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Changing concepts in the surgical treatment of pulsion diverticula of the lower esophagus
Volume 50, Number 4 OCtODCY
1965
The Journal of T H O R A C I C A N
CARDIOVASCULAR SURGERY
Changing concepts in the surgical treatment of pulsion diverticula of the lower esophagus Thomas H. Allen, M.D. (by invitation), and O. Theron Clagett, M.D., Rochester, Minn.
Ourgical excision of symptomatic pulsion diverticula of the lower portion of the esophagus is generally accepted as the treatment of choice. Although such diver ticula are relatively uncommon lesions, enough experience has been gained during the past 20 years to justify some changes in therapeutic concepts. In 1956, Habein and associates1 at the Mayo Clinic reported the cases of 24 pa tients, with lower esophageal (epiphrenic) pulsion diverticula, who were treated surgically between 1944 through 1953. The principal symptoms were dysphagia and regurgitation. All but 7 of the patients had one or more of the following associated lesions: hiatal hernia, achalasia, diffuse esophageal spasm, and esophagitis. From the Section of Surgery, Mayo Clinic and Mayo Foundation (Dr. Clagett). Dr. Allen is a resident in thoracic surgery in the Mayo Graduate School of Medicine (University of Minnesota), Rochester, Minn. Read at the Forty-fifth Annual Meeting of the American Association for Thoracic Surgery, New Orleans, La., March 29-31, 1965.
Diverticulectomy alone was performed in 21 cases, and associated lesions were corrected in 3 (Table I). Right thoracotomy was used in 17 cases, and the left-sided approach was employed in the remaining 7. Which hemithorax to enter was dictated primarily by the location of the diverticulum. As in most reported series, the lesion was on the right side in the majority of cases. Postoperative complications devel oped in 6 of the 24 patients (Table II). Five of these patients suffered major morbidity as a result of leakage at the suture line. Four patients had empyema that required open drainage; 1 died as a result of this complication. Recurrence of the diverticulum was noted in 4 patients. Three of these patients had pre-existing diffuse esophageal spasm, and 3 had leakage at the suture line early in the postoperative course. During the subsequent 10-year period, 1954 through 1963, 17 patients underwent operative treatment of epiphrenic diver455
Journal of
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Thoracic and Cardiovascular Surgery
Table I. Surgical treatment of epiphrenic diverticula from 1944 through 1953 Procedure Diverticulectomy Diverticulectomy with esophagogastric myotomy Diverticulectomy with hiatal hernia repair Total
{Num ber 21 1 2* 24
*One hiatal hernia was repaired transabdominally months prior to diverticulectomy.
Table II. Postoperative complications in 24 patients with epiphrenic diverticula from 1944 through 1953 Complication Esophagobronchial fistula, twenty-seventh day (closed after dilatation) Suture line leak with empyema (open drainage required) Mild esophageal bleeding from suture line (controlled with endoscopie application of Gelfoam) Total
Num ber 1 4 1
6
Table III. Surgical treatment of epiphrenic diverticula from 1954 through 1963 Procedure Diverticulectomy Diverticulectomy with esophagogastric myotomy and hiatal herniorrhaphy Diverticulectomy with esophagogastric myotomy Diverticulectomy with hiatal hernior rhaphy Diverticulectomy with esophagogastrectomy and right lower lobectomy Total
Num ber 4 6 4 2 1 17
ticula (Table III). All but 2 of the patients had one or more associated lesions. Four patients had diverticulectomy alone, and the remainder had procedures designed to correct the associated lesions. Left thoracotomy was used in 13 cases and was planned for another patient who aspirated during induction of anesthesia and did not undergo definitive surgery. The diverticulum was approached from the right side in 4 cases;
involvement of the right lower lobe clearly indicated a right thoracotomy in 1 of these. Postoperative complications developed in 3 patients. The first patient underwent diverticulectomy alone. A right thoracotomy incision was used. After operation, dysphagia developed with roentgenographic evidence of achalasia and delay in passage of barium with some dilatation of the esophagus not present before operation. There was no indication of achalasia on esophageal motility studies before operation. Postoperative motility studies showed aboli tion of peristalsis, suggestive of injury to the vagus nerves. The dysphagia disap peared after dilatation. The second patient had esophagomyotomy and hiatal hernia repair accompanying the diverticulectomy. The surgeon inad vertently excised some normal mucosa in resecting the neck of the diverticulum. Con sequently, he closed the defect transversely. Significant narrowing of the distal portion of the esophagus and a leak from the suture line developed after operation. The leak closed after dilatation, and the patient was considered to have a generally excellent result 18 months later. The third patient had a squamous cell carcinoma in the diverticulum that had in volved the right lower lobe with the forma tion of a pulmonary abscess. An esophagogastrectomy and a right lower lobectomy were performed; however, since it was im possible to contain the abscess, pleural and mediastinal contamination occurred. An abdominal wound dehiscence and an esophagopleural fistula developed after operation, and the patient ultimately died from the complications. One other death occurred in this series. The patient had a large epiphrenic diver ticulum with far-advanced achalasia and a small hiatal hernia. During anesthetic induction he aspirated and subsequently died as a result of the complication. Although this patient did not have definitive surgical treatment, his death was a direct complication of his disease and an attempt at surgical management.
