Cardiovascular and Thoracic Surgery

ALERT BAR

Esophageal Duplication Cyst

An esophageal diverticulum is a pouch that protrudes outward in a weak portion of the esophageal lining. This pocket-like structure can appear anywhere in the esophageal lining between the throat and stomach.

Esophageal diverticula can affect people of all ages, although most cases occur in middle-aged and elderly individuals. Overall, esophageal diverticula are rare, showing up in less than 1 percent of upper gastrointestinal X-rays and occurring in less than 5 percent of patients who complain of dysphagia (difficulty in swallowing).

Typically, esophageal diverticula are nuisances that enlarge slowly over many years, gradually producing increasing symptoms, such as dysphagia, regurgitation and aspiration pneumonia, caused by breathing in regurgitated diverticula content. When symptoms of esophageal diverticula worsen, a person may be unable to swallow due to an obstruction near the diverticulum; rarely, the esophagus may rupture. An obstruction or rupture caused by an esophageal diverticulum is dangerous, and both complications require immediate attention.

Regurgitation caused by a diverticulum often occurs at night when lying down, which can lead to choking, aspiration pneumonia (a lung infection caused by pulmonary aspiration, the entry of secretions or foreign material into the trachea and lungs), and lung abscesses.
Although rare, squamous cell carcinoma can develop in 0.5 percent of those with diverticula. This is thought to be caused by chronic irritation of the diverticula by prolonged food retention. It is important to note that the fear of cancer is not a reason to surgically treat diverticula.

Symptoms

It is believed that the internal pressure produced by the esophagus to move food into the stomach can herniate the esophageal lining through a weakened wall, creating a pouch or a diverticulum. There is usually distal end obstruction. Esophageal diverticula are more common in people who have motility disorders of the esophagus, such as achalasia, that cause difficulty in swallowing, regurgitation of food, and, in some people, a spasm-type pain. The symptoms of esophageal diverticula include:

  • Dysphagia (difficulty swallowing, characterized by a feeling of food caught in the throat)
  • Pulmonary aspiration (the entry of secretions or foreign material into the trachea and lungs)
  • Aspiration pneumonia (a lung infection caused by pulmonary aspiration)
  • Regurgitation of swallowed food and saliva
  • Pain when swallowing
  • Cough
  • Neck pain
  • Weight loss
  • Bad breath (halitosis)

Some people may experience a gurgling sound as air passes through the diverticulum. This is known as Boyce's sign.

Tests

The tests most commonly used to diagnose and evaluate esophageal diverticulum include:

  • Barium swallow: The patient swallows a barium preparation (liquid or other form) and its movement through the esophagus is evaluated using X-ray technology.
  • Gastrointestinal endoscopy: A flexible, narrow tube called an endoscope is passed through the gastrointestinal tract and projects images of the inside onto a screen.
  • Esophageal manometry: This test measures the timing and strength of esophagus contractions and muscular valve relaxations.
  • 24-h pHmetry: A test to check for the presence of gastroesophageal reflux disease (GERD).
Treatment

Cases of esophageal diverticulum that cause minor symptoms can be treated through lifestyle changes, such as eating a bland diet, chewing food thoroughly, and drinking plenty of water after meals. If symptoms become severe, several types of surgery are available to remove the diverticula, repair the defects and relieve a patient’s symptoms and improve their quality of life.

Treatment of diverticula require:

  • An examination of the diverticula;
  • Repair of the weakened wall; and
  • Relief of obstruction

The type of surgical treatment recommended depends on the size and location of diverticula, and include:

  • Cricopharyngeal myotomy: Used in the removal of small diverticula, this surgical treatment can be completed using an open or minimally invasive approach, known as transoral robotic surgery. During transoral robotic surgery, the robot's precise wrist-like action allows surgical removal of the tumor by working in multiple directions in tight spaces with the capability to work around corners. Guiding the surgery from the command console, the surgeon uses 3-D imaging and instruments attached to the robotic arms, which improves precision
  • Diverticulopexy with cricopharyngeal myotomy: Used to remove larger diverticula, this procedure involves turning the diverticular sac upside down and suspending it by suturing it to the esophageal wall.
  • Diverticulectomy and cricopharyngeal myotomy: Diverticulectomy for the treatment of Zenker's diverticula (the most common type of diverticula of the esophagus; Zenker’s diverticula are usually located in the back of the throat, just above the esophagus) has been performed for almost a century. Involving a complete excision of the diverticular sac, this procedure is recommended for diverticula greater than 4 centimeters in size.
  • Endoscopic diverticulotomy (Dohlman procedure): This procedure divides the septum between the cervical esophagus and the diverticular pouch. By dividing the septum, food can freely drain from the pouch to the esophagus.

Minimally invasive (Laparoscopic) approaches, such as endoscopic diverticulotomy, offer patients many benefits, including:

  • Limited number of small scars instead of one large abdominal scar
  • Shorter hospital stay
  • Reduced postoperative pain
  • Shorter recovery time
  • Quicker return to daily activities, including a regular diet

Your health care team will discuss the possible risks and benefits of each procedure with you.