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PULSION DIVERTICULA OF THE MID-THORACIC ESOPHAGUS
PULSION DIVERTICULA OF THE MID-THORACIC ESOPHAGUS Sam W. Law, M.D.*
M
and John W. Overstreet, M.D.,**
Houston,
Texas
esophageal divertieula are often discovered during roentgenographic examination of the esophagus, but are accorded little attention because of the recognized rarity of correlated dysphagia. Since the initial classi fication by Eokitansky 1 in 1840, and the definitive clinical study by Zenker and von Ziemssen2 in 1877, it has been widely accepted3"6 that all mid-thoracic esophageal divertieula are produced by extrinsic traction or tenting resulting from the adherence of inflammatory mediastinal lymph nodes. The typical traction divertieulum of the mid-thoracic esophagus is conical or funnel-shaped with a wide orifice, is small (rarely exceeding 2 cm. in length), and is situated horizontally or extends superiorly. It is a true divertieulum, having a complete investment by the esophageal muscle coats. Each of these characteristics promotes easy emptying of the divertieulum. Since food accumu lation is prevented, there is no tendency to progressive enlargement of the sac, and no associated dysphagia. Pulsion divertieula of the esophagus are pear-shaped protrusions of mucosa and submucosa through a small defect in the muscle layers of the esophageal wall. Hanging dependently from a narrow neck, the divertieulum diverts food from the swallowed bolus and progressively increases in size. Dysphagia or regurgitant emptying of the diverticular contents causes the patient to seek assistance. In recent years, there have been occasional reports of symptomatic midthoracic pulsion divertieula of the esophagus with relief of dysphagia following surgical excision.7"9 Two such patients are presented in this report, and pertinent recent developments in the study of esophageal disease are discussed. ID-THORACIC
CASE REPORTS CASE 1.—W. F . C. (No. 56-16621), a 62-year-old white man, was admitted to the Methodist Hospital, Houston, Texas, on Sept. 9, 1956. The patient stated t h a t he had been in excellent health until several months prior to admission, when he began experiencing heartburn. This was described as a burning distress in the upper retrosternal region, assoProm the Cora and Webb Mading Department of Surgery, Baylor University College of Medicine, and the Methodist Hospital, Houston, Texas. Received for publication April 1, 1964. •Clinical Instructor, Cora and Webb Mading Department of Surgery, Baylor University College of Medicine; Acting Chief, Surgical Service, Veterans Administration Hospital; and Active Staff, Surgical Service, Methodist Hospital, Houston, Texas. Present address: 508 Her mann Professional Bldg., Houston 25, Texas. ••Clinical Associate Professor, Cora and Webb Mading Department of Surgery, Baylor University College of Medicine ; and Senior Attending Staff, the Methodist Hospital, Houston, Texas. 855
856
LAW AND O V E E S T R E E T
J. Thoracic and Cardiovas. Surg.
eiated with a sensation of fullness, and often followed by the vomiting of food eaten 3 or 4 hours earlier, which relieved the heartburn. The food was noted to appear as it had been when eaten, without sourness or evidence of digestion. I n the weeks immediately preceding admission, the patient had experienced several episodes of vomiting with little preceding heartburn or nausea, while shaving in the morning immediately following breakfast. The patient had not experienced the sensation of food sticking in the throat. No relationship to recumbency could be established and there had been no weight loss.
Fig. 1.—Barium contrast esophagogram of W. F. C. (Case 1) demonstrates mid-thoracic esophageal pulsion diverticulum arising from the left anterolateral aspect a t the level of the manubrio-sternal junction. The fluid level in the dependent, pear-shaped diverticulum is evident.