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Discussion During the 20 years from 1944 through 1963, 160 patients with pulsion diverticula of the distal portion of the esophagus have been seen at the Mayo Clinic. Forty-one patients underwent surgical correction, and 118 patients were managed nonoperatively, either because the symptoms were too mild to justify major surgery, a period of weight reduction was considered wise prior to de finitive treatment, or the patient refused operation. The selection of patients for operative treatment depended primarily on the magni tude of the symptoms, the size of the diverticulum, and the presence of associated lesions of the diaphragm and lower esopha gus. Approximately one third of all patients with epiphrenic pulsion diverticula were asymptomatic and were not operated upon unless there was a significant increase in the size of the lesion. Even mildly sympto matic diverticula in poor risk patients were managed nonoperatively with satisfactory results for a long time.2 In the remaining two thirds, dysphagia and régurgitation were the most frequent symptoms. It is often difficult to determine the pre cise role of the diverticulum in generating the symptoms when associated lesions are present. Since 50 to 70 per cent of patients with lower esophageal diverticula have other lesions of the distal part of the esophagus or of the diaphragm, careful evaluation of all epiphrenic diverticula is important. Habein and associates1 suggested that surgical treatment of the diverticulum should not be undertaken if correction of the associated lesions could not be ac complished. In analyzing the surgical experience from 1944 through 1953, we found that only 3 patients had concomitant definitive correc tion of associated lesions. The final 9 patients in the series received preoperative esophageal dilatation, however. The 5 pa tients with postoperative suture line leak had uncorrected diffuse spasm, and 3 of the recurrences occurred in patients with an early postoperative esophageal leak. Ten
Table IV. Incidence of associated lesions of the diaphragm and lower portion of esophagus in 160 patients seen at the Mayo Clinic from 1944 through 1963 with surgically and nonsurgically treated epiphrenic pulsion diverticula of the esophagus Lesion
Num ber*
Hiatal hernia Diffuse esophageal spasm Achalasia Esophagitis Eventration of the diaphragm Carcinoma of the esophagus Carcinoma of the epiphrenic diverticulum
55 39 16 14 2 1 1
*Some patients had two or more lesions, and 66 had no associated lesions.
of the 24 patients had moderate or severe symptoms after diverticulectomy, and it is significant that they all had a recurrent diverticulum, diffuse spasm, or diaphrag matic hernia. In contrast, from 1954 through 1963, of the 17 patients who underwent surgery for epiphrenic diverticula (Table III), 15 had associated lesions that were treated at the time of diverticulectomy. Left thoracotomy was used in all but 4 patients. The leakage at the suture line of 1 patient in this group may well have been caused by a technical error rather than lower esopha geal obstruction secondary to unrelieved spasm. The other patient in this series with post operative dysphagia had evidence of injury to the vagus nerves. Although the patient's symptoms cleared after dilatation and a good result was obtained, the complication emphasizes the importance of gentle hand ling of the tissues and minimal disturbance of normal anatomic relationships. This 20-year experience with epiphrenic pulsion diverticula of the esophagus has illustrated the frequent association of other lower esophageal and diaphragmatic lesions (Table IV). The most commonly occurring lesions (hiatal hernia, diffuse spasm, and achalasia) are associated with some type of motility disorder which, if uncorrected, may
458
Journal of
Allen and Clagett
Thoracic and Cardiovascular Surgery
lead to disruption of an esophageal suture line. Esophageal motility studies and careful interpretation of fluoroscopic and roentgenographic examinations of the esophagus should identify achalasia and diffuse spasm. Although these entities may not always be obvious without special studies, the presence of slightly hypertrophied esopha geal musculature should alert the surgeon to the possibility of a subclinical neuromuscular disorder. We agree with Effler3 that an esophagogastric myotomy should be performed on all patients undergoing resection of epiphrenic
diverticula, even if the esophagus "appears normal" and motility studies are not diag nostic. Although preoperative dilatation may provide some protection for the suture line, it is not as reliable as myotomy and the benefits are not always permanent. When present, hiatal hernia is repaired after the diverticulectomy and myotomy are completed. Surgical considerations Each patient is carefully evaluated for the presence of retained food and liquid in the esophagus. Complete emptying of the diverticulum or dilated esophagus prior
Diverticulum I
^4—
LLung^
Fig. 1. a, b and c. Sketch of the surgical excision of epiphrenic diverticulum. (From Payne, W. S., and Clagett, O. T.: Pharyngeal and Esophageal Diverticula, Current Prob. Surg., April, 1965, Year Book Medical Publishers, Inc. Reprinted with permission.)
