Hospital Medicine

Esophageal diverticula

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I. What every physician needs to know.

Esophageal diverticula occur throughout the esophagus. When found in the proximal esophagus they are referred to as Zenker's diverticula and are the result of weakened musculature in 'Killian's triangle'. Located in the posterior hypopharynx, this area is particularly susceptible to increased esophageal pressures which can be seen in esophageal dysmotilty and Upper Esophageal Sphincter dysfunction. This mechanism for diverticula formation is described as pulsion. Zenker's diverticula are not "true" diverticula in that all levels of the esophageal wall are not involved, solely the mucosa herniates through a weak area of musculature.

Mid esophageal diverticula can either be congenital or acquired. Acquired diverticula can either be pulsion diverticula or what is referred to as traction diverticula. Traction diverticula form when exterior forces in the mediastinum pull on the esophageal wall. This is most commonly seen in the presence of mediastinal lymphadenopathy secondary to either infection (histoplasmosis, tuberculosis) or malignancy.

Distal esophageal diverticula (epiphrenic diverticula) also occur in the presence of increased esophageal pressures as a result of dysmotility and Lower Esophageal Sphincter dysfunction (achalasia, hypertensive LES). Like Zenkers', epiphrenic diverticula are also pseudodiverticula.

II. Diagnostic Confirmation: Are you sure your patient has Esophageal Diverticula?

Esophageal diverticula are diagnosed with barium swallow. Barium fills the diverticula and may also reveal some of the abnormal esophageal motility involved in the diverticular formation.

A. History Part I: Pattern Recognition:

Esophageal diverticula may be asymptomatic. However, when symptomatic, patients can have a variety of complaints ranging from mild dysphagia to recurrent regurgitation and aspiration.

Symptomatic patients with Zenker's typically complain of halitosis, dysphagia, sensation of a mass in the neck and regurgitation as the diverticulum fills with undigested food. Zenker's can occasionally become large enough to compress and obstruct the esophagus. Pulmonary complications of recurrent regurgitation and aspiration may occur, including chronic cough, pneumonia and even lung abscess.

Mid esophageal traction diverticula tend to be small and asymptomatic.

Mid esophageal pulsion and epiphrenic diverticula typically occur in the setting of concomitant motility disorders. Symptoms from the diverticula are difficult to discern from those related to the motility disorder and include dysphagia, regurgitation, aspiration and chest pain.

B. History Part 2: Prevalence:

Esophageal diverticula present in older patients, generally in those older than 50 years of age. All subtypes are rare diagnoses. Zenkers has an estimated prevalence of .01 to .11% and is the most common of the esophageal diverticula.

C. History Part 3: Competing diagnoses that can mimic Esophageal Diverticula.

  1. Esophageal Rings

  2. Esophageal Webs

  3. Esophageal Strictures

  4. Achalasia

  5. GERD

  6. Esophageal Cancer

  7. Esophageal Spasm

  8. Hypertensive LES or UES

All of the above diagnoses may be difficult to discern from a potential esophageal diverticulum via history and physical exam and may require barium swallow, manometry, endoscopy or pH monitoring to make the distinction.

D. Physical Examination Findings.

The physical exam of patients with esophageal diverticula is typically normal but in advanced cases may reveal a mass in the neck, cachexia and evidence of pulmonary complications.

E. What diagnostic tests should be performed?

N/A

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

Laboratory tests are not useful in diagnosing esophageal diverticula.

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

Esophageal diverticula may be incidentally noted on chest x-ray, computed tomography (CT) scan and endoscopy. However, barium swallow is the indicated diagnostic test when an esophageal diverticulum is suspected, regardless of whether it is felt to be in the proximal, mid or distal esophagus.

Once the diagnosis has been made, patients may need esophageal manometry and pH monitoring to evaluate the degree of underlying esophageal dysmotility and reflux to guide surgical intervention. Endoscopy should be undertaken with caution when evaluating a patient for dysphagia if diverticula is felt to be a possibility. EGD performed in a patient with an esophageal diverticulum increases the risk of perforation.

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

N/A

III. Default Management.

Traditional treatment of esophageal diverticula has been surgical. Less-invasive, endoscopic treatments are also becoming very prevalent and are the treatment of choice in patients who are not ideal surgical candidates.