On physical examination, the patient was 5 feet 9 inches tall and weighed 175 pounds. There were no abnormal physical findings. Laboratory examinations were within normal limits. Barium contrast roentgenographie examination of the esophagus demonstrated a diverticulum located just below the arch of the aorta, at the level of the manubrio-sternal junction anteriorly (Fig. 1 ) . The diverticulum appeared to arise from the left anterolateral aspect of the esophagus. Barium passed through the esophagus without delay, but the diverticulum was dependent and retained barium throughout the examination. No delay or defect was noted a t the cardia, and the stomach and duodenum appeared normal. Eoentgenograms of the chest were not remarkable. Esophagoscopy demonstrated the oriflce of the diverticulum situated anteriorly and to the left a t 30 cm. from the incisor teeth. There was minimal angulation of the esophagus and the esophagoseope was easily passed by the opening. There was no evidence of an esophageal hiatal hernia. A left thoracotomy was performed on September 13. Exposure of the esophagus demon strated a diverticulum presenting anteriorly and to the left at the level of the left mainstem bronchus, approximately 4 cm. below the tracheal bifurcation. The pleura and mediastinal
Vol. 48. No. 5 November. 1964
P U L S I O X DIVERTICULA OF ESOPHAGUS
857
tissues about the diverticulum were distinctly edematous. Several adjacent lymph nodes were noted, but there was no attachment of the lymph nodes to the diverticular sae. The diver ticulum was formed of mucosa and submucosa protruding through a defect in the muscle coats of the esophagus. The sac was excised and the mucosa closed with inverted sutures. The muscular layers of the esophageal wall were then repaired. The postoperative course was uneventful, and the patient was discharged on Sept. 25, 1956. He has been free of symptoms since discharge, and there has been no evidence of recurrence of the diverticulum.
Fig. 2.—Barium contrast esophagogram of N. B. S. (Case 2) demonstrates pulsion diverticulum of the mid-thoracic esophagus arising from the right side.
CASE 2.—N. B. S. (No. 14-05-53), a 53-year-old white female schoolteacher, was ad mitted to the Methodist Hospital on June 2, 1963. The patient complained of intermittent difficulty with swallowing of about 2 years' duration. This was described as a sensation upon swallowing that the food was "swelling up and going around a bump" in the upper retrosternal region. There had been an occasional coughing spell at night while the patient was recumbent, but no recognizable regurgitation. Infrequent episodes of simple retrosternal pain were described. A barium esophagogram made in February, 1963, had demonstrated a mid-thoracic esophageal diverticulum and the patient had been placed on a bland diet with antispasmodics and antacids, and a weight reduction program. The latter had been mod erately successful, but the dysphagia had persisted unchanged. The patient had undergone several gynecologic operations in the remote past. The re maining history was unremarkable. Physical examination upon admission to the hospital demonstrated the patient to be of small stature and moderately obese, but mentally alert and in no distress. There were no abnormal physical findings. The laboratory examinations were within normal range. Barium contrast roentgenographic examination of the esophagus demonstrated a 4 by 5.5 cm. diverticulum arising from the right at the junction of the middle and lower thirds (Fig. 2 ) . The neck of the diverticulum distended to a maximum of about 1 cm. in diameter.
LAW AND OVERSTREET
858
J. Thoracic and Cardiovas. Surg.
The diverticulum was dependent and impressed the adjacent esophagus slightly, but did not interfere with the free flow of esophageal contents. Thorough examination of the cardia, stomach, duodenum, and the small bowel demonstrated no additional abnormalities. On June 4, a right thoracotomy was performed. Exposure of the esophagus demonstrated a pulsion diverticulum 6 cm. in length, arising from the right lateral aspect of the esophagus at the junction of the middle and lower thirds. No lymph nodes were present in the area of the diverticulum, and the wall of the sac had no significant attachment to adjacent structures. The neck of the diverticulum was transected and the opening was repaired with inverted sutures. The defect in the muscular wall of the esophagus was then closed. The patient's postoperative course was entirely uneventful and she was discharged from the hospital on J u n e 18. On Aug. 13, 1963, fluoroscopic examination during ingestion of barium showed no obstruction or defect in the esophagus, and films of the barium-filled esophagus confirmed the absence of narrowing or significant irregularity in the area of the mid-esophagus from which the diverticulum had been resected. The patient has been entirely free of symptoms since surgical treatment. DISCUSSION