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Pulsion diverticula of lower esophagus
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October, 1965
to operation is important. One of the two deaths during the last 10 years resulted from aspiration during induction of anes thesia. An attempt to empty the esophagus had been made preoperatively; however, the toilet was obviously incomplete. Left thoracotomy should be used almost routinely. The chest is incised through the bed of the eighth rib with or without rib resection. If the rib is resected, the inter costal nerve should be divided posteriorly before the ribs are retracted. This manuever prevents traction on the spinal nerve root and tends to reduce the incidence of late postoperative chest wall pain. Although many epiphrenic diverticula present to the right, the lower portion of the esophagus can be carefully mobilized and rotated so that the diverticulum can be easily resected. Putney and Clerf4 have shown that lower esophageal pulsion diver ticula are true diverticula and contain all
the layers; however, the muscular layers are markedly attenuated and the sac con tains mainly mucosa, submucosa, muscularis mucosa, and a fibrous layer. The neck of the sac is carefully dissected free and ex cised without decreasing the lumen of the esophagus. The cut-and-sew technique is used, and the esophageal mucosal defect is closed longitudinally with interrupted 4-0 silk sutures (Fig. 1). The stitches are placed so that the mucosal edges are inverted into the lumen. The muscle layers are then closed with a continuous stitch of 3-0 chromic catgut. When the diverticulum is on the right, the muscle layer can be closed satisfactorily over the mucosal suture line, leaving the left side of the esophagus available for the myotomy. If the diverticulum is on the left, a pleural flap can be sutured over the mu cosal repair after the myotomy has been completed. Myotomy can be performed on
M Lcosa Fig. 2. Sketch of eosphagogastric myotomy. (From Payne, W. S., and Clagett, O. T.: Pharyngeal and Esophageal Diverticula, Current Prob. Surg., April, 1965, Year Book Medical Publishers, Inc. Reprinted with permission.)
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the right side through a left thoracotomy incision; however, it cannot be carried as high as is occasionally necessary. Making the myotomy is an important part of the procedure (Fig. 2). It should be ex tended as far as the inferior pulmonary vein in most cases, but when motility studies demonstrate a long segment of diffuse spasm, the myotomy probably
should be carried up to the level of the aortic arch. Distally, the incision extends on to the gastric side for a distance of 1 cm. The normal relationships of the hiatus are preserved. The mediastinal pleura is closed loosely and pleural drainage is established. To prevent vomiting, nasogastric suction is employed for 24 hours. Sips of water are started on the third day;
Fig. 3. (Case 1.) a, Preoperative roentgenogram demonstrates large epiphrenic diverticulum pre senting to right, b, Postoperative roentgenogram demonstrates fistula from esophagus into right pleural space and bronchi, c, Postoperative roent genogram made after resection of lower esophagus and fistula with transverse colon interposition between esophagus and stomach.
