Diverticula of the mid‐ and lower esophagus: Pathogenesis and surgical management

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Abstract
Ten patients with diverticula of the mid‐ or lower esophagus are reviewed with a focus on esophageal function, particularly motility, and its relation to surgical treatment. Median age is 56 years (range 16–79). There are 5 males and 5 females. The predominant symptoms were dysphagia and regurgitation, generally of 3 to 4 years' duration. All diverticula were identified by both barium upper gastrointestinal tract series and endoscopy. Three patients had 2 diverticula. The lower esophageal high pressure zone (LEHPZ) was assessed manometrically in 7 patients and the function of the esophageal body in all. LEHPZ pressure, length, and relaxation were normal in 4 patients, incomplete relaxation was present in 1 patient, and 2 had increased pressure. All 10 had abnormal esophageal body function including abnormalities of amplitude, duration, or propagation of contractions. pH assessment for reflux and clearance was performed in 4 patients. The acid clearance test was abnormal in all 4, and 2 patients had gastroesophageal reflux. One patient was managed medically and the other 9 surgically. Surgical treatment included diverticulectomy, myotomy, and an antireflux procedure in 7 patients; diverticulopexy, myotomy, and antireflux procedure in 1, and myotomy and antireflux procedure in 1. There was no operative mortality. Longterm clinical results are good. We conclude that symptomatic midesophageal and epiphrenic diverticula are caused by an abnormality of esophageal body or LEHPZ function which can be identified manometrically. These should, therefore, be thought of as pulsion diverticula. Surgery that addresses the underlying motor disorder can be performed safely and provides relief of symptoms.