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Eur J Cardiothorac Surg 1998;14:380-387
© 1998 Elsevier Science NL

Tailored surgery for esophageal body diverticula¹

Department of Surgery I, `A. Gemelli' Medical School, Catholic University of Rome, Rome, Italy

Received 28 September 1997; received in revised form 22 June 1998; accepted 8 July 1998.

Corresponding author. Via A. Catalani, 30-00199 Rome, Italy. Tel.: +39 6 3053853; fax: +39 6 3051162; e-mail: icpsc@unicatt.rm.it

	Abstract

Top Abstract Introduction Materials and methods Results of clinical and... Discussion Conclusions Appendix A. Conference... References

 
Objective: The aim of our study was to identify the presence of associated functional disorders (dysmotility or gastro-esophageal reflux, GER), to select patients who need surgery and to plan a tailored surgical treatment in patients affected by esophageal body diverticula. Methods: We report on 51 consecutive patients with esophageal body diverticula, observed at our department, who underwent a thorough functional evaluation by means of radiology, endoscopy and manometry; 24 h pH-monitoring was performed in 11 patients who complained of symptoms of GER. The treatment of choice was planned in each patient on the basis of the following elements: the need of diverticulum excision and correction of esophageal body dismotility, LES dysfunction or GER. Results: An esophageal motor dysfunction was detected in 73% (37 patients) of our total cases with an impaired LES function in 53% (27 patients); GER was identified in nine out the 11 patients submitted for 24 h pH-monitoring. On the overall series, we observed dysmotility or GER in 49/51 patients (96%). Sixteen patients did not require surgical treatment and eight patients refused it; 27 patients underwent tailored surgery. The overall complication rate was 11% (two esophageal fistulae, one acute coronary disease) with 7% mortality rate (one septic shock from esophageal leakage and one myocardial infarction). At follow up (average 47 months; range 6–103 months) 92% satisfactory results (Visick I and II) and only 8% of poor results were observed in our series. None of 13 patients who underwent conservative management had major complications at mean follow-up of 64 months. Conclusions: Based upon our experience, we believe that any case of diverticulum of the esophageal body deserves a complete physiopathological evaluation because an underlying functional disorder is associated in most cases. The evidence that the diverticulum per se can be considered as the ultimate phenomenon of an underlying functional disease determined the need for a tailored surgery, planning treatment of the functional disorder as the primary goal, not necessarily associated with a diverticulectomy. In our experience a tailored surgical treatment provided best results.

Key Words: Esophageal diverticulum • Motor disorders • Gastro-esophageal reflux

	Introduction

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Surgical excision of symptomatic esophageal body diverticula was accepted as the treatment of choice until the mid 1970s. Subsequently a more careful pre-operative assessment, and a better understanding of the esophageal motor function, suggested that diverticulectomy alone was not sufficient to treat the underlying functional disorder or the associated lesions almost always present. More recently a tailored surgical approach, accordingly to the underlying functional disorder, has become the principle of modern surgery for esophageal diverticula.

An abnormality of the esophageal body or lower esophageal sphincter (LES) can be manometrically identified in most patients with a diverticulum [1].

The role of gastroesophageal reflux (GER) still must be fully elucidated, although 24 h esophageal pH monitoring is essential to rule out GER in these patients.

The purpose of this report was to present our clinical experience with management of thoracic esophageal diverticula, to establish principles for selection of patients who need surgical treatment, and to suggest a tailored surgical management based on a correction of the underlying functional disorder.

	Materials and methods

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Fifty-one patients with diverticula of the mid or lower esophagus referred, between 1983 and 1995, to the Thoracic Surgery Esophageal Function Laboratory of the Department of Surgery I at the Catholic University of Rome are the subject of this report.

Patient's records were carefully reviewed to determine the dominant symptoms at the time of presentation, the details of the diagnostic work-up, and the type of surgical procedure performed.

An evaluation by means of upper GI series and endoscopy was performed in all the patients.

Manometric evaluation was performed in all patients according to the method previously described [2]. All the patients had manometric evaluation of the esophageal body and LES; we routinely use the endoscopic guidance to pass the manometry catheter into the stomach when it was difficult to pass through the LES.

Esophageal 24 h pH monitoring was performed in 11 patients who complained of heartburn and acid regurgitation, by means of a portable solid-state recording device (Synectics-Digitrapper pH monitor, Synectics, Sweden) with a single crystal antimony electrode placed 5 mm from the distal end of the catheter. Results were classified according to the Johnson–DeMeester criteria [3].