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clear liquids are allowed on the fourth day, and full liquids on the fifth. By the sixth day most patients can take a mechanical diet without difficulty. Effler3 described a mucosal ridge that projects into the esophageal lumen opposite the orifice of the diverticulum. He recom mends that this be resected since it may be a source of obstruction after operation. We have not noticed this lesion endoscopically, nor have we noticed clinical events suggest ing it; however, no attempt has been made to look for it since the esophageal lumen is not routinely opened for wide visual in spection (see Fig. 1). The following case reports of patients seen in 1964 illustrate examples of compli cations that follow diverticulectomy in the presence of uncorrected associated lesions. Report of cases CASE 1. A 52-year-old woman initially had dysphagia with solid foods in October, 1963. Later, liquids were tolerated with difficulty. A barium-swallow study was interpreted as showing a diverticulum of the lower portion of the esopha gus (Fig. 3, a). In December, 1963, a transthoracic diverticulectomy was performed. After op eration, a right pleural effusion and an esophagobronchocutaneous fistula, along with progressive dysphagia, developed. The patient was treated with closed thoracotomy drainage and a tem porary gastrostomy. In April, 1964, when she came to the Mayo Clinic, she had lost 25 pounds since December, 1963, and had dysphagia with liquids and solids and intermittent paroxysms of coughing after swallowing fluids. Chest roentgenograms revealed an old inflammatory process in the right lower lobe. A meglumine diatrizoate (Gastrografin) swallow study showed free com munication between the esophagus and a 3-cm. cavity in the right pleural space, which in turn communicated with the posterior and later basal segments of the right lower lobe (Fig. 3, b). Re view of the original roentgenogram of the esopha gus (Fig. 3, a) was strongly suggestive of achalasia. Esophagoscopic examination revealed a moder ate amount of granulation tissue around the ori fice of the fistula. A firm stricture located just be low the fistula would not accept a small fiber bougie. The mucosa of the bronchus of the right lower lobe was distorted and edematous, and bloody purulent secretions were present in the lumen. Since the esophageal stricture did not seem amenable to successful dilatation, an aggressive surgical approach was elected while the patient's
general condition was still satisfactory. The fistula and the distal part of the esophagus were resected, and gastrointestinal continuity was re-established with the use of a segment of transverse colon. A Heineke-Mikulicz pyloroplasty was performed, and a temporary gastrostomy was established. The operation was executed through separate abdomi nal and left thoracotomy incisions. The post operative course was uneventful, and fluoroscopic examination demonstrated free passage of barium into the stomach (Fig. 3, c). The gastrostomy tube was removed, and on the sixteenth postopera tive day the patient was discharged. She was able to eat a soft diet without difficulty. Two months after the operation, she was well and enjoying a regular diet. CASE 2. A 57-year-old man had dysphagia and régurgitation of undigested food in November, 1962. Roentgenographic examination revealed an epiphrenic diverticulum and delayed passage of barium into the stomach (Fig. 4, a). In June, 1963, the diverticulum was removed. The surgeon was able to pass his finger with ease through the lower esophageal sphincter. Although motility studies in August, 1963, were suggestive of achalasia, the patient was essentially symptom
Fig. 4. (Case 2.) a, Preoperative roentgenogram demonstrates epiphrenic diverticulum. Note nar row esophagogastric junction, b, Recurrent epi phrenic diverticulum. Note esophageal spasm and narrow esophagogastric junction.
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free until December, 1963, when the dysphagia recurred and he became aware of lower esophageal spasm. Roentgenograms revealed a recurrent epiphrenic diverticulum (Fig. 4, b). After three dilatations, the patient was able to swallow liquids and very soft foods; however, the spasms per sisted. At the Mayo Clinic in March, 1964, fluoroscopic examination demonstrated a large epiphrenic diverticulum with transient spasm of the esophagus. The esophagogastric junction was narrow but not obstructed. The endoscopist did not find an organic stricture, but the cardia had the sensation characteristic of achalasia. Motility studies revealed severe diffuse spasm in the lower half of the esophagus along with distal obstruc tion that was suggestive of a hiatal hernia. At operation a very large and thick-walled esophagus was found with a diverticulum located 3 cm. above the esophagogastric junction. A small hiatal hernia was present. Diverticulectomy, esophago gastric myotomy, and hiatal herniorrhaphy were performed. Due to scarring and reaction from the previous operation, the vagus nerves could not be identified, and their integrity was doubted. The possible need for a pyloroplasty at a future date was considered. After 3 or 4 weeks, the patient experienced several episodes of vomiting after taking liquids but subsequently became asympto matic and was doing well 2 months later. Summary and conclusions A review of the surgical treatment of epiphrenic pulsion diverticula of the esopha
gus at the Mayo Clinic reveals that failure to correct associated defects of the dia phragm and lower portion of the esophagus may increase postoperative morbidity, due to leakage at the suture line. In addition, routine performance of an esophagogastric myotomy is recommended after epiphrenic diverticulectomy, and an incision through the bed of the left eighth rib is recom mended for general use in excision of epiphrenic diverticula and in correction of associated lesions of the diaphragm and lower portion of the esophagus. REFERENCES 1 Habein, H. C , Jr., Kirklin, J. W., Clagett, O. T., and Moersch, H. J.: Surgical Treatment of Lower Esophageal Pulsion Diverticula, A. M. A. Arch. Surg. 72: 1018, 1956. 2 Habein, H. C , Jr., Moersch. H. J., and Kirklin, J. W.: Diverticula of the Lower Part of the Esophagus: A Clinical Study of One Hundred Forty-nine Nonsurgical Cases, Arch. Int. Med. 97: 768, 1956. 3 Effler, D. B.: Benign Esophageal Lesions. Read at the Postgraduate Course in Thoracic Surgery, Clinical Congress, American College of Sur geons, Chicago, 111., Oct. 5 to 9, 1964. 4 Putney, F. J., and Clerf, L. H.: Epiphrenic Esophageal Diverticulum, Tr. Am. Bronchoesophageal A. 34: 30, 1953.