Pulsion diverticula of the esophagus occurring in the pharyngo-esophageal and epiphrenie positions are well recognized as obscure and indolent lesions capable of producing severe dysphagia and inanition. 3 ' 10 The progressive im provement in the surgical treatment of these pulsion diverticula is well known. The common disregard of mid-thoracic traction diverticula is laudable in that it has prevented unwarranted surgical attack on these lesions, but, more im portantly, it has forced a continued search for the true cause of the patient's symptoms. It must be recognized that, while the mid-esophageal traction diverticulum does not produce symptoms of dysphagia or regurgitation, these traction diver ticula may produce symptoms related to the original mediastinal disease. 3 ' 6 Erosion of the inflammatory process into the diverticular sac may produce hemorrhage, perforation into the mediastinum with abscess formation, or per foration into the tracheobronchial tree with fistula. The occurrence of a pulsion diverticulum in the mid-thoracic esophagus contradicts concepts of long standing. As a result, the equivocal term "tractionpulsion diverticulum" has been used. 4 ' 6 However, in the 2 patients presented in this report, there was no evidence of a traction mechanism found at operation, and the pear-shaped diverticular sac in each patient was clearly a pulsion or false diverticulum. Other well-documented examples of symptomatic pulsion diverticula of the mid-thoracic esophagus have been reported.7"9- "■ 1 5 Cross, Johnson, and Gerein,11 Gahagan, 9 and others 12 ' 13 have emphasized that mid-thoracic pulsion diverticula of the esophagus are often found in con junction with disorders of esophageal peristalsis, or with lesions of the distal esophagus interfering with esophageal emptying. In recent years there has been intensive investigation of normal and deranged esophageal function through the use of intraluminal pressure and pH recordings, and esophageal functional dynamics have been correlated with these measurements with cinefluorography. With these methods, Cross and co-workers11 have documented the increased intraluminal pressures in certain patients with esophageal diverticular disease.
Vol. 48, No. 5 November, 1964
P U L S I O N DIVERTICULA O F ESOPHAGUS
859
Thus, after 120 years, there is objective documentation of the "pulsion" mecha nism postulated by Eokitansky 1 in 1840. Esophageal pulsion diverticula have been reported in association with esophageal hiatal hernia, achalasia, esophageal stricture, 10 diffuse esophageal spasm, localized esophageal muscle hypertrophy or hypertonicity, benign tumors of the esophageal wall," and the lower esophageal mucosal flap (described by Effler13). Certainly the esophageal diverticulum may represent only one aspect of the patient's disordered esophageal function. Simple excision of the diverticu lum without simultaneous correction of associated or underlying problems may result in disruption of the esophageal repair, recurrence of the diverticulum, or in continuation of symptoms. It is unlikely that every patient with an esophageal diverticulum will be found to have associated abnormalities. It is difficult to support the recent recommendation by Belsey15 that esophageal myotomy must be included in the treatment of every esophageal diverticulum, or persistence of symptoms or recurrence of the diverticulum is inevitable. The recurrence rates in the collected series of diverticulectomy tabulated by Postlethwait and Sealy6 and the clinical course of the present 2 patients suggest that excellent results follow simple diverticulectomy if no other abnormality is present. It is necessary to re-emphasize that each patient with esophageal diverticular disease, and especially the patient with a mid-thoracic pulsion diverticulum, must be thoroughly evaluated for the presence of other esophageal abnormalities. If associated lesions are discovered, it is mandatory that they be corrected simultaneously with diverticulectomy. SUMMARY
The cases of 2 patients are reported; each had a typical pulsion diverticulum of the mid-thoracic esophagus. No associated esophageal abnormalities were present. Symptoms of dysphagia and regurgitation were completely relieved by excision of the diverticula. Eeeent developments in the study of esophageal disease are briefly reviewed. The frequency of other esophageal abnormalities associated with esophageal diverticula is emphasized. REFERENCES 1. Rokitansky, C.: Spindelformige Erweiterung der Speisrolire, Med. Jahrb. d. k. k. osterr. Staates 2 1 : 219-222, 1840. (Cited by De Bakey et a U ) . 2. Zenker, F . A., and von Ziemssen, H . : Diseases of the Esophagus in Cyclopedia of the Practice of Medicine, New York, 1878, William Wood & Co., vol. 8, pp. 51-89. (Cited by De Bakey et al.3). 3. De Bakey, M. E., Heaney, J . P., and Creech, O.: Surgical Considerations in Diverticula of the Esophagus, J . A. M. A. 150: 1076, 1952. 4. Naclerio, E. A . : Diverticula of the Thoracic Esophagus, Am. J . Surg. 9 3 : 218, 1957. 5. Mustard, R. A.: Diverticula of the Esophagus, Canad. M. A. J . 76: 822, 1957. 6. Postlethwait, E. W., and Sealy, W. C : Surgery of the Esophagus, Springfield, 111., 1961, Charles C Thomas, Publisher, pp. 104-132. 7. Harrington, S. W.: The Surgical Treatment of Pulsion Diverticula of the Thoracic Esophagus, Ann. Surg. 129: 606, 1949.
