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Diverticulum Of The Esophagus

Category: DISEASES OF THE ESOPHAGUS
Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery

Diverticula may, and usually do, consist in a pouching by herniation,
of the whole thickness of the esophageal wall; or they may be
herniations of the mucosa between the muscular layers. They are
classified according to their etiology, as traction and pulsion
diverticula.

[FIG. 99.--Traction diverticulum of the esophagus rendered visible in
the roentgenogram by a swallowed opaque mixture. Case of H. W.
Dachtler, Am. Journ. Roentgenology.]

Traction diverticulum of the esophagus (Fig. 99) is a rare

condition, usually occurring in the thorax, and as a rule constituting
a one-sided enlargement of the gullet rather than a true pouch
formation. It is supposed to be formed by the pulling during cough,
respiration, and swallowing, on localized adhesions of the esophagus
to periesophageal structures, such as inflammatory peribronchial
glands.

Diagnosis is often incidental to examination of the gastrointestinal
tract for other conditions, because traction diverticula usually cause
no symptoms. Unless a very large esophagoscope be used, a traction
diverticulum may easily be overlooked in the mucosal folds. Careful
lateral search, however, will reveal the dilatation, and the localized
periesophageal fixation may be demonstrated. The subdiverticular
esophagus is readily followed, its lumen opening during inspiration
unless very close to the diaphragm, which is very rare. Perhaps most
cases will be discovered by the roentgenologist. It has been said that
traction diverticula are more readily demonstrated in the
roentgenologic examination, if the patient be placed with pelvis
elevated.

Pulsion diverticulum of the esophagus is an acquired hernia of the
mucosa between the circular and oblique fibers of the inferior
constrictor muscle of the pharynx. A congenital anatomic basic factor
in etiology probably exists. The pouching develops in the middle part
of the posterior wall, between the orbicular and oblique fibers of the
cricopharyngeus muscle, at which point there is a gap, leaving the
mucosa supported only by a not very resistant fascia (Fig. 100). When
small, the sac is in the midline, but with increase in size, it
presents either to the right or the left side, commonly the latter.
The sac may be very small, or it may be sufficiently large to hold a
pint or more, and to cause the neck to bulge when filled. When large,
the pouch extends into the mediastinum. It will be seen that
anatomically the pulsion diverticulum has its origin in the pharynx;
the symptoms, however, are referable to the esophagus and the
subdiverticular esophagus is stenosed by compression of the pouch;
therefore, it is properly classified as an esophageal disease.

[FIG. 100.--Schema illustrative of the etiology of pressure
diverticula. O, oblique fibers of the cricopharyngeus attached to the
thyroid cartilage, T. The fundiform fibers, F, encircle the mouth of
the esophagus. Between the two sets of fibers is a gap in the support
of the esophageal wall, through which the wall herniates owing to the
pressure of food propelled by the oblique fibers, O, advance of the
bolus being resisted by spasmodic contraction of the orbicular fibers,
F.]

Etiology.--Pressure diverticula occur after middle life, and more
often in men than in women. The hasty swallowing of unmasticated food,
too large a bolus, defective or artificial teeth, flaccidity of
tissues, and spasm of the cricopharyngeus muscle, are etiologic
factors. Cicatricial stenosis below the level of the inferior
constrictor is a contributory cause in some cases.

Prognosis.--After the pouch is formed, it steadily increases in
size, since the swallowed food first fills and distends the sac before
the overflow passes down the esophagus. When a pendulous sac becomes
filled with food, it presses on the subdiverticular esophagus, and
produces compression stenosis; so that there exists a vicious
circle. The enlargement of the sac produces increasing stenosis with
consequent further distension of the pouch. This explains the
clinically observed fact, that unless treated, pulsion diverticula
increase progressively in size, and consequently in distressing
symptoms. The sac becomes so large in some cases as to contribute to
the occurrence of cerebral apoplexy by interference with venous
return. Practically all cases can be cured by radical operation. The
operative mortality varies with the age, state of nutrition, and
general health of the patient. In general it may be said to have a
mortality of at least 10 per cent, largely due to the fact that most
cases are poor surgical subjects. Recurrences after radical operation
are due to a persistence of the original causes, i.e., bolting of
food; stenosis, spasmodic or organic, of the esophageal lumen; and
weakness in the support of the esophageal wall, which, unsupported,
has little strength of its own.

Symptoms.--Dysphagia, regurgitation, a gurgling sound and subjective
bubbling sensation on swallowing, sour odor to the breath, and cough,
are the chief symptoms. With larger pouches, emaciation, pressure
sensation in the neck and upper mediastinum, and the presence of a
mass in the neck when the sac is filled, are present. Tracheal
compression by the filled pouch may produce dyspnea. The sac may be
emptied by pressure on the neck, this means of relief being often
discovered by the patient. The sac sometimes spontaneously empties
itself by contraction of its enveloping muscular layer, and one of the
most annoying symptoms is the paroxysm of coughing, waking the
patient, when during the relaxation of sleep the sac empties itself
into the pharynx and some of its contents are aspirated into the
larynx. There are no pathognomonic symptoms. Those recited are common
to other forms of esophageal stenosis, and are urgent indications for
diagnostic esophagoscopy.