1965
The Journal of T H O R A C I C A N
CARDIOVASCULAR SURGERY
Changing concepts in the surgical treatment of pulsion diverticula of the lower esophagus Thomas H. Allen, M.D. (by invitation), and O. Theron Clagett, M.D., Rochester, Minn.
Ourgical excision of symptomatic pulsion diverticula of the lower portion of the esophagus is generally accepted as the treatment of choice. Although such diver ticula are relatively uncommon lesions, enough experience has been gained during the past 20 years to justify some changes in therapeutic concepts. In 1956, Habein and associates1 at the Mayo Clinic reported the cases of 24 pa tients, with lower esophageal (epiphrenic) pulsion diverticula, who were treated surgically between 1944 through 1953. The principal symptoms were dysphagia and regurgitation. All but 7 of the patients had one or more of the following associated lesions: hiatal hernia, achalasia, diffuse esophageal spasm, and esophagitis. From the Section of Surgery, Mayo Clinic and Mayo Foundation (Dr. Clagett). Dr. Allen is a resident in thoracic surgery in the Mayo Graduate School of Medicine (University of Minnesota), Rochester, Minn. Read at the Forty-fifth Annual Meeting of the American Association for Thoracic Surgery, New Orleans, La., March 29-31, 1965.
Diverticulectomy alone was performed in 21 cases, and associated lesions were corrected in 3 (Table I). Right thoracotomy was used in 17 cases, and the left-sided approach was employed in the remaining 7. Which hemithorax to enter was dictated primarily by the location of the diverticulum. As in most reported series, the lesion was on the right side in the majority of cases. Postoperative complications devel oped in 6 of the 24 patients (Table II). Five of these patients suffered major morbidity as a result of leakage at the suture line. Four patients had empyema that required open drainage; 1 died as a result of this complication. Recurrence of the diverticulum was noted in 4 patients. Three of these patients had pre-existing diffuse esophageal spasm, and 3 had leakage at the suture line early in the postoperative course. During the subsequent 10-year period, 1954 through 1963, 17 patients underwent operative treatment of epiphrenic diver455
Journal of
456
Allen and Clagett
Thoracic and Cardiovascular Surgery
Table I. Surgical treatment of epiphrenic diverticula from 1944 through 1953 Procedure Diverticulectomy Diverticulectomy with esophagogastric myotomy Diverticulectomy with hiatal hernia repair Total
{Num ber 21 1 2* 24
*One hiatal hernia was repaired transabdominally months prior to diverticulectomy.
Table II. Postoperative complications in 24 patients with epiphrenic diverticula from 1944 through 1953 Complication Esophagobronchial fistula, twenty-seventh day (closed after dilatation) Suture line leak with empyema (open drainage required) Mild esophageal bleeding from suture line (controlled with endoscopie application of Gelfoam) Total
Num ber 1 4 1
6
Table III. Surgical treatment of epiphrenic diverticula from 1954 through 1963 Procedure Diverticulectomy Diverticulectomy with esophagogastric myotomy and hiatal herniorrhaphy Diverticulectomy with esophagogastric myotomy Diverticulectomy with hiatal hernior rhaphy Diverticulectomy with esophagogastrectomy and right lower lobectomy Total
Num ber 4 6 4 2 1 17
ticula (Table III). All but 2 of the patients had one or more associated lesions. Four patients had diverticulectomy alone, and the remainder had procedures designed to correct the associated lesions. Left thoracotomy was used in 13 cases and was planned for another patient who aspirated during induction of anesthesia and did not undergo definitive surgery. The diverticulum was approached from the right side in 4 cases;
involvement of the right lower lobe clearly indicated a right thoracotomy in 1 of these. Postoperative complications developed in 3 patients. The first patient underwent diverticulectomy alone. A right thoracotomy incision was used. After operation, dysphagia developed with roentgenographic evidence of achalasia and delay in passage of barium with some dilatation of the esophagus not present before operation. There was no indication of achalasia on esophageal motility studies before operation. Postoperative motility studies showed aboli tion of peristalsis, suggestive of injury to the vagus nerves. The dysphagia disap peared after dilatation. The second patient had esophagomyotomy and hiatal hernia repair accompanying the diverticulectomy. The surgeon inad vertently excised some normal mucosa in resecting the neck of the diverticulum. Con sequently, he closed the defect transversely. Significant narrowing of the distal portion of the esophagus and a leak from the suture line developed after operation. The leak closed after dilatation, and the patient was considered to have a generally excellent result 18 months later. The third patient had a squamous cell carcinoma in the diverticulum that had in volved the right lower lobe with the forma tion of a pulmonary abscess. An esophagogastrectomy and a right lower lobectomy were performed; however, since it was im possible to contain the abscess, pleural and mediastinal contamination occurred. An abdominal wound dehiscence and an esophagopleural fistula developed after operation, and the patient ultimately died from the complications. One other death occurred in this series. The patient had a large epiphrenic diver ticulum with far-advanced achalasia and a small hiatal hernia. During anesthetic induction he aspirated and subsequently died as a result of the complication. Although this patient did not have definitive surgical treatment, his death was a direct complication of his disease and an attempt at surgical management.