860
LAW AND OVEESTREET
J. Thoracic and Cardiovas. Surg.
8. Maier, H. C.: Dysphagia From Diverticulum of the Mid-Thoracic Esophagus, Gastroenterol. 2 3 : 318, 1953. 9. Gahagan, T.: Diverticula of the Thoracic Esophagus, Henry Ford Hosp. M. Bull. 10: 449, 1962. 10. De Bakey, M. E., and Creech, O.: Surgical Treatment of Epiplirenic Diverticulum of the
Esophagus, J .
THORACIC SURG. 23:
486,
1952.
11. Cross, F . S., Johnson, G. F., and Gerein, A. N . : Esophageal Diverticula, A. M. A. Arch. Surg. 83: 525, 1961. 12. Habein, H. C , Kirkland, J . W., Clagett, O. T., and Moersch, H. J . : Surgical Treatment of Lower Esophageal Pulsion Diverticula, A. M. A. Arch. Surg. 72: 1018, 1956. 13. Effler, D. B., Barr, D., and Groves, L. K . : Epiplirenic Diverticulum of the Esophagus, A. M. A. Arch. Surg. 79: 459, 1959. 14. Razin, E., and Adler, E. H . : Association of Benign Esophageal Tumors and Diverticula, New York J . Med. 62: 2554, 1962. 15. Belsey, R.: Functional Disease of the Esophagus, Postgrad. M. J . 39: 290, 1963.
M
and John W. Overstreet, M.D.,**
Houston,
Texas
esophageal divertieula are often discovered during roentgenographic examination of the esophagus, but are accorded little attention because of the recognized rarity of correlated dysphagia. Since the initial classi fication by Eokitansky 1 in 1840, and the definitive clinical study by Zenker and von Ziemssen2 in 1877, it has been widely accepted3"6 that all mid-thoracic esophageal divertieula are produced by extrinsic traction or tenting resulting from the adherence of inflammatory mediastinal lymph nodes. The typical traction divertieulum of the mid-thoracic esophagus is conical or funnel-shaped with a wide orifice, is small (rarely exceeding 2 cm. in length), and is situated horizontally or extends superiorly. It is a true divertieulum, having a complete investment by the esophageal muscle coats. Each of these characteristics promotes easy emptying of the divertieulum. Since food accumu lation is prevented, there is no tendency to progressive enlargement of the sac, and no associated dysphagia. Pulsion divertieula of the esophagus are pear-shaped protrusions of mucosa and submucosa through a small defect in the muscle layers of the esophageal wall. Hanging dependently from a narrow neck, the divertieulum diverts food from the swallowed bolus and progressively increases in size. Dysphagia or regurgitant emptying of the diverticular contents causes the patient to seek assistance. In recent years, there have been occasional reports of symptomatic midthoracic pulsion divertieula of the esophagus with relief of dysphagia following surgical excision.7"9 Two such patients are presented in this report, and pertinent recent developments in the study of esophageal disease are discussed. ID-THORACIC
CASE REPORTS CASE 1.—W. F . C. (No. 56-16621), a 62-year-old white man, was admitted to the Methodist Hospital, Houston, Texas, on Sept. 9, 1956. The patient stated t h a t he had been in excellent health until several months prior to admission, when he began experiencing heartburn. This was described as a burning distress in the upper retrosternal region, assoProm the Cora and Webb Mading Department of Surgery, Baylor University College of Medicine, and the Methodist Hospital, Houston, Texas. Received for publication April 1, 1964. •Clinical Instructor, Cora and Webb Mading Department of Surgery, Baylor University College of Medicine; Acting Chief, Surgical Service, Veterans Administration Hospital; and Active Staff, Surgical Service, Methodist Hospital, Houston, Texas. Present address: 508 Her mann Professional Bldg., Houston 25, Texas. ••Clinical Associate Professor, Cora and Webb Mading Department of Surgery, Baylor University College of Medicine ; and Senior Attending Staff, the Methodist Hospital, Houston, Texas. 855
