Esophageal Diverticula

Question 1

Definition of esophageal diverticula

Answer 1

Outpouching of esophageal wall

Question 2

Defintion of true (vs. false) esophageal diverticulum

Answer 2

• True esophageal diverticulum: involves all 3 layers of esophagus
• False esophageal diverticulum: outpouching of mucosa and submucosa between displaced muscle fibers

Question 3

Categories of esophageal diverticulum

Answer 3

• Pulsion diverticulum (false diverticuli)
  
  • Results from increased pressure gradient across muscular sphincter
  • Associated wtih esophageal motility disorder
  • Zenker and Epiphrenic diverticuli
• Traction diverticulum
  
  • extra-esophageal inflammatory process draws all three layers of esophagus into a true diverticulum
  • most common in mid esophagus (d/t chronic lymphadenitis)
  • no relationship with esophageal dysmotility
  • associated with fistuals

Question 4

MC esophageal diverticulum

Answer 4

Zenker’s diverticulum

• False diverticulum
• Above cricopharyngeus muscle (Killian’s triangle)
• Lateral projection near C6-7 vertebral body

Question 5

Pathophysiology of Zenker’s diverticulum

Answer 5

Hypertonicity of criciopharyngeaus muscle

(Lower esophageal motility and LES normal)

Question 6

Pathophysiology of epiphrenic diverticulum

Answer 6

• False diverticulum
• Esophageal dysmotility disorder
• Within 4 cm of GEJ

Question 7

Pathophysiology of mid-thoracic, diverticula

Answer 7

• True diverticulm
• Chronic inflammation (e.g. chronic lymphadenitis)
  
  • Posterior mediastinum
• Usually within 4-5 cm of carina

Question 8

Clinical presentation of esophageal diverticulum

Answer 8

• Dysphagia
• Fetor and regurgitation of food
• Neck mass (Zenker’s)
• Risk of aspiration is high

Question 9

Diagnostic w/u for esophageal diverticula

Answer 9

• Barium esophagram
• Endoscopy to characterize extent of diverticulum
  
  • Wide vs. narrow opeing
  • Mucosal abnormalities
  • Evaluate for malignancy
  • Must be careful not to perforate
• ​Manometry (distal or epiphrenic diverticula d/t high association with motility disorder)

Question 10

Treatment of Zenker’s diverticulum

Answer 10

Cricopharyngeomyotomy + Diverticulectomy

• Alternative Treatmetn:
  
  • Suspension and pexy of diverticulum (small, < 2cm diverticula) may be an option in addition to myotomy.
  • Transoral, endoscopic stapler
    
    • Opens diverticulum and divides cricopharyngeaus

Question 11

Treatment of mid-esophageal, traction diverticula

Answer 11

• Right thoracotomy
• Diverticulectomy
• Contralateral esophagomytomy if motility disorder suspected

Question 12

Treatment of epiphrenic diverticula

Answer 12

• Low left thoracotomy
• Diverticulectomy (mucosa oversewn)
• Esophagomyotomy (high association with motility disorder)
• Partial fundoplications