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October, 1965
Discussion During the 20 years from 1944 through 1963, 160 patients with pulsion diverticula of the distal portion of the esophagus have been seen at the Mayo Clinic. Forty-one patients underwent surgical correction, and 118 patients were managed nonoperatively, either because the symptoms were too mild to justify major surgery, a period of weight reduction was considered wise prior to de finitive treatment, or the patient refused operation. The selection of patients for operative treatment depended primarily on the magni tude of the symptoms, the size of the diverticulum, and the presence of associated lesions of the diaphragm and lower esopha gus. Approximately one third of all patients with epiphrenic pulsion diverticula were asymptomatic and were not operated upon unless there was a significant increase in the size of the lesion. Even mildly sympto matic diverticula in poor risk patients were managed nonoperatively with satisfactory results for a long time.2 In the remaining two thirds, dysphagia and régurgitation were the most frequent symptoms. It is often difficult to determine the pre cise role of the diverticulum in generating the symptoms when associated lesions are present. Since 50 to 70 per cent of patients with lower esophageal diverticula have other lesions of the distal part of the esophagus or of the diaphragm, careful evaluation of all epiphrenic diverticula is important. Habein and associates1 suggested that surgical treatment of the diverticulum should not be undertaken if correction of the associated lesions could not be ac complished. In analyzing the surgical experience from 1944 through 1953, we found that only 3 patients had concomitant definitive correc tion of associated lesions. The final 9 patients in the series received preoperative esophageal dilatation, however. The 5 pa tients with postoperative suture line leak had uncorrected diffuse spasm, and 3 of the recurrences occurred in patients with an early postoperative esophageal leak. Ten
Table IV. Incidence of associated lesions of the diaphragm and lower portion of esophagus in 160 patients seen at the Mayo Clinic from 1944 through 1963 with surgically and nonsurgically treated epiphrenic pulsion diverticula of the esophagus Lesion
Num ber*
Hiatal hernia Diffuse esophageal spasm Achalasia Esophagitis Eventration of the diaphragm Carcinoma of the esophagus Carcinoma of the epiphrenic diverticulum
55 39 16 14 2 1 1
*Some patients had two or more lesions, and 66 had no associated lesions.
of the 24 patients had moderate or severe symptoms after diverticulectomy, and it is significant that they all had a recurrent diverticulum, diffuse spasm, or diaphrag matic hernia. In contrast, from 1954 through 1963, of the 17 patients who underwent surgery for epiphrenic diverticula (Table III), 15 had associated lesions that were treated at the time of diverticulectomy. Left thoracotomy was used in all but 4 patients. The leakage at the suture line of 1 patient in this group may well have been caused by a technical error rather than lower esopha geal obstruction secondary to unrelieved spasm. The other patient in this series with post operative dysphagia had evidence of injury to the vagus nerves. Although the patient's symptoms cleared after dilatation and a good result was obtained, the complication emphasizes the importance of gentle hand ling of the tissues and minimal disturbance of normal anatomic relationships. This 20-year experience with epiphrenic pulsion diverticula of the esophagus has illustrated the frequent association of other lower esophageal and diaphragmatic lesions (Table IV). The most commonly occurring lesions (hiatal hernia, diffuse spasm, and achalasia) are associated with some type of motility disorder which, if uncorrected, may
458
Journal of
Allen and Clagett
Thoracic and Cardiovascular Surgery
lead to disruption of an esophageal suture line. Esophageal motility studies and careful interpretation of fluoroscopic and roentgenographic examinations of the esophagus should identify achalasia and diffuse spasm. Although these entities may not always be obvious without special studies, the presence of slightly hypertrophied esopha geal musculature should alert the surgeon to the possibility of a subclinical neuromuscular disorder. We agree with Effler3 that an esophagogastric myotomy should be performed on all patients undergoing resection of epiphrenic
diverticula, even if the esophagus "appears normal" and motility studies are not diag nostic. Although preoperative dilatation may provide some protection for the suture line, it is not as reliable as myotomy and the benefits are not always permanent. When present, hiatal hernia is repaired after the diverticulectomy and myotomy are completed. Surgical considerations Each patient is carefully evaluated for the presence of retained food and liquid in the esophagus. Complete emptying of the diverticulum or dilated esophagus prior
Diverticulum I
^4—
LLung^
Fig. 1. a, b and c. Sketch of the surgical excision of epiphrenic diverticulum. (From Payne, W. S., and Clagett, O. T.: Pharyngeal and Esophageal Diverticula, Current Prob. Surg., April, 1965, Year Book Medical Publishers, Inc. Reprinted with permission.)