856
LAW AND O V E E S T R E E T
J. Thoracic and Cardiovas. Surg.
eiated with a sensation of fullness, and often followed by the vomiting of food eaten 3 or 4 hours earlier, which relieved the heartburn. The food was noted to appear as it had been when eaten, without sourness or evidence of digestion. I n the weeks immediately preceding admission, the patient had experienced several episodes of vomiting with little preceding heartburn or nausea, while shaving in the morning immediately following breakfast. The patient had not experienced the sensation of food sticking in the throat. No relationship to recumbency could be established and there had been no weight loss.
Fig. 1.—Barium contrast esophagogram of W. F. C. (Case 1) demonstrates mid-thoracic esophageal pulsion diverticulum arising from the left anterolateral aspect a t the level of the manubrio-sternal junction. The fluid level in the dependent, pear-shaped diverticulum is evident.
On physical examination, the patient was 5 feet 9 inches tall and weighed 175 pounds. There were no abnormal physical findings. Laboratory examinations were within normal limits. Barium contrast roentgenographie examination of the esophagus demonstrated a diverticulum located just below the arch of the aorta, at the level of the manubrio-sternal junction anteriorly (Fig. 1 ) . The diverticulum appeared to arise from the left anterolateral aspect of the esophagus. Barium passed through the esophagus without delay, but the diverticulum was dependent and retained barium throughout the examination. No delay or defect was noted a t the cardia, and the stomach and duodenum appeared normal. Eoentgenograms of the chest were not remarkable. Esophagoscopy demonstrated the oriflce of the diverticulum situated anteriorly and to the left a t 30 cm. from the incisor teeth. There was minimal angulation of the esophagus and the esophagoseope was easily passed by the opening. There was no evidence of an esophageal hiatal hernia. A left thoracotomy was performed on September 13. Exposure of the esophagus demon strated a diverticulum presenting anteriorly and to the left at the level of the left mainstem bronchus, approximately 4 cm. below the tracheal bifurcation. The pleura and mediastinal
Vol. 48. No. 5 November. 1964
P U L S I O X DIVERTICULA OF ESOPHAGUS
857
tissues about the diverticulum were distinctly edematous. Several adjacent lymph nodes were noted, but there was no attachment of the lymph nodes to the diverticular sae. The diver ticulum was formed of mucosa and submucosa protruding through a defect in the muscle coats of the esophagus. The sac was excised and the mucosa closed with inverted sutures. The muscular layers of the esophageal wall were then repaired. The postoperative course was uneventful, and the patient was discharged on Sept. 25, 1956. He has been free of symptoms since discharge, and there has been no evidence of recurrence of the diverticulum.
Fig. 2.—Barium contrast esophagogram of N. B. S. (Case 2) demonstrates pulsion diverticulum of the mid-thoracic esophagus arising from the right side.
CASE 2.—N. B. S. (No. 14-05-53), a 53-year-old white female schoolteacher, was ad mitted to the Methodist Hospital on June 2, 1963. The patient complained of intermittent difficulty with swallowing of about 2 years' duration. This was described as a sensation upon swallowing that the food was "swelling up and going around a bump" in the upper retrosternal region. There had been an occasional coughing spell at night while the patient was recumbent, but no recognizable regurgitation. Infrequent episodes of simple retrosternal pain were described. A barium esophagogram made in February, 1963, had demonstrated a mid-thoracic esophageal diverticulum and the patient had been placed on a bland diet with antispasmodics and antacids, and a weight reduction program. The latter had been mod erately successful, but the dysphagia had persisted unchanged. The patient had undergone several gynecologic operations in the remote past. The re maining history was unremarkable. Physical examination upon admission to the hospital demonstrated the patient to be of small stature and moderately obese, but mentally alert and in no distress. There were no abnormal physical findings. The laboratory examinations were within normal range. Barium contrast roentgenographic examination of the esophagus demonstrated a 4 by 5.5 cm. diverticulum arising from the right at the junction of the middle and lower thirds (Fig. 2 ) . The neck of the diverticulum distended to a maximum of about 1 cm. in diameter.
