What is an esophageal diverticulum?
An esophageal diverticulum is a pouch that protrudes outward in a weak portion of the esophageal lining. This pocket-like structure can appear anywhere in the esophageal lining between the throat and stomach.
Esophageal diverticula (pleural of diverticulum) are classified by their location within the esophagus:
- Zenker’s diverticula (pharyngoesophageal) is the most common type of diverticula of the esophagus. Zenker’s diverticula are usually located in the back of the throat, just above the esophagus
- Midthoracic diverticula, in the mid-chest
- Epiphrenic diverticula, above the diaphragm
Who is affected by esophageal diverticula?
Esophageal diverticula can affect people of all ages, although most cases occur in middle-aged and elderly individuals.
Overall, esophageal diverticula are rare, showing up in less than 1 percent of upper gastrointestinal X-rays and occurring in less than 5 percent of patients who complain of dysphagia (difficulty in swallowing).
Are esophageal diverticula serious?
Typically, esophageal diverticula are nuisances that enlarge slowly over many years, gradually producing increasing symptoms, such as dysphagia, regurgitation and aspiration pneumonia, caused by breathing in regurgitated diverticula content.
When symptoms of esophageal diverticula worsen, a person may be unable to swallow due to an obstruction near the diverticulum; rarely, the esophagus may rupture. An obstruction or rupture caused by an esophageal diverticulum is dangerous, and both complications require immediate attention.
Regurgitation caused by a diverticulum often occurs at night when lying down, which can lead to choking, aspiration pneumonia (a lung infection caused by pulmonary aspiration, the entry of secretions or foreign material into the trachea and lungs), and lung abscesses.
Although rare, squamous cell carcinoma can develop in 0.5 percent of those with diverticula. This is thought to be caused by chronic irritation of the diverticula by prolonged food retention. It is important to note that the fear of cancer is not a reason to surgically treat diverticula.
What causes esophageal diverticula?
While the first case of an esophageal diverticulum was reported nearly 250 years ago, little is still known about this condition. It is believed that the internal pressure produced by the esophagus to move food into the stomach can herniate the esophageal lining through a weakened wall, creating a pouch or a diverticulum. There is usually distal end obstruction.
Esophageal diverticula are more common in people who have motility disorders of the esophagus, such as achalasia, that cause difficulty in swallowing, regurgitation of food, and, in some people, a spasm-type pain.
What are the symptoms of esophageal diverticula?
The symptoms of esophageal diverticula include:
- Dysphagia (difficulty swallowing, characterized by a feeling of food caught in the throat)
- Pulmonary aspiration (the entry of secretions or foreign material into the trachea and lungs)
- Aspiration pneumonia (a lung infection caused by pulmonary aspiration)
- Regurgitation of swallowed food and saliva
- Pain when swallowing
- Cough
- Neck pain
- Weight loss
- Bad breath (halitosis)
Some people may experience a gurgling sound as air passes through the diverticulum. This is known as Boyce's sign.
How is esophageal diverticulum diagnosed?
The tests most commonly used to diagnose and evaluate esophageal diverticulum include:
Barium swallow: The patient swallows a barium preparation (liquid or other form) and its movement through the esophagus is evaluated using X-ray technology.
Gastrointestinal endoscopy: A flexible, narrow tube called an endoscope is passed through the gastrointestinal tract and projects images of the inside onto a screen.
Esophageal manometry: This test measures the timing and strength of esophagus contractions and muscular valve relaxations.
24-h pHmetry: A test to check for the presence of gastroesophageal reflux disease (GERD).
How is esophageal diverticulum treated?
Cases of esophageal diverticulum that cause minor symptoms can be treated through lifestyle changes, such as eating a bland diet, chewing food thoroughly, and drinking plenty of water after meals.
If symptoms become severe, several types of surgery are available to remove the diverticula, repair the defects and relieve a patient’s symptoms and improve their quality of life.
Treatment of diverticula require:
- An examination of the diverticula;
- Repair of the weakened wall; and
- Relief of obstruction
The type of surgical treatment recommended depends on the size and location of diverticula, and include:
Cricopharyngeal myotomy: Used in the removal of small diverticula, this surgical treatment can be completed using an open or trans oral approach.
Diverticulopexy with cricopharyngeal myotomy: Used to remove larger diverticula, this procedure involves turning the diverticular sac upside down and suspending it by suturing it to the esophageal wall.
Diverticulectomy and cricopharyngeal myotomy: Diverticulectomy for the treatment of Zenker's diverticula has been performed for almost a century. The procedure involves complete excision of the diverticular sac.
Recently, Cleveland Clinic surgeons have improved the outcome of this procedure by adding the Heller myotomy laparoscopic approach to ensure the movement of food through the lower esophageal sphincter.
Endoscopic diverticulotomy (Dohlman procedure): This procedure divides the septum between the cervical esophagus and the diverticular pouch. By dividing the septum, food can freely drain from the pouch to the esophagus. Cleveland Clinic surgeons complete this division by using a Zenker’s diverticuloscope and a minimally invasive stapling technique to treat Zenker’s diverticulum.
What are the benefits of minimally invasive surgery to treat esophageal diverticulum?
Laparoscopic approaches, such as endoscopic diverticulotomy, offer patients many benefits, including:
- Limited number of small scars instead of one large abdominal scar
- Shorter hospital stay
- Reduced postoperative pain
- Shorter recovery time
- Quicker return to daily activities, including a regular diet
What are the risks of minimally invasive surgery to treat esophageal diverticulum?
The possible complications of minimally invasive surgery include:
- Damage to the lung, spleen, stomach, esophagus or liver
- Postoperative infection or bleeding
- Pneumonia
- Deep vein thrombosis
