMedCentralGoogle Scholar
  31. 31.
    Jordan PH, Kinner BM. New look at epiphrenic diverticula. World J Surg. 1999;23:147–52.CrossRefGoogle Scholar
  32. 32.
    Fernando HC, Luketich JD, Samphire J, et al. Minimally invasive operation for esophageal diverticula. Ann Thorac Surg. 2005;80:2076–81.CrossRefGoogle Scholar
  33. 33.
    D’Journo XB, Ferraro P, Martin J, et al. Lower esophageal sphincter dysfunction is part of the functional abnormality in epiphrenic diverticulum. Br J Surg. 2009;96:892–900.CrossRefGoogle Scholar
  34. 34.
    Reznik SI, Rice TW, Murthy SC, et al. Assessment of a pathophysiology-directed treatment for symptomatic epiphrenic diverticulum. Dis Esophagus. 2007;20:320–7.CrossRefGoogle Scholar
  35. 35.
    Vinson PP. Diverticula of the thoracic portion of the esophagus: report of 42 cases. Arch Otolaryngol. 1934;19:508–10.CrossRefGoogle Scholar
  36. 36.
    Streitz JM, Glick ME, Ellis H. Selective use of myotomy for treatment of epiphrenic diverticula. Manometric and clinical analysis. Arch Surg. 1992;127:585–8.CrossRefGoogle Scholar
  37. 37.
    Thomas ML, Anthony AA, Fosh BG, et al. Oesophageal diverticula. Br J Surg. 2001;88:629–42.CrossRefGoogle Scholar
  38. 38.
    Rossetti G, Fei L, del Genio G, et al. Epiphrenic diverticula mini-invasive surgery: a challenge for expert surgeons – personal experience and review of the literature. Scand J Surg. 2013;102:129–35.CrossRefGoogle Scholar
  39. 39.
    Zenker FA, von Ziemssen H. Cyclopedia of the practice of medicine. London: Sampson, Low, Marston, Searle and Rivinigton; 1878. p. 46–89.Google Scholar
  40. 40.
    Kragh J. Tuberculosis diverticula of the oesophagus (so-called traction diverticula). Acta Otolaryngol. 1922;4:49–62.CrossRefGoogle Scholar
  41. 41.
    Ribbert H. Die traktionsdivertikel des oseophagus. Virchows Arch (Pathol Anat). 1904;178:351–67.CrossRefGoogle Scholar
  42. 42.
    Borrie J, Wilson RLK. Oesophageal diverticula: principles of management and appraisal of classification. Thorax. 1980;35:759.CrossRefGoogle Scholar
  43. 43.
    Evander A, Little AG, Ferguson MK, et al. Diverticula of the mid- and lower esophagus: pathogenesis and surgical management. World J Surg. 1986;10:820–8.CrossRefGoogle Scholar
  44. 44.
    Nakamura T, Ota M, Marumiya K, et al. Partial esophagectomy for a superficial carcinoma arising from a mid-esophageal diverticulum. Gen Thorac Cardiovasc Surg. 2010;58:163–7.CrossRefGoogle Scholar
  45. 45.
    Mou Y, Zeng H, Wang Q, et al. Giant mid-esophageal diverticula successfully treated by per-oral endoscopic myotomy. Surg Endosc. 2016;30:335–8.CrossRefGoogle Scholar
  46. 46.
    Sugarbaker DJ, Bueno R, Krasna MJ, Mentzer SJ, Zellos L. Adult Chest Surgery: http://www.accesssurgery.com.

Copyright information

© SAGES 2019

Authors and Affiliations

  1. 1.Department of Thoracic SurgeryBrigham and Women’s HospitalBostonUSA

Personalised recommendations