LAW AND OVERSTREET
858
J. Thoracic and Cardiovas. Surg.
The diverticulum was dependent and impressed the adjacent esophagus slightly, but did not interfere with the free flow of esophageal contents. Thorough examination of the cardia, stomach, duodenum, and the small bowel demonstrated no additional abnormalities. On June 4, a right thoracotomy was performed. Exposure of the esophagus demonstrated a pulsion diverticulum 6 cm. in length, arising from the right lateral aspect of the esophagus at the junction of the middle and lower thirds. No lymph nodes were present in the area of the diverticulum, and the wall of the sac had no significant attachment to adjacent structures. The neck of the diverticulum was transected and the opening was repaired with inverted sutures. The defect in the muscular wall of the esophagus was then closed. The patient's postoperative course was entirely uneventful and she was discharged from the hospital on J u n e 18. On Aug. 13, 1963, fluoroscopic examination during ingestion of barium showed no obstruction or defect in the esophagus, and films of the barium-filled esophagus confirmed the absence of narrowing or significant irregularity in the area of the mid-esophagus from which the diverticulum had been resected. The patient has been entirely free of symptoms since surgical treatment. DISCUSSION
Pulsion diverticula of the esophagus occurring in the pharyngo-esophageal and epiphrenie positions are well recognized as obscure and indolent lesions capable of producing severe dysphagia and inanition. 3 ' 10 The progressive im provement in the surgical treatment of these pulsion diverticula is well known. The common disregard of mid-thoracic traction diverticula is laudable in that it has prevented unwarranted surgical attack on these lesions, but, more im portantly, it has forced a continued search for the true cause of the patient's symptoms. It must be recognized that, while the mid-esophageal traction diverticulum does not produce symptoms of dysphagia or regurgitation, these traction diver ticula may produce symptoms related to the original mediastinal disease. 3 ' 6 Erosion of the inflammatory process into the diverticular sac may produce hemorrhage, perforation into the mediastinum with abscess formation, or per foration into the tracheobronchial tree with fistula. The occurrence of a pulsion diverticulum in the mid-thoracic esophagus contradicts concepts of long standing. As a result, the equivocal term "tractionpulsion diverticulum" has been used. 4 ' 6 However, in the 2 patients presented in this report, there was no evidence of a traction mechanism found at operation, and the pear-shaped diverticular sac in each patient was clearly a pulsion or false diverticulum. Other well-documented examples of symptomatic pulsion diverticula of the mid-thoracic esophagus have been reported.7"9- "■ 1 5 Cross, Johnson, and Gerein,11 Gahagan, 9 and others 12 ' 13 have emphasized that mid-thoracic pulsion diverticula of the esophagus are often found in con junction with disorders of esophageal peristalsis, or with lesions of the distal esophagus interfering with esophageal emptying. In recent years there has been intensive investigation of normal and deranged esophageal function through the use of intraluminal pressure and pH recordings, and esophageal functional dynamics have been correlated with these measurements with cinefluorography. With these methods, Cross and co-workers11 have documented the increased intraluminal pressures in certain patients with esophageal diverticular disease.