Diagnosis.--Roentgenray study with barium mixtures, is the first
step in the diagnosis (Fig. 101). This is to be followed by diagnostic
esophagoscopy. Malignant, spasmodic, cicatricial, and compression
stenosis are to be excluded by esophagoscopic appearances. Aneurysm is
to be eliminated by the usual means. The Boyce sign is almost
invariably present, and is diagnostic. It is elicited by telling the
patient to swallow, which action imprisons air in the sac. The
imprisoned air is forced out by finger-pressure on the neck, over the
sac. The exit of the air bubble produces a gurgling sound audible at
the open mouth of the patient.

Esophagoscopic Appearances in Pulsion Diverticulum.--The
esophagoscope will without difficulty enter the mouth of the sac which
is really the whole bottom of the pharynx, and will be arrested by the
blind end of the pouch, the depth of which may be from 4 to 10 cm. In
some cases the bottom of the pouch is in the mediastinum. The walls
are often pasty, and may be eroded, or ulcerated, and they may show
vessels or cicatrices. On withdrawing the tube and searching the
anterior wall, the subdiverticular slit-like opening of the esophagus
will be found, though perhaps not always easily. The esophageal
speculum will be found particularly useful in exposing the
subdiverticular orifice, and through this a small esophagoscope may be
passed into the esophagus, thus completing the diagnosis. Care must be
exercised not to perforate the bottom of the diverticular pouch by
pressure with the esophagoscope or esophageal speculum. The walls of
the sac are surprisingly thin.

[FIG. 101.--Pulsion diverticulum filled with bismuth mixture in a man
of fifty years.]

Treatment of Pulsion Diverticulum.--If the pouch is small, the
subdiverticular esophageal orifice may be dilated with esophagoscopic
bougies, thus overcoming the etiologic factor of spastic or organic
stenosis. The redundancy remains, however, though the symptoms may be
relieved. Cutting the common wall between the esophagus and the sac by
means of scissors passed through the endoscopic tube, has been
successfully done by Mosher.

Various methods of external operation have been devised, among which
are: (1) Freeing the sac through an external cervical incision and
suturing its fundus upward against the pharynx, which has proved
successful in some cases. (2) Inversion of the sac into the pharynx
and suture of the mouth of the pouch. In a case so treated the pouch
was blown out again during a fit of sneezing eight months after
operation. (3) Plication of the walls of the sac by catgut sutures, as
in the Matas obliterative operation for aneurysm. (4) Freeing and
removing the sac, with suture of the esophageal wound. (5) Removal of
the sac by a two-stage operation, in which method the initial step is
the deliverance of the sac into the cervical wound, where it remains
surrounded by gauze packing until adhesions have walled off the
mediastinum. The work is completed by cutting off the sac and either
suturing the esophageal wound or touching it with the cautery, and
allowing it to heal by granulation. External exposure and amputation
of the sac has been more frequently done than any other operation.
Unless the pouch is large, it is extremely difficult to find after the
surgeon has exposed the esophagus, for the reasons that at operation
it is empty and that when the adhesions about it are removed the walls
of the sac contract. After removal, the sac is disappointingly small
as compared with its previous size in the roentgenogram, which shows
it distended with opaque material. It has been the chagrin of skilled
surgeons to find the diverticulum present functionally and
roentgenographically precisely the same as before the performance of
the very trying and difficult operation. The time of operation may be
shortened at least by one-half by the aid of the esophagoscopist in
the Gaub-Jackson operation. Intratracheally insufflated ether is the
anesthesia of choice. After the surgeon has exposed the esophagus by
dissection, the endoscopist introduces the esophagoscope into the sac,
and delivers it into the wound, while the surgeon frees it from
adhesions. The esophagoscope is now withdrawn from the pouch and
entered into the esophagus proper, below the diverticulum, while the
surgeon cuts off the hernial sac and sutures the esophagopharyngeal
wound over the esophagoscope. The presence of the esophagoscope
prevents too tight suture and possible narrowing of the lumen (Fig.
102).

[FIG. 102.--Schematic representation of esophagoscopic aid in the
excision of a diverticulum in the Gaub-Jackson operation. At A the
esophagoscope is represented in the bottom of the pouch after the
surgeon has cut down to where he can feel the esophagoscope. Then the
esophagoscopist causes the pouch to protrude as shown by the dotted
line at B. After the surgeon has dissected the sac entirely loose from
its surroundings, traction is made upon the sac as shown at H and the
esophagoscope is inserted down the lumen of the esophagus as shown at
C. The esophagoscope now occupies the lumen which the patient will
need for swallowing. It only remains for the surgeon to remove the
redundancy, without risk of removing any of the normal wall. The
esophagoscope here shown is of the form squarely cut off at the end.
The standard form of instrument with slanted end will serve as well.]

After-care.--Feeding may be carried on by the placing of a small
nasal feeding tube into the stomach at the time of operation.
Gastrostomy for feeding as a preliminary to the esophageal operation
has been suggested, and is certainly ideal from the viewpoint of
nutrition and esophageal rest. The decision of its performance may
perhaps be best made by the patient himself. Should leakage through
the neck occur, the fistula should be flushed by the intake of sterile
water by mouth. Oral sepsis should, of course, be treated before
operation and combated after operation by frequent brushing of the
teeth and rinsing of the mouth with Dakin's solution, one part, to ten
parts of peppermint water. A postoperative barium roentgenogram should
be made in every case as a matter of record and to make certain the
proper functioning of the esophagus.





Next: Paralysis Of The Esophagus
Previous: Cicatricial Stenosis Of The Esophagus

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