Diverticulum Of The Esophagus


Categories: DISEASES OF THE ESOPHAGUS
Sources: 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.





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