Diverticula of the Esophageal Body
Radiographic abnormalities such as segmental spasm, corkscrewing, compartmentalization, and diverticulum are the anatomic results of disordered motility function. Of these, the most persistent and easiest to demonstrate is an esophageal diverticulum. Diverticula occur most commonly with nonspecific motility disorders, but can occur with all of the primary motility disorders. In the latter situation, the motility disorder is usually diagnosed before the development of the diverticulum. When present, a diverticulum may temporarily alleviate the symptom of dysphagia by becoming a receptacle for ingested food, and substitute the symptoms of postprandial pain and the regurgitation of undigested food. If a motility abnormality of the esophageal body or LES cannot be identified, a traction or congenital cause for the diverticulum should be considered. Because development in radiology preceded development motility monitoring, diverticula of the esophagus were considered historically to be a primary abnormality, the cause, rather than the consequence, of motility disorders. Consequently, earlier texts focused on them as specific entities based upon their location.
The latest microscopes in the medical field include cordless microscopes that make magnification of a specific area easier and hassle-free for the physician. These medical cordless microscopes are especially useful in areas where space is limited and greater magnification is required.
Epiphrenic diverticula arise from the terminal third of the thoracic esophagus and are usually found adjacent to the diaphragm. They have been associated with distal esophageal muscular hypertrophy, esophageal motility abnormalities, and increased luminal pressure. They are “pulsion” diverticula, and have been associated with diffuse spasm, achalasia, or nonspecific motor abnormalities of the body of the esophagus.
Whether the diverticulum should be surgically resected or suspended depends on its size and proximity to the vertebral body. When diverticula are associated with esophageal motility disorders, esophageal myotomy from the distal extent of the diverticulum to the stomach is indicated; otherwise, one can expect a high incidence of suture line rupture due to the same intraluminal pressure that initially gave rise to the diverticulum. If the diverticulum is suspended to the prevertebral fascia of the thoracic vertebra, a myotomy is begun at the neck of the diverticulum and extended across the LES. If the diverticulum is excised by dividing the neck, the muscle is dosed over the excision site and a myotomy is performed on the opposite esophageal wall, starting at the level of diverticulum. When a large diverticulum is associated with a hiatal hernia, the diverticulum is excised, a myotomy is performed if there is an associated esophageal motility abnormality, and the hernia is repaired with the use of cordless microscopes because of the high incidence of postoperative reflux when it is omitted.
Midesophageal or traction diverticula were first described in the nineteenth century. At that time, they were frequently noted in patients who had mediastinal lymph node involvement with tuberculosis. It was theorized that adhesions form between the inflamed mediastinal nodes and the esophagus. By contraction, the adhesions exerted traction on the esophageal wall and led to a localized diverticulum, as seen on medical microscopes. This theory was based on the findings of early dissections and subsequent tissue studies on the microscope, where adhesions between diverticula and lymph nodes were commonly found. It is now believed that some diverticula in the midesophagus may also be caused by motility abnormalities.
Most midesophageal diverticula are asymptomatic and incidentally discovered during investigation for nonesophageal complaints. In such patients, the radiological abnormality may be ignored. Patients with symptoms of dysphagia, regurgitation, chest pain, or aspiration, in whom a diverticulum is discovered, should be thoroughly investigated (sample tissues should be taken and studied under a microscope) or an esophageal motor abnormality and treated appropriately. Occasionally, a patient will present with a bronchoesophageal fistula manifested by a chronic cough on ingestion of meals. The slum in such patients is most likely to have an inflammatory etiology.
The indication for surgical intervention is the degree of symptomatic disability. Usually midesophageal diverticula can be suspended due to their proximity to the spine. If motor abnormality is documented, a myotomy should be performed similarly to that described for an epiphrenic diverticulum.