	Results of clinical and functional evaluations

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There were 20 male and 31 female patients, with a male/female ratio of 1:1.5. Patient age ranged between 14 and 77 years, with a mean age of 55 years.

Dysphagia was present in 40 patients (78.4%) and regurgitation was present in 34 patients (66.6%): 19 complained of food regurgitation and 15 of GER.

Some degrees of dysphagia or regurgitation were the prominent features of the clinical picture in 49 patients (96%): 17 patients had dysphagia and food regurgitation (33.3%), eight patients had dysphagia and GER (15.6%), 15 patients had dysphagia without regurgitation (29.4%), seven patients had GER (13.7%) and two patients had only food regurgitation (3.9%).

Severe heartburn was seen in 16 patients (31.4%), while chronic nocturnal cough consistent with recurrent aspiration was present in six patients (11.8%).

A barium esophagogram demonstrated the presence of a mid- or lower esophageal diverticulum with an epiphrenic location in 21 and a mid-esophageal in 28. The diverticula varied in size between 1.3 and 14 cm in diameter ( Fig. 1 ). Multiple diverticula were seen in two patients. The barium esophagogram suggested an associated motor disorder in 14 patients (27.4%). Additionally 16 patients (31.4%) had an associated hiatal hernia (seven patients), GER (six patients) or both (three patients).

View larger version (106K): [in this window] [in a new window]   Fig. 1. Radiologic appearance of a giant epiphrenic diverticulum in a patient with esophageal vigorous achalasia (no. 17).

A motor disorder of the esophagus was identified in 46/51 patients (90.2%): 19 patients had abnormal peristalsis, nine patients had altered LES function and 18 had both (Table 1); in the whole series, an impaired peristalsis was detected in 37/51 patients (73%). The motility pattern was consistent with that of nutcracker esophagus (NE) in eight, diffuse esophageal spasm (DES) in six and esophageal achalasia (one vigorous) in five of them. The other 18 patients did not fit into a specific motility disorder diagnosis and were classified as having a not-specific esophageal motility disorder (NEMD).

Twenty-four-hours pH-monitoring revealed GER in nine patients out of 11 studied (82%). A total of 22 patients (43%) showed evidence of GER, hypotonic LES or hiatal hernia at diagnostic work-up; 17/27 (63%) patients with normal or minimal derangement of esophageal motility plus 5/24 (21%) patients with major esophageal motor disorders (Table 1).

In our experience a motor disorder of the esophageal body isolated or associated to LES was identified in 37 patients (73%). Among 14 patients with normal esophageal body motility, one had an hypertensive LES; eight had a hypotonic LES or a reduction of intrabdominal LES length due to the presence of hiatal hernia. In the remaining five patients with normal manometrical patterns, three had GER at 24 h pH-monitoring and two refused the test. Of the overall series we observed dysmotility or GER in 49/51 patients (96%).

Surgical treatment
The presence of dysphagia for solids, especially if severe and associated with episodes of total obstruction, regurgitation of undigested food or chronic cough consistent with recurrent aspiration were, in our opinion, clear clinical indications to surgical treatment.

Moreover we planned surgical treatment in the presence of diverticular mucosal inflammation or abnormal 24 h pH monitoring.

When surgery was indicated, we adopted a tailored approach planned on the following elements: the need of diverticulum excision and correction of esophageal body dysmotility, LES dysfunction or GER.

Diverticulectomy
It was performed for undigested food retention with regurgitation or chronic cough consistent with recurrent aspiration or in presence of radiographic documentation of enlargement of the diverticulum or severe inflammation of the diverticular mucosa on endoscopy.

We did not perform diverticulectomy in presence of wide neck diverticula without food retention in the pouch, pulmonary aspiration or mucosal lesions.

Left posterolateral thoracotomy is the opening incision. The esophagus is isolated above and below the level of the diverticulum and a stapled diverticulectomy is performed after a 54 Fr Savary dilator is introduced in the esophageal lumen to prevent esophageal post-operative stenosis.

Esophagomyotomy
It was performed on the side opposite the diverticulum, only in presence of DES or NE. Regardless of the level of the diverticulum, in all patients the myotomy was extended from 2 cm above the esophageal hiatus to the inferior surface of the aortic arch.

We did not perform an esophagomyotomy in patients with normal motility or NEMD [4] of esophageal body.

