Pharyngeal and oesophageal diverticula

Pharyngeal and oesophageal diverticula

Oesophageal diverticula can be classified as true diverticula, which involve a full-thickness oesophageal wall, and false diverticula, which involve mucosal outpouching only . Diver ticula are usually described by their location as pharyngeal, Gustav Killian , 1860–1921, Professor of Laryngology , Freiburg and later Berlin, Germany . - - midoesophageal and epiphrenic. Diverticula alone seldom produce troublesome symptoms unless large or secondary to an underlying oesophageal motility disorder. The most common symptoms are dysphagia, regurgitation, halitosis and recurrent aspiration. Pharyngeal pouch (Zenker’s diverticulum) Zenker’s diverticulum is a false pulsion diverticulum as it protrudes posteriorly above the cricopharyngeal sphincter through the natural weak point (the dehiscence of Killian) between the oblique and horizontal fibres of the inferior pharyngeal constrictor. The pathophysiology is believed to involve loss of coordination between pharyngeal contraction - and opening of the upper sphincter ( Figure 66.30 ).

Figure 66.30 Barium contrast study showing a Zenker’s diverticulum.

desynchronisation of swallowing with predominantly pha ryngeal dysphagia. As the pouch enlarges, it tends to fill with food on eating, and the fundus descends into the mediasti num. Regurgitation of trapped food can occur and lead to aspira tion. Another symptom is halitosis. Conventional sur gical treatment involves an open left cervical incision (most diverticula point towar ds the left side) with diverticulectomy and cricopharyngeus myotomy . Another option is diverticular suspension, whereby the diverticulum is dissected and inverted with its ape x pointing cranially . This will stop food from enter ing the pouch. The absence of a suture line lessens the chance of a postoperative leak. A cricopharyngeus myotomy is also an integral part of the surgery . Newer techniques include tran soral introduction of a linear stapler to divide the se ptum in between the diverticulum and the true oesophageal lumen. This creates a common channel, and the myotomy is in e ff ect performed by the stapler transection ( Figure 66.31 ). Midoesophageal diverticula (Rokitansky diverticulum) Midoesophageal diverticula are usually small traction divertic ula of no particular consequence. In granulomatous diseases with chronic inflammation, fibrosis or lymphadenopathy in the mediastinum can exert traction force onto the oesophageal wall and cause full-thickness outpouching. Rarely it may cause fistula tion into the airway in uncontrolled pulmonary tuber culosis. Asymptomatic midoesophageal diverticulum does not warrant any treatment. HRM may be indicated in symptomatic patients to exclude pulsion diverticulum due to oesophageal motility disorder, e.g. hypercontractile oesophagus . Epiphrenic diverticula Epiphrenic diverticula are pulsion diverticula typically situated at the distal 10 /uni00A0 cm of the oesophagus. They are commonly associated with oesophageal motility disorders, e.g. achalasia, or other causes of oesophageal outflow obstruction. Barium oesophagogram is a useful investigation depicting the size and anatomical relationship of the diver ticulum and, at the same time, screening for oesophageal motility disorder ( Figure 66.32 ). Large diverticula should be excised combined with a myotomy from the neck of the diverticulum to the cardia to reliev e the functional obstruc tion. Concurrent fundoplication or repair of hiatus hernia may be necessary , depending on the size of the diverticulum or associated conditions. A laparoscopic approach is the preferred option to reduce morbidity .