Volume 50 Number 4
Pulsion diverticula of lower esophagus
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October, 1965
to operation is important. One of the two deaths during the last 10 years resulted from aspiration during induction of anes thesia. An attempt to empty the esophagus had been made preoperatively; however, the toilet was obviously incomplete. Left thoracotomy should be used almost routinely. The chest is incised through the bed of the eighth rib with or without rib resection. If the rib is resected, the inter costal nerve should be divided posteriorly before the ribs are retracted. This manuever prevents traction on the spinal nerve root and tends to reduce the incidence of late postoperative chest wall pain. Although many epiphrenic diverticula present to the right, the lower portion of the esophagus can be carefully mobilized and rotated so that the diverticulum can be easily resected. Putney and Clerf4 have shown that lower esophageal pulsion diver ticula are true diverticula and contain all
the layers; however, the muscular layers are markedly attenuated and the sac con tains mainly mucosa, submucosa, muscularis mucosa, and a fibrous layer. The neck of the sac is carefully dissected free and ex cised without decreasing the lumen of the esophagus. The cut-and-sew technique is used, and the esophageal mucosal defect is closed longitudinally with interrupted 4-0 silk sutures (Fig. 1). The stitches are placed so that the mucosal edges are inverted into the lumen. The muscle layers are then closed with a continuous stitch of 3-0 chromic catgut. When the diverticulum is on the right, the muscle layer can be closed satisfactorily over the mucosal suture line, leaving the left side of the esophagus available for the myotomy. If the diverticulum is on the left, a pleural flap can be sutured over the mu cosal repair after the myotomy has been completed. Myotomy can be performed on
M Lcosa Fig. 2. Sketch of eosphagogastric myotomy. (From Payne, W. S., and Clagett, O. T.: Pharyngeal and Esophageal Diverticula, Current Prob. Surg., April, 1965, Year Book Medical Publishers, Inc. Reprinted with permission.)
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the right side through a left thoracotomy incision; however, it cannot be carried as high as is occasionally necessary. Making the myotomy is an important part of the procedure (Fig. 2). It should be ex tended as far as the inferior pulmonary vein in most cases, but when motility studies demonstrate a long segment of diffuse spasm, the myotomy probably
should be carried up to the level of the aortic arch. Distally, the incision extends on to the gastric side for a distance of 1 cm. The normal relationships of the hiatus are preserved. The mediastinal pleura is closed loosely and pleural drainage is established. To prevent vomiting, nasogastric suction is employed for 24 hours. Sips of water are started on the third day;
Fig. 3. (Case 1.) a, Preoperative roentgenogram demonstrates large epiphrenic diverticulum pre senting to right, b, Postoperative roentgenogram demonstrates fistula from esophagus into right pleural space and bronchi, c, Postoperative roent genogram made after resection of lower esophagus and fistula with transverse colon interposition between esophagus and stomach.