Cardiomyotomy
It was performed in patients with hypertensive or unrelaxing LES by the thoracic, if diverticulectomy was required, or abdominal route when the pouch required no excision. The myotomy was extend 5 cm above and 2–3 cm under the level of the proximal transverse vein of the stomach.

Cardiomyotomy was not performed in the presence of normotensive or hypotensive LES with normal relaxation.

Anti-reflux procedure
An anti-reflux procedure was added only when GER or incompetence of LES was present and when the myotomy involved the cardia.

We adopted the following guidelines for anti-reflux procedure choice:

• A modified transthoracic Belsey Mark IV fundoplication, through the diaphragmatic hiatus, was performed in patients with pre-existing or post-myotomy altered esophageal clearing;
  
• In patients with totally absent peristalsis, as in esophageal achalasia, we prefer the Dor anti-reflux procedure;
  
• A floppy Nissen fundoplication is our preferred technique for GER correction in patients with normal esophageal clearance.
  

According to our protocol, surgical treatment was indicated in 35 patients.

Only 27 patients underwent tailored surgery (Table 2) as follows: simple diverticulectomy (5 patients); diverticulectomy and esophagomyotomy (5 patients); diverticulectomy and modified transthoracic Belsey Mark IV fundoplication with esophagomyotomy (4 patients) plus cardiomyotomy (3 patients); a Heller cardiomyotomy plus a Dor anti-reflux procedure (6 patients); a floppy Nissen anti-reflux procedure (4 patients).

• One high-risk patient (ASA IV [5]), affected by DES, was excluded from surgical treatment;
  
• Six patients refused surgery (two patients affected by food regurgitation associated with an hypertensive LES; two patients with GER; one patient with NE and one patient with NE and GER).
  
• One patient with GER underwent surgical treatment elsewhere.
  

In our series, 16 patients were lacking indication for surgical treatment (neither food retention in the diverticulum with regurgitation or inhalation, nor major functional disorders like DES, NE, achalasia or GER).

Follow-up of patients was obtained through direct patient or family or contact with referring physicians. All patients were re-evaluated by means of clinical examination and an upper GI series. Post-operative esophageal manometry and 24 h pH-monitoring were planned only in patients with major functional disorders (NE, DES, Achalasia, GER).

Results of surgical treatment (Table 3)
The overall complication rate was 11% (two esophageal fistulae and one acute coronary disease) with 7% mortality rate (one septic shock from esophageal leakage and one myocardial infarction).

Only 14 patients underwent post-operative functional evaluation. At esophageal motility study, we observed that esophagomyotomy induced a significant decrease of amplitude and duration, without any modification of peristaltic pattern, of esophageal body waves in patients with DES or NE. Cardiomyotomy caused an effective reduction of LES basal pressure in patients with unrelaxing or hypertensive sphincter.

Two patients had unsatisfactory clinical results. Manometry showed the presence of NE undiagnosed pre-operatively at stationary manometry in a patients that had undergone a floppy Nissen (no. 9); a second patient (no. 17) had a persistent spasm of cervical esophagus after a diverticulectomy plus esophagocardiomyotomy and anti-reflux procedure for DES. Both were managed by medical treatment with little benefit.

Post-operative 24 h pH-monitoring showed a normal total reflux time (TRT) in all patients who had an anti-reflux procedure, regardless of the surgical technique employed.

Post-operative GER was recorded only in a patient (no. 7) who underwent diverticulectomy and esophagomyotomy for DES.

Results of conservative treatment
The ASA IV patient and those who refused surgical treatment or were operated upon elsewhere have been excluded from follow-up; another three patients were lost at follow-up. None of the remaining 13 patients (mean follow-up: 64 months; range: 42–99 months) complained of food regurgitation, pulmonary complications or worsening of pre-existing symptoms. No modification of diverticulum size was observed at radiological controls in all patients with the exception of one who showed an enlargement from 2 cm to 4 cm after 2 years of follow-up. This patient refused surgical treatment.

	Discussion

Top Abstract Introduction Materials and methods Results of clinical and... Discussion Conclusions Appendix A. Conference... References

 
The presence of an underlying functional disorder in midesophageal or epiphrenic diverticula is still matter of debate. Although the term `esophageal folklore' has been used to describe functional studies [6], pre-operative knowledge of the pathophysiology of an esophageal diverticulum is, however, essential when surgical treatment is planned.

DES, NE, vigorous achalasia, and NEMD are commonly associated in most patients with esophageal diverticula (Table 4). Functional disorders of the esophageal body or LES can be identified by motility studies, so that pre-operative manometry is a key diagnostic test [7] [8].

