Ann Thorac Surg 2001;71:1692-1694
© 2001 The Society of Thoracic Surgeons
Case report
Giant midesophageal pulsion diverticulum: a report of two operated cases
Sivert Svane, MDa,*
a Department of Surgery, Buskerud Central Hospital, Drammen, Norway
Accepted for publication June 21, 2000.
* Address reprint requests to Dr Svane, Department of Surgery, Buskerud Central Hospital, 3004 Drammen, Norway
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Abstract
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A giant midesophageal pulsion diverticulum is a medical rarity. Two successfully operated cases are reported. One patient had no clinical symptoms and was misinterpreted as a mediastinal tumor. Esophageal myotomy was not performed.
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Introduction
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Most diverticula of the midesophagus (epibronchial diverticula) are incidental findings and considered asymptomatic. They are usually less than 3 cm in length and have the same wall layers as the esophagus. These types are traditionally referred to as traction diverticula, but recent investigations indicate that motility disorders are the main causes [1]. Thus, esophagomyotomy and antireflux procedures are recommended concomitant to diverticulum extirpation [2].
Far less often, pulsion diverticula are found in the same area of the esophagus [3]. With a 10-year interval, we have observed two cases of giant midesophageal pulsion diverticula. Such cases are very rare in medical literature.
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Case reports
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Patient 1
The first patient was a 67-year-old, previously healthy man. He strongly denied having any problems with swallowing or digestion, and had no pulmonary symptoms. An occasional chest radiography showed an increase in breadth on the right side of the mediastinum (Fig 1). At that time, computed tomography (CT) was not available. A barium swallow was not carried out. The final clinical diagnosis after tomography and bronchoscopy was a tumor of the mediastinum. On right-sided thoracotomy, a pulsion diverticulum the size of a large orange was found in the middle section of the intrathoracic esophagus. Proximal to the neck of the diverticulum, the esophagus was obviously dilated. The opening in the esophagus measured 2.5 x 2.5 cm and was situated 5.5 cm below the tracheal bifurcation. The lower part of the esophagus appeared normal. The diverticulum was extirpated in toto with closure of the mucosa and submucosa with two layers interrupted chromic catgut sutures. The peripheral muscle fibers were pulled over the row of sutures. A small area of the mediastinal pleura was left open for drainage. The esophageal passage was controlled with a thick gastric rubber tube inserted through the mouth. Esophageal myotomy was not performed. The diverticulum was almost full of foul smelling, decomposed quite large pieces of meat, peas, and fragments of vegetables. Histologically, the diverticular wall was composed of stratified squamous epithelium and intact submucosa. Only scattered pieces of the outer muscular coat were detected. There was considerable chronic inflammatory reaction. In the following 15 years, he still had no problems with eating and swallowing. Barium swallows showed an ordinary caliber of the esophagus with rapid passage of the contrast into a normal stomach.
Patient 2
The second patient was an 83-year-old woman who had never been seriously ill. She had developed a remarkable thoracic kyphosis secondary to osteoporosis. When she was about 80 years old, she got increasing problems with swallowing combined with retrosternal pain at mealtimes. Finally she could only take fluid nutrition. A barium swallow revealed a giant midesophageal diverticulum (Fig 2), while the lower part of the esophagus and the stomach appeared normal. On right-sided thoracotomy, rather far back, there was a midesophageal pulsion diverticulum with the shape and size of a medium-sized lemon. Proximal to the diverticulum, the esophagus was somewhat dilated. The opening in the esophagus corresponding to the diverticular neck measured 2 x 1.5 cm and was situated approximately 6 cm below the tracheal bifurcation. The diverticulum was empty. It was extirpated using the same procedure as described in the previous case. Esophageal myotomy was not performed. The main features of the histologic picture were fairly similar to the findings in the previous case. The operation as well as the postoperative period were surprisingly uncomplicated. Swallowing gave no problems in the following nine years. Barium swallows showed rapid passage to a normal stomach without signs of stenosis or recurrence.
