Esophageal Diverticula

Esophageal Diverticula are acquired conditions of the esophagus found primarily in adults. They are divided into traction and pulsion diverticula based on the pathophysiology that induced their formation.

A pharyngoesophageal (or Zenker) diverticulum is a pulsion diverticulum. It is the most common type of symptomatic diverticulum. Symptoms include progressive cervical dysphagia, cough on assuming a recumbent position, and spontaneous regurgitation of undigested food, leading to episodes of choking and aspiration. Diagnosis with a barium swallow should prompt surgical correction with cricopharyngeal myotomy and diverticulectomy or suspension. Notably, almost all patients with a pharyngoesophageal diverticulum have GER that is thought to produce cricopharyngeal dysfunction. Endoscopic approaches (i.e., stapling to produce a myotomy and/or diverticulectomy) are being developed but do not have the success rate of open myotomy.

A traction or midesophageal or parabronchial diverticulum occurs in conjunction with mediastinal granulomatous disease often due to histoplasmosis or tuberculosis. Symptoms are rare, but when they are present, they mandate operative excision of the diverticulum and adjacent inflammatory mass. On rare occasions, these diverticula present with chronic cough from an esophagobronchial fistula.

An epiphrenic or pulsion diverticulum can be located at almost every level but typically occurs in the distal 10 cm of the thoracic esophagus. Many patients are asymptomatic at the time of diagnosis, and in those who are symptomatic, it is difficult to determine whether the complaints stem from the diverticulum or from the underlying esophageal disorder.

The diagnosis is made with a contrast esophagogram; however, endoscopic examination and esophageal function studies are essential in defining the underlying pathophysiology. In advanced disease, the diagnosis can be confused with achalasia owing to the dependency of the diverticulum and the lateral displacement and narrowing of the GE junction.

Operative treatment is recommended for patients with progressive or incapacitating symptoms associated with abnormal esophageal peristalsis. Surgery consists of diverticulectomy or diverticulopexy, along with an extramucosal esophagomyotomy. The myotomy extends from the neck of the diverticulum down to the stomach. When the diverticulum is associated with a hiatal hernia and reflux, a concomitant nonobstructive antireflux procedure (Belsey Mark IV) is recommended. Any associated mechanical obstruction also must be corrected