Surgical Treatment

Zenkers- There are several different surgical procedures employed for treatment of Zenkers diverticula with the preferred option being concomitant diverticulectomy and cricopharyngeal myotomy. The diverticula is resected and to relieve increased pressure that is felt to contribute to the formation of Zenkers, the cricopharyngeal (upper esophageal sphincter) muscle is incised.

Other procedures involve a lone diverticulectomy, two stage procedure of diverticulectomy followed by cricopharyngeal myotomy and lastly an isolated cricopharyngeal myotomy. An additional procedure, diverticuloplexy, has been employed in very large diverticula (greater than 10cm) to reduce complications that are seen with the diverticulectomy and myotomy procedure. In a diverticuloplexy, the diverticula is pulled cranially and attached to the sternocleidomastoid followed by a cricopharyngeal myotomy.

Mid and Epi-phrenic Diverticula - Mid-esophageal traction diverticula are typically small, asymptomatic and often do not require repair. If epiphrenic and mid esophageal pulsion diverticula are symptomatic, further evaluation of potential concomitant motility disorder should occur.

Patients with minimal symptoms should be treated conservatively. Patients with severe symptoms can be further evaluated for surgical intervention with diverticulectomy and long esopageal myotomy (which relieves underlying/causative increased intraluminal pressure). Antireflux procedure may occur at the same time if detected by preoperative pH probe. Careful evaluation for need to proceed with surgical intervention should occur. This surgery has traditionally occurred via a posterolateral thoracotomy but laparoscopic approaches have recently been described.

Endoscopic Approaches

Several endoscopic therapies are also available for treatment of Zenkers diverticulum that have been shown to provide good symptom relief while reducing rates of perioperative complications. Employing either a CO2 laser or endoscopic stapler, the common wall formed by the posterior esophagus and anterior aspect of the diverticula is transected creating one lumen. Both procedures have been shown to be efficacious with some evidence that there is decreased risk of perforation using the endoscopic stapler.

A. Immediate management.

Patients with esophageal diverticula requiring admission to the hospital typically require repair or are being hospitalized for complications of diverticula including aspiration or severe malnutrition. Treatment of these complications are important prior to surgical intervention. However, their presence also indicates severity of disease that requires diverticula repair.

B. Physical Examination Tips to Guide Management.

Post-operative and post-procedure fever should prompt consideration of mediastinitis/perforation.

Surgical wound should be monitored to ensure proper healing.

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

Patients are typically NPO for 1-2 days after repair. Prior to initiating a diet, a gastrograffin swallow is performed to confirm successful intervention without complications.

D. Long-term management.

Patients should be followed perioperatively to ensure persistent resolution of symptoms and no development of complications.

E. Common Pitfalls and Side-Effects of Management.

  • Documented perioperative mortality rates for cricopharyngeal myotomy with or without diverticulectomy is approximately 1.8%

  • Complications of the diverticulectomy and cricopharyngeal myotomy include:

    • ◦ Vocal cord paralysis, which is often transient (3.1%)

    • ◦ Esophagocutaneous fistula (1.8%)

    • ◦ Mediastinits

    • ◦ Esophageal stenosis

IV. Management with Co-Morbidities.

N/A

A. Renal Insufficiency.

Typical preoperative evaluation for risk to benefit ratio and perioperative management for patients with CKD.

B. Liver Insufficiency.

Typical preoperative evaluation for risk to benefit ratio and perioperative management for patients with liver disease.

C. Systolic and Diastolic Heart Failure.

Typical preoperative evaluation for risk to benefit ratio and perioperative management for patients with heart failure.

D. Coronary Artery Disease or Peripheral Vascular Disease.

Typical preoperative evaluation for risk to benefit ratio and perioperative management for patients with coronary artery disease.

E. Diabetes or other Endocrine issues.

No change in standard management.

F. Malignancy.

No change in standard management.

G. Immunosuppression (HIV, chronic steroids, etc).

Consider stress dose steroids perioperatively.

H. Primary Lung Disease (COPD, Asthma, ILD).

Patients with chronic lung disease will likely have greater severity of pulmonary symptoms and frequent exacerbations of COPD/RAD if element of aspiration is present.

I. Gastrointestinal or Nutrition Issues.

Those with severe malnutrition resulting from esophageal obstruction or chronic regurgitation may require gastrostomy tube placement preoperatively.

J. Hematologic or Coagulation Issues.

Coagulopathic patients should be corrected with FFP and Vitamin K prior to surgical intervention with goal coagulation profile and platelets dependent on surgeon's preference.