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clear liquids are allowed on the fourth day, and full liquids on the fifth. By the sixth day most patients can take a mechanical diet without difficulty. Effler3 described a mucosal ridge that projects into the esophageal lumen opposite the orifice of the diverticulum. He recom mends that this be resected since it may be a source of obstruction after operation. We have not noticed this lesion endoscopically, nor have we noticed clinical events suggest ing it; however, no attempt has been made to look for it since the esophageal lumen is not routinely opened for wide visual in spection (see Fig. 1). The following case reports of patients seen in 1964 illustrate examples of compli cations that follow diverticulectomy in the presence of uncorrected associated lesions. Report of cases CASE 1. A 52-year-old woman initially had dysphagia with solid foods in October, 1963. Later, liquids were tolerated with difficulty. A barium-swallow study was interpreted as showing a diverticulum of the lower portion of the esopha gus (Fig. 3, a). In December, 1963, a transthoracic diverticulectomy was performed. After op eration, a right pleural effusion and an esophagobronchocutaneous fistula, along with progressive dysphagia, developed. The patient was treated with closed thoracotomy drainage and a tem porary gastrostomy. In April, 1964, when she came to the Mayo Clinic, she had lost 25 pounds since December, 1963, and had dysphagia with liquids and solids and intermittent paroxysms of coughing after swallowing fluids. Chest roentgenograms revealed an old inflammatory process in the right lower lobe. A meglumine diatrizoate (Gastrografin) swallow study showed free com munication between the esophagus and a 3-cm. cavity in the right pleural space, which in turn communicated with the posterior and later basal segments of the right lower lobe (Fig. 3, b). Re view of the original roentgenogram of the esopha gus (Fig. 3, a) was strongly suggestive of achalasia. Esophagoscopic examination revealed a moder ate amount of granulation tissue around the ori fice of the fistula. A firm stricture located just be low the fistula would not accept a small fiber bougie. The mucosa of the bronchus of the right lower lobe was distorted and edematous, and bloody purulent secretions were present in the lumen. Since the esophageal stricture did not seem amenable to successful dilatation, an aggressive surgical approach was elected while the patient's
general condition was still satisfactory. The fistula and the distal part of the esophagus were resected, and gastrointestinal continuity was re-established with the use of a segment of transverse colon. A Heineke-Mikulicz pyloroplasty was performed, and a temporary gastrostomy was established. The operation was executed through separate abdomi nal and left thoracotomy incisions. The post operative course was uneventful, and fluoroscopic examination demonstrated free passage of barium into the stomach (Fig. 3, c). The gastrostomy tube was removed, and on the sixteenth postopera tive day the patient was discharged. She was able to eat a soft diet without difficulty. Two months after the operation, she was well and enjoying a regular diet. CASE 2. A 57-year-old man had dysphagia and régurgitation of undigested food in November, 1962. Roentgenographic examination revealed an epiphrenic diverticulum and delayed passage of barium into the stomach (Fig. 4, a). In June, 1963, the diverticulum was removed. The surgeon was able to pass his finger with ease through the lower esophageal sphincter. Although motility studies in August, 1963, were suggestive of achalasia, the patient was essentially symptom
Fig. 4. (Case 2.) a, Preoperative roentgenogram demonstrates epiphrenic diverticulum. Note nar row esophagogastric junction, b, Recurrent epi phrenic diverticulum. Note esophageal spasm and narrow esophagogastric junction.
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free until December, 1963, when the dysphagia recurred and he became aware of lower esophageal spasm. Roentgenograms revealed a recurrent epiphrenic diverticulum (Fig. 4, b). After three dilatations, the patient was able to swallow liquids and very soft foods; however, the spasms per sisted. At the Mayo Clinic in March, 1964, fluoroscopic examination demonstrated a large epiphrenic diverticulum with transient spasm of the esophagus. The esophagogastric junction was narrow but not obstructed. The endoscopist did not find an organic stricture, but the cardia had the sensation characteristic of achalasia. Motility studies revealed severe diffuse spasm in the lower half of the esophagus along with distal obstruc tion that was suggestive of a hiatal hernia. At operation a very large and thick-walled esophagus was found with a diverticulum located 3 cm. above the esophagogastric junction. A small hiatal hernia was present. Diverticulectomy, esophago gastric myotomy, and hiatal herniorrhaphy were performed. Due to scarring and reaction from the previous operation, the vagus nerves could not be identified, and their integrity was doubted. The possible need for a pyloroplasty at a future date was considered. After 3 or 4 weeks, the patient experienced several episodes of vomiting after taking liquids but subsequently became asympto matic and was doing well 2 months later. Summary and conclusions A review of the surgical treatment of epiphrenic pulsion diverticula of the esopha
gus at the Mayo Clinic reveals that failure to correct associated defects of the dia phragm and lower portion of the esophagus may increase postoperative morbidity, due to leakage at the suture line. In addition, routine performance of an esophagogastric myotomy is recommended after epiphrenic diverticulectomy, and an incision through the bed of the left eighth rib is recom mended for general use in excision of epiphrenic diverticula and in correction of associated lesions of the diaphragm and lower portion of the esophagus. REFERENCES 1 Habein, H. C , Jr., Kirklin, J. W., Clagett, O. T., and Moersch, H. J.: Surgical Treatment of Lower Esophageal Pulsion Diverticula, A. M. A. Arch. Surg. 72: 1018, 1956. 2 Habein, H. C , Jr., Moersch. H. J., and Kirklin, J. W.: Diverticula of the Lower Part of the Esophagus: A Clinical Study of One Hundred Forty-nine Nonsurgical Cases, Arch. Int. Med. 97: 768, 1956. 3 Effler, D. B.: Benign Esophageal Lesions. Read at the Postgraduate Course in Thoracic Surgery, Clinical Congress, American College of Sur geons, Chicago, 111., Oct. 5 to 9, 1964. 4 Putney, F. J., and Clerf, L. H.: Epiphrenic Esophageal Diverticulum, Tr. Am. Bronchoesophageal A. 34: 30, 1953.