Epiphrenic diverticulum

Epiphrenic diverticulum

Epiphrenic diverticula, arising from the esophagus in its lower segment, are uncommon. I have seen only five instances of this curious outpouching. All the patients were past 60 years. Each one was located about 2 to 3 inches above the diaphragmatic hiatus, just proximal to the pinchcock segment of the distal esoph­agus, thus duplicating the mechanism of formation seen in the cervical segment of the organ. There undoubtedly must exist a defect in the esophageal wall, whether congenital in origin or due to brown atrophy of the musculature, which permits protrusion of the mucosa to take place. In time the diverticulum enlarges, usu­ally toward the right side of the posterior mediastinum, abutting against the light mediastinal pleura. These sacs are, as a rule, of globular shape and loosely. iltached to the surrounding areolar tissue. The neck at the site of emergence from I he esophagus is considerably larger than that seen in Zenker’s diverticulum.

The symptoms exhibited by these patients vary with the stage of development and size of the sac. In the beginning, there is a vague and occasional lower substernal dysphagia accompanied by mild discomfort. With an increase in the size of the diverticulum, retention of food in the sac produces regurgitation, especially during l he night. Putrefaction of the retained food causes unpleasant breath. When the sac reaches large proportions, it may produce esophageal obstruction by compression within the mediastinum. Anorexia and weight loss are usually associated with the latter stages of the enlarging process. As with cervival diverticula, aspiration of retained food may cause repeated attacks of pneumonitis.

Roentgen examination after swallowing a barium mixture usually discloses Ihe exact nature of the process (Fig. 10). It is a necessary aid in establishing the diagnosis. I am opposed to esophagoscopy either before or instead of x-ray examina­tion. Once the diagnosis is established by roentgenography, esophagoscopy becomes unnecessary. It adds little, if any, information to that already disclosed by the films, liesides, esophagoscopy is not without considerable danger from the standpoint of instrumental perforation. It is quite easy to push the esophagoscope into the sac through its wide neck.

The decision to operate for this condition will depend largely on the stage of Ihe disease when the patient is first seen, the size of the diverticulum, and the sever­ity of the symptoms. If the sac is small, it is doubtful if operation should be under­taken because the diverticulum may never reach large proportions. Regulation of eating habits with the administration of antispasmodics may produce symptomatic relief. When a large sac is disclosed by x-ray examination and the symptoms are severe and persistent, operative correction should be undertaken.

Operative Technique. In spite of the fact that the diverticulum usually pro­jects toward the right side, I have employed the left transthoracic approach for the simple reason that should a more extensive procedure become necessary or should there also be present a coexisting hiatus hernia, the technical details of the operative correction would be much easier. It must be remembered that from the left side the lower esophagus can be rotated with ease, thereby approaching the simplicity of a right-sided approach. The patient is placed on the operating table on his right side and fixed in this position as described in the section on carcinoma of the esophagus. By breaking the operating table somewhat at the level of the lower thoracic cage, the intercostal spaces are made wider and the mediasti­num is brought closer to the surgeon. However, he must not forget to have the table straightened when the chest wound is to be closed.

esophagus disclosing

Fig. 10. Roentgenogram of the esophagus disclosing the presence of large epiphrenic diverticulum.

There is also present a traction diverticulum in the middle of the organ.

A long incision is made over the left eighth interspace. The musculature is sev­ered and all divided vessels are carefully ligated. With operative incisions of this size, I have always employed an all-silk technique. The reason for this is that, with the myriad of ligatures that are required for complete hemostasis, there is practically 110 accumulation of serum postoperatively as compared with the appreciable collec­tions that follow the use of similar quantities of catgut. I am certainly not favorably impressed with the appearance of such wounds that electrocoagulation is used for hemostasis instead of ligatures. The routine use of the Bovie machine for hemostasis has always suggested innate laziness on the part of the surgeon.

The incision in the interspace should be exactly between the contiguous ribs. This avoids injury to the intercostal vessels and preserves the intercostal muscles for later closure. The wound edges are covered with thick toweling, and a rib – spreader is inserted. If the surgeon now opens the spreader gradually over a period of eight to ten minutes, one notch at a time, he will obtain a wide opening of the chest without breaking the eighth or ninth ribs. If he does it hurriedly, one or both ribs will invariably be fractured. This makes for a more painful convalescence. The inferior pulmonary ligament is divided and the lung retracted cephalad. An incision is now made in the mediastinal pleura overlying the lower esophagus, which is then bluntly mobilized from the mediastinum. A Penrose tube is placed about it for traction purposes. The sac is now grasped and gradually separated from its areolar attachments until it emerges from the esophagus at the broad neck. Injury to the vagus nerves should be avoided.

The pleural cavity and wound are now covered with moist towels to set up a “dirty field.” The sac is removed piecemeal from one end of the neck to the other in exactly the same manner as described for Zenker’s diverticulum. The mucosal sutures are inverted toward the lumen (Fig. 11). A firm muscle repair is essential. However, these sutures should not be tied too tightly because it is easy to cut through the musculature in this region. The “dirty field” is discarded after the mucosal closure is completed. The cut edges of the mediastinal pleura are now loosely approximated over the esophagus, and the chest wound is ready for closure. A soft rubber tube is inserted into the chest through a stab wound in a subjacent intercostal space. The eighth and ninth ribs are approximated with two Bailey clamps, and the anesthetist is instructed to inflate the lung until it hugs the rib cage. I discarded the use of periscostal approximating sutures years ago because of the appreciable incidence of postoperative intercostal neuralgia. Instead I place interrupted 00 silk sutures in the external intercostal muscles, thus avoiding any injury or suturing of the intercostal nerves. Since the adoption of this technique, intercostal neuralgia has all but disappeared. I am emphasizing this point of technique because it is not generally appreciated. The Bailey approximating clamps are now removed, and the thoracic musculature is repaired carefully in layers. During the closure of the chest wound, the anesthetist maintains expansion of the lung until the dressing is applied. Underwater drainage through the intercostal chest tube is maintained until its removal on the sixth or seventh day. It need hardly be emphasized that this tube should be securely fastened to the water bottle to prevent inadvertent displacement during the postoperative period.

Postoperative care of the patient follows the same routine as described in the previous section. I never use an indwelling Levin tube because its presence in the vicinity of an esophageal suture line may produce pressure necrosis. As a matter of record, I saw two examples of this complication in consultation not too many years ago. In each instance, postmortem examination disclosed the Levin tube resting in a trough of necrotic tissue at the suture line following esophagectomy for carcinoma. I purposely leave the underwater drainage tube for five to seven days as a vent for possible suture line leakage. The appearance of gastric contents in the drainage calls for immediate exploration of the mediastinum. However, this should rarely, if ever, occur following the operation just described.

Fig. 11. Diagrammatic representation of the method of excision of an epiphrenic diverticulum and repair of the esophagus in two layers.

 

 

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