K. Dementia or Psychiatric Illness/Treatment.

No change in standard management.

V. Transitions of Care.

A. Sign-out considerations While Hospitalized.

If post-repair patient becomes febrile or experiences acute worsening of pain evaluate surgical incision site and check plain x-ray with consideration of CT chest or soft tissue neck to evaluate for mediastinitis. If imaging reveals widening of paratracheal tissues with evidence of gas in the mediastinum or soft tissues of the neck, the patient requires immediate airway assessment, antibiotics and emergent surgical debridement.

B. Anticipated Length of Stay.

Patients typically discharge on post-operative day 3.

C. When is the Patient Ready for Discharge.

Once post-operative imaging reveals adequate diverticular repair without complication, the patient may resume a diet. If this is tolerated and there are no signs of surgical complications then the patient may be discharged.

D. Arranging for Clinic Follow-up.

N/A

1. When should clinic follow up be arranged and with whom.

The patient should follow up with the surgeon or endoscopist who performed the reparative procedure in 1-2 weeks for a wound check and to re-evaluate symptoms. Patients are typically discharged on soft mechanical diet and will require follow up prior to advancing diet.

2. What tests should be conducted prior to discharge to enable best clinic first visit.

None

3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.

None

E. Placement Considerations.

None

F. Prognosis and Patient Counseling.

Both surgical and endoscopic modalities have high success rates for symptom improvement (>90%). Surgical intervention does have an associated perioperative mortality of approximately 1.8%. Recurrence rate after diverticulectomy and cricopharyngeal myotomy for Zenkers diverticula is approximately 3.6%. Endoscopic approaches have shown to have decreased rates of complications when compared to surgical intervention.

Patients who experience recurrent symptoms of dysphagia and regurgitation should schedule follow up to be evaluated for diverticula recurrence or surgical complication such as esophageal stenosis.

VI. Patient Safety and Quality Measures.

A. Core Indicator Standards and Documentation.

None

B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

Patients should be discharged on mechanical soft diet and should not advance diet until follow up.

Patients should be discharged with adequate pain control.

No heavy lifting or straining for one week after procedure.

VII. What's the evidence?

Cassivi, SD, Deschamps, C, Nichols FC, 3rd. "Diverticula of the esophagus.". Surg Clin North Am.. vol. 85. 2005. pp. 495-503.

Cook, IJ, Gabb, M, Panagopoulos, V. "Pharyngeal (Zenker's) diverticulum is a disorder of upper esophageal sphincter opening.". Gastroenterology.. vol. 103. 1992. pp. 1229-35.

D'Journo, XB, Ferraro, P, Martin, J, Chen, LQ, Duranceau, A. "Lower oesophageal sphincter dysfunction is part of the functional abnormality in epiphrenic diverticulum.". Br J Surg.. vol. 96. 2009. pp. 892-900.

Watemberg, S, Landau, O, Avrahami, R. "Zenker's diverticulum: reappraisal.". Am J Gastroenterol. vol. 91. 1996. pp. 1494-1498.

Feeley, M. "Zenker's Diverticulum: Analysis of Surgical Complications From Diverticulectomy and Cricopharyngeal Myotomy.". Laryngoscope. vol. 109. pp. 858.

Costamagna, G, Iacopini, F, Tringali, A. "Flexible endoscopic Zenker's diverticulotomy: cap-assisted technique vs. diverticuloscope-assisted technique.". Endoscopy.. vol. 39. 2007. pp. 146-52.

Smith, SR, Genden, EM, Urken, ML. "Endoscopic stapling technique for the treatment of Zenker diverticulum vs. standard open-neck technique:a direct comparisoncharge analysis.". Arch Otolaryngol Head Neck Surg. vol. 128. 2002. pp. 141-144.

Chang, CY, Payyapilli, RJ, Scher, RL. "Endoscopic staple diverticulostomy for Zenker’s diverticulum: review of literature and experience in 159 consecutive cases.". Laryngoscope. vol. 113. 2003. pp. 957-965.

Narne, S, Cutrone, C, Bonavina, L. "Endoscopic diverticulotomy for the treatment of Zenker's diverticulum: results in 102 patients with staple-assisted endoscopy.". Ann Otol Rhinol Laryngol.. vol. 108. 1999. pp. 810-5.

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