More recently, in the study of Altorki and colleagues [11], esophageal manometry revealed an underlying motor disorder in 12 of 15 patients studied; moreover matching the results of esophagogram, esophagoscopy, manometry, and intra-operative findings, they identified an associated motor disorder in all patients with esophageal body diverticula.

We confirm these data, as we identified a motor disorder of the esophageal body isolated or associated to LES dysfunction in 46 patients (90%).

Although the role of GER still remains unclear, hiatus hernia with reflux esophagitis and stricture in the distal esophagus are other conditions commonly associated with the presence of pulsion diverticula. Hiatus hernia has been associated with epiphrenic diverticulum in 10–75% of patients, but the incidence of significant reflux is difficult to determine [12].

GER, hypotony of LES or hiatal hernia were identified in 43% of all our patients, with an incidence of such conditions as high as 63% in those with normal or minimal motility changes. Moreover GER could be detected in 82% of patients submitted to esophageal 24 h pH-monitoring.

Our results confirm the view that most esophageal diverticula are associated with a motor disorder. Moreover the incidence of GER is not negligible and may play an etiophatological role in the genesis of pulsion diverticula. In presence of esophageal diverticula a functional disorder is nearly always detectable by a through functional evaluation: on the overall series we observed dysmotility or GER in 49/51 patients (96%).

Indications for surgery should be carefully assessed, and patient's complaints should be evaluated.

We think that the presence of food retention in the pouch determines the need for diverticular resection, regardless of diverticulum size. Regurgitation, recurrent episodes of aspiration, contrast media retention on esophagogram or on radionuclide esophageal transit study, mucosal inflammation clearly indicate the presence of food retention and require pouch resection. The diverticulum size is not, in our opinion, a reliable guide to treatment although, also in our series, small mid-esophageal diverticula were usually asymptomatic and rarely needed surgical treatment, while large diverticula were always associated with retention of undigested food and, according to other authors [11] [13], require surgical treatment.

`Masterful inactivity' advocated as the treatment of choice in asymptomatic or mildly disturbing diverticula [6] leads to some criticism due to the reported 15% [11] to 32% [9] prevalence of potentially life-threatening complications such as pulmonary sepsis from recurrent respiratory aspiration, severe nutritional depletion and carcinoma of the esophagus in patients with lower esophageal diverticulum who did not undergo any treatment. In our experience we never observed such complications, during a mean follow-up of 64 months, in patients affected by esophageal body diverticula who underwent conservative treatment based upon the absence of food retention, major motility disorders or GER.

As leakage at the suture line has been reported in numerous patients with an underlying motility disorder gone untreated, many surgeons believe that routine esophagomyotomy should accompany every diverticulectomy extending the myotomy across the lower esophageal sphincter onto the stomach distally and as far proximally as the arch of the aorta [11] [14]. Other authors [9] [15] and we stress a selective use of myotomy on esophageal motility tests results.

In patients without a motility disorder, myotomy of the esophageal body will lead to impaired peristalsis while, if omitted, does not worsen the long-term surgical results or increase the risk of recurrence [15]. Therefore, we have adopted the policy of extending the myotomy to areas of altered motility recorded by manometry to prevent recurrent `blow-outs' at a higher level. Anyway, to eliminate any possible risk of residual functional obstruction due to motor disorders undetected by stationary manometry as occurred in one patient of our series, in our opinion, the absence of impaired motility must be pre-operatively confirmed by means of 24 h motility recording [8].

Esophagomyotomy is mandatory for hypertonic esophageal motor disorders (NE, DES) treatment, and effectively reduced the amplitudes and duration of esophageal body waves in our patients. As the rationale of myotomy is the reduction of endoluminal esophageal pressure, it must be avoided in presence of NEMD or akinesia that are characterized by a hypotonic motility pattern [4] that never changed, during the follow-up of our patients, into an hypertonic disorder.

For the same reason we confirm that the routine performance of a cardiomyotomy is not necessary or desirable in patients with a normally relaxing LES of normal amplitude [15]. Also, in our series, cardiomyotomy provided a satisfactory relief of dysphagia in all patients with reduction of LES basal pressure at post-operative esophageal motility study.

Our choice to perform partial fundoplication in patients with unpaired motility, reserving total fundoplication for patients with normal motility, was justified. All anti-reflux procedures were effective in providing GER control without generating obstructive symptoms. The one patient that developed post-operative dysphagia after total fundoplication showed a delayed esophageal emptying due to a NE, with regular transit across the gastro-esophageal junction at radionuclide esophageal transit study.

