Esophageal Diverticula Treatment & Management
- Author: Jack Bragg, DO; Chief Editor: Julian Katz, MD more...
Asymptomatic and minimally symptomatic esophageal body diverticula do not require treatment.
In many patients with mid esophageal and epiphrenic diverticula, dysphagia is related to underlying dysmotility; thus, treatment should be directed to the motility disorder when feasible. For instance, achalasia can be treated with pneumatic dilation, botulinum toxin injection into the lower esophageal sphincter, or surgical Heller esophagomyotomy.
Treatment of esophageal intramural pseudodiverticulosis is directed toward underlying strictures or dysmotility.
Treatment of Zenker diverticulum traditionally has been surgical, although the specific operation used still is controversial. Surgical options include diverticulectomy with cricopharyngeal myotomy, diverticular suspension (diverticulopexy) with cricopharyngeal myotomy, and cricopharyngeal myotomy alone.
Consider diverticulectomy when esophageal body diverticula are believed to be the cause of aspiration. An abdominal laparoscopic approach may be feasible for some patients with epiphrenic diverticula. Case reports of endoscopic treatment of giant midesophageal diverticula have been reported. However, patients who are being considered for diverticulectomy should first undergo careful study with barium swallow, flexible endoscopy, and esophageal manometry. Treatment directed at an underlying esophageal motility disorder, such as achalasia, cannot be ignored.
Diverticulectomy usually is not performed by itself, because it does not correct the defect in cricopharyngeal function that usually contributes to the formation of a Zenker diverticulum. While the transcervical approach has been used traditionally, the transoral route using a rigid esophagoscope also may be used.
Good results have been obtained by performing a diverticulotomy using a flexible endoscope and needle-knife papillotome to cut the common wall between the diverticulum and the oropharynx as well as the cricopharyngeus while the patient is consciously sedated. Data suggest that this technique offers good results with a relatively high success rate, but it should be performed in large centers with surgeons who are experienced with this technique. In some variations of this technique, the diverticulum is stapled.
Other novel techniques are being developed. Flexible endoscopic diverticulotomy approaches have been explored using various techniques, including argon plasma coagulation, monopolar coagulation forceps, and needle-knife incision.[9, 10, 13, 14] These techniques typically use a cap or hood attached to the endoscope. The goal of these techniques is the division of the septum between the diverticulum and the esophagus, thus performing a cricopharyngeal myotomy.
Increased efforts to a laparoscopic approach to repair both epiphrenic diverticula and Zenker diverticula have been explored. The literature supports open surgery and a laparoscopic approach as appropriate methods of repair. The laparoscopic technique uses stapler closure, and multiple case reports cite wound leakage from stapler failure as a complication. With complication rates as high as 20%, a skilled surgeon with experience in this procedure is beneficial. Benefits of the laparoscopic approach include decreased morbidity because of no thoracotomy wounds and chest tubes and a less invasive approach.
A study of 229 endoscopic diverticulotomies (in 189 patients), conducted by Kos et al, indicated that better results can be achieved using a combination of CO2 laser and Acuspot in the endoscopic procedure than by employing endoscopic diverticulotomy with electrocautery or with a carbon dioxide (CO2) laser alone. The investigators reported the following postsurgical results:
Endoscopy with CO 2 laser: Dysphagia was absent following 78.4% of procedures; repeat surgery was required following 19.6% of procedures
Endoscopy with electrocautery: Dysphagia was absent bsent following 72% of procedures; repeat surgery was required following 24.3% of procedures
Endoscopy with CO 2 laser and Acuspot: Dysphagia was absent following 84.6% of procedures; repeat surgery was required following 13% of procedures
Several reports in the literature lately describe surgical treatment of esophageal diverticula. One recent publication analyzed a single surgeon’s experience with endoscopic CO2 laser and stapler repair of Zenker diverticulum by comparing dysphagia and regurgitation outcomes in 148 patients. This report concluded that endoscopic CO2 laser and staple methods are effective in treating Zenker diverticulum. The laser can have greater efficacy and result in lower recurrence rates.
Most of the reports involve treatment of Zenker diverticula and discuss open versus endoscopic methods.[17, 18, 19, 20] None was a controlled study. They were series reports or retrospective reviews. There is no consensus of which method is the best.
Consult a gastroenterologist for patients who have symptoms associated with esophageal diverticula or who have esophageal motility disorders, such as achalasia.
Consult a general or thoracic surgeon (with experience) after gastroenterological evaluation for patients who have significant symptoms associated with Zenker diverticulum, achalasia, or diverticula.
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