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Comment
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A review of the literature after 1925 gives the clear impression that there are only a very few scattered accounts of midesophageal (epibronchial) giant diverticula [4–11]. A precise localization of the anatomical point of origin of these giant diverticula cannot be established on the basis of the available data, but it seems to be 5 to 7 cm distal to the tracheal bifurcation. The age of 11 reported patients (our cases included) varied between 35 and 91 years with a mean of 69 years. There was no gender difference.
A convincing etiological explanation of the pulsion diverticula in this characteristic section of esophagus has not been found [7]. It has been assumed that there must be a weak point, possibly because of a congenital defect in the esophageal wall. The importance of a large and long-lasting consumption of alcohol has also been stressed [3, 9]. It is likewise an open question as to how long it takes for a giant midesophageal diverticulum to develop. The contents of these diverticula are practically never mentioned in literature [9]. Our cases indicate that the diverticulum may be empty or filled with decomposed food remains. In the literature, we have found only one case where histologic examination was performed with demonstration of an ulceration [8]. Considerable chronic inflammatory changes were found in our cases.
Most patients with giant midesophageal diverticulum have chest pressure and discomfort as the main symptom [5, 7, 8, 10, 11]. Abdominal pain and dyspepsia may occur [4, 6]. Like our second case, dysphagia and loss of weight have also been reported [9]. Our first case allegedly had no symptoms, and was misinterpreted as a mediastinal tumor. A similar case has been observed [10].
In addition to our cases, we have found another four successfully operated cases of giant midesophageal pulsion diverticulum in the literature [5, 8, 10, 11]. Prophylactic myotomy was only performed in one of these cases [10]. In our cases, too, we were surprised at the peaceful postoperative course with return to normal swallowing function without signs of esophageal motor dysfunction, cardiospasm, reflux problems or recurrence 12 and 9 years respectively after the operation. These facts are in contrast to our experience with the more frequent epiphrenic pulsion diverticula, which are usually associated with functional motor disturbances demanding myotomy. The same applies to the surgical treatment of the midesophageal diverticula of the so-called traction type. In our opinion, it is questionable whether myotomy should be performed as a routine in the surgical treatment of the midesophageal pulsion diverticulum. Preoperative esophageal manometry may probably indicate the optimal surgical procedure.
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References
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- Kaye MD. Oesophageal motor dysfunction in patients with diverticula of the mid-thoracic oesophagus Thorax 1974;29:666-672.[Abstract/Free Full Text]
- Evander A, Little AG, Ferguson MK, Skinner DB. Diverticula of the mid- and lower esophagus. pathogenesis and surgical management. World J Surg 1986;10:820-828.[Medline]
- LeCount ER. Epibronchial pulsion diverticula of the esophagus Chicago Pathol Soc Trans 1915;10:35-37.
- Billiard, Decoularé-Delafontaine. Gros diverticule intra-thoracique de l’oesophage. J Radiol (Paris) 1926;10:508–10.
- Barrett NR. Diverticula of the thoracic oesophagus Lancet 1933;1:1009-1011.
- Cassou R, Raymond P. Diverticule géant de l’oesophage thoracique simulant un hydropneumothorax enkysté, avec mégaoesophage Arch Mal Digest (Paris) 1950;39:611-614.
- Shaw HJ. Diverticula of the thoracic oesophagus J Laryngol Otol 1954;68:70-81.[Medline]
- Jonasson OM, Gunn LC. Midesophageal diverticulum with hemorrhage Arch Surg 1965;90:713-715.[Medline]
- Etherington RJ, Clements D. Giant mid-oesophageal diverticulum. a rare cause of dysphagia. Br J Radiol 1990;63:221-222.[Abstract/Free Full Text]
- Arana E, Latorre FF, Diaz C. Diverticulos gigantes de esófago medio apareciendo como masas mediastinicas en radiografias de tórax Arch Bronconeumol 1995;31:44-45.[Medline]
- Trempe F. Large pulsion diverticulum of the middle third of the thoracic oesophagus Can Med Assoc J 1955;73:38-39.
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Abstract
Introduction