In our experience this tailored surgical treatment provided excellent to good results in 92% of patients at a mean follow-up of 4 years, with a low mortality and morbidity rate.

Although mortality for a benign condition like esophageal diverticulum is difficult to justify, it should be emphasized that, in some series, a very unfavourable outcome was reported after conservative treatment of diverticula [7].

	Conclusions

Top Abstract Introduction Materials and methods Results of clinical and... Discussion Conclusions Appendix A. Conference... References

 
Our study confirms previous observations regarding the high prevalence of esophageal motor disorders among patients with esophageal body diverticula.

We believe that surgical intervention is indicated in symptomatic patients for relief from dysphagia and regurgitation when these symptoms are present. Moreover thoracic esophageal diverticula may be a site of food retention, which would result in life-threatening episodes of aspiration, and must thereby be eliminated.

The role of esophageal function tests is essential in identifying the nature of the associated functional disorder so that, if surgical treatment is considered, the underlying disorder can be surgically corrected in every patient. We stress the use of 24 h esophageal motility recording to discover patients with intermittent motor disorders undetected at stationary manometry.

Surgical therapy must be directed not only at excising the diverticulum, if indicated, but mainly at correcting any underlying motor disturbance or distal mechanical obstruction otherwise it leaves the patient, at best, with continuing symptoms or, worse yet, with a leaking suture line, mediastinitis, and death.

Correction of reflux and hernia repair are important adjuncts, as GER has a not negligible role, in our experience, when patients with normal motility are concerned.

In our experience a tailored surgery, planning treatment of the functional disorder as the primary goal, provided best immediate and long-term results.

	Footnotes

 
Presented at the 11th Annual Meeting of The European Association for Cardio-thoracic Surgery, Copenhagen, Denmark, September 28 – October 1, 1997.

	Appendix A. Conference discussion

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Dr A. Al-Qudah (Amman, Jordan): I would like to ask the speaker about the value of esophageal body motility as the end result. As in all your cases esophagomyotomy was done except in those with food retention in the upper part and you have labelled it esophagomyotomy, esophageal myotomy or cardiomyotomy. So at the end, whether you do esophageal body motility or not, you will do a myotomy. Second question, what is the length of the myotomy above and below the diverticula? Third question, what is the cause of the recurrence rate? You have a recurrence rate of 8%. What are the causes of this recurrence rate?

Dr Castrucci: Diverticulectomy is not indicated for small esophageal body diverticula without food retention; we stress that myotomy should be performed only when major motor disorders of the esophageal body or lower esophageal sphincter are present at pre-operative motility studies.

We perform a long myotomy of the esophageal body from the inferior pulmonary vein up to the aortic arch, esophagomyotomy, only in presence of nutcracker esophagus or diffuse esophageal spasm. In other cases we do not feel it is a good practice because it will result in an impairment of esophageal body motility.

We had no recurrences of diverticula but two patients in our series experienced, at follow-up, persisting dysphagia. In the first patient a nutcracker esophagus was pre-operatively undiagnosed and untreated; in the second one an esophagomyotomy for diffuse esophageal spasm resulted in an unrelieved cervical dysphagia.

Dr K. Moghissi (UK): Firstly, did you in fact have any pH or manometric studies of the results post-operatively? Secondly, in cases when you did the myotomy, was this myotomy just below the diverticulum and for how far down was it towards the gastroesophageal junction, or did you do a long myotomy?

Dr Castrucci: Do you mean if we take down the gastroesophageal junction when we perform a thoracic myotomy?

Dr Moghissi: Yes.

Dr Castrucci: No. When we perform a myotomy on the esophageal body, a cardiomyotomy is not carried out unless two associated motility disorders of esophageal body and lower esophageal sphincter are present. If the patients have hypertensive or unrelaxing lower esophageal sphincter together with diffuse esophageal spasm or nutcracker esophagus, an extended myotomy, an esophagocardiomyotomy from the aortic arch down to the stomach, is performed by the thoracic route.

Dr Moghissi: And about checking the manometry and pH studies post-operatively, have you done any?

Dr Castrucci: No, not many patients have had these tests post-operatively, so we do not have conclusive results.

	References

Top Abstract Introduction Materials and methods Results of clinical and... Discussion Conclusions Appendix A. Conference... References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Castrucci, G. Articles by Picciocchi, A. Search for Related Content PubMed PubMed Citation Articles by Castrucci, G. Articles by Picciocchi, A.