Vol. 48, No. 5 November, 1964
P U L S I O N DIVERTICULA O F ESOPHAGUS
859
Thus, after 120 years, there is objective documentation of the "pulsion" mecha nism postulated by Eokitansky 1 in 1840. Esophageal pulsion diverticula have been reported in association with esophageal hiatal hernia, achalasia, esophageal stricture, 10 diffuse esophageal spasm, localized esophageal muscle hypertrophy or hypertonicity, benign tumors of the esophageal wall," and the lower esophageal mucosal flap (described by Effler13). Certainly the esophageal diverticulum may represent only one aspect of the patient's disordered esophageal function. Simple excision of the diverticu lum without simultaneous correction of associated or underlying problems may result in disruption of the esophageal repair, recurrence of the diverticulum, or in continuation of symptoms. It is unlikely that every patient with an esophageal diverticulum will be found to have associated abnormalities. It is difficult to support the recent recommendation by Belsey15 that esophageal myotomy must be included in the treatment of every esophageal diverticulum, or persistence of symptoms or recurrence of the diverticulum is inevitable. The recurrence rates in the collected series of diverticulectomy tabulated by Postlethwait and Sealy6 and the clinical course of the present 2 patients suggest that excellent results follow simple diverticulectomy if no other abnormality is present. It is necessary to re-emphasize that each patient with esophageal diverticular disease, and especially the patient with a mid-thoracic pulsion diverticulum, must be thoroughly evaluated for the presence of other esophageal abnormalities. If associated lesions are discovered, it is mandatory that they be corrected simultaneously with diverticulectomy. SUMMARY
The cases of 2 patients are reported; each had a typical pulsion diverticulum of the mid-thoracic esophagus. No associated esophageal abnormalities were present. Symptoms of dysphagia and regurgitation were completely relieved by excision of the diverticula. Eeeent developments in the study of esophageal disease are briefly reviewed. The frequency of other esophageal abnormalities associated with esophageal diverticula is emphasized. REFERENCES 1. Rokitansky, C.: Spindelformige Erweiterung der Speisrolire, Med. Jahrb. d. k. k. osterr. Staates 2 1 : 219-222, 1840. (Cited by De Bakey et a U ) . 2. Zenker, F . A., and von Ziemssen, H . : Diseases of the Esophagus in Cyclopedia of the Practice of Medicine, New York, 1878, William Wood & Co., vol. 8, pp. 51-89. (Cited by De Bakey et al.3). 3. De Bakey, M. E., Heaney, J . P., and Creech, O.: Surgical Considerations in Diverticula of the Esophagus, J . A. M. A. 150: 1076, 1952. 4. Naclerio, E. A . : Diverticula of the Thoracic Esophagus, Am. J . Surg. 9 3 : 218, 1957. 5. Mustard, R. A.: Diverticula of the Esophagus, Canad. M. A. J . 76: 822, 1957. 6. Postlethwait, E. W., and Sealy, W. C : Surgery of the Esophagus, Springfield, 111., 1961, Charles C Thomas, Publisher, pp. 104-132. 7. Harrington, S. W.: The Surgical Treatment of Pulsion Diverticula of the Thoracic Esophagus, Ann. Surg. 129: 606, 1949.
860
LAW AND OVEESTREET
J. Thoracic and Cardiovas. Surg.
8. Maier, H. C.: Dysphagia From Diverticulum of the Mid-Thoracic Esophagus, Gastroenterol. 2 3 : 318, 1953. 9. Gahagan, T.: Diverticula of the Thoracic Esophagus, Henry Ford Hosp. M. Bull. 10: 449, 1962. 10. De Bakey, M. E., and Creech, O.: Surgical Treatment of Epiplirenic Diverticulum of the
Esophagus, J .
THORACIC SURG. 23:
486,
1952.
11. Cross, F . S., Johnson, G. F., and Gerein, A. N . : Esophageal Diverticula, A. M. A. Arch. Surg. 83: 525, 1961. 12. Habein, H. C , Kirkland, J . W., Clagett, O. T., and Moersch, H. J . : Surgical Treatment of Lower Esophageal Pulsion Diverticula, A. M. A. Arch. Surg. 72: 1018, 1956. 13. Effler, D. B., Barr, D., and Groves, L. K . : Epiplirenic Diverticulum of the Esophagus, A. M. A. Arch. Surg. 79: 459, 1959. 14. Razin, E., and Adler, E. H . : Association of Benign Esophageal Tumors and Diverticula, New York J . Med. 62: 2554, 1962. 15. Belsey, R.: Functional Disease of the Esophagus, Postgrad. M. J . 39: 290, 1963.