Chapter 21: Esophageal Diverticula and Benign Tumors

ESOPHAGEAL DIVERTICULA

Diverticula of the esophagus are a rare entity, with a prevalence that ranges between 0.06% and 4%.^1,2 Esophageal diverticula are classified according to their location along the esophagus (pharyngoesophageal, midesophageal, or epiphrenic), and the mechanism of formation (pulsion or traction). Most common diverticula are those located in the pharyngoesophageal and epiphrenic locations. These are usually pulsion diverticula in which an increase of intraluminal pressure leads to herniation of mucosa and submucosa through the muscular layer resulting in a false diverticulum. Mid-esophageal diverticula are commonly traction diverticula. These are much less frequent and are the result of a focal traction of all layers (mucosa, submucosa, and musculature) of the esophageal wall by a periesophageal inflammatory process resulting in a true diverticulum.

Pharyngoesophageal Diverticulum (Zenker Diverticulum)

PATHOPHYSIOLOGY

Zenker diverticula are the most common diverticula of the esophagus. These arise in an area of muscular gap at the transition of the cricopharyngeal muscle and the inferior constrictors of the pharynx (Killian triangle) (Fig. 21-1), and are more frequently found on the left side of the esophagus due to the slight convexity of the esophagus to the left. Pathophysiologic mechanisms for this condition include muscular weakness and upper esophageal sphincter (UES) dysfunction. UES dysfunction is characterized by incomplete relaxation of the UES, increased intrapharyngeal pressure, and discoordinated pharyngeal contractions.^3–5 Gastroesophageal reflux is present in up to 95% of patients and may be related to esophageal longitudinal muscle reflex contraction and consequent widening of the gap between pharyngeal constrictors and cricopharyngeal muscles⁶ or spasm of the UES.⁷

SYMPTOMS AND DIAGNOSIS

Cervical dysphagia is the most common presenting symptom and is often associated with regurgitation, halitosis, choking, chronic cough, hoarseness, gurgling, or aspiration pneumonia. Findings on physical examination may include the Boyce sign (a neck mass gurgling on palpation) and weight loss. The presence of progressive dysphagia, odynophagia, hemoptysis, and hematemesis is more suspicious for a malignancy and may be a squamous cell cancer arising from the diverticulum (incidence up to 1.1%).

Diagnostic tools include:

1. Barium esophagram is performed to assess size and location of the diverticulum and the size of the diverticular neck. In addition, it determines the distance from the diaphragm, therefore giving the surgeon the possibility of choosing between a laparoscopic or thoracoscopic approach.

2. Upper endoscopy is mandatory in order to rule out the presence of cancer or other esophageal diseases and to evaluate signs of reflux

3. Esophageal manometry is important to define the underlying esophageal motility disorder. We usually obtain this ...