Pharyngo-Esophageal Diverticulum: Its Management and Complications* Frank H

PHARYNGO-ESOPHAGEAL DIVERTICULUM: ITS MANAGEMENT AND COMPLICATIONS* FRANK H. LAHEY, M.D. DEPARTMENT OF SURGERY, THE LAHEY CLINIC BOSTON, MASSACHUSETTS THE SUBJECT of pharyngo-esophageal diverticulum has been discussed over the years by various authors, and the principles involved with the occur- rence and with the management of this lesion have now been very well estab- lished. In spite of this fact, the number of surgeons who have had a relatively large experience with this lesion is fairly limited and it, therefore, seems to me to be of value for those who have had these experiences with this lesion to discuss them and to report the views, accumulated with them. Pharyngo-esophageal diverticula are known to originate quite consistently at the same level, that is the junction of the esophagus with the pharynx. They are known to be related to the anatomy of this point and are brought about by the relationship between the inferior constrictor muscle and the obliquely passing fibers of the cricopharyngei as they descend upon the posterior wall of the esophagus to become longitudinal. As may be seen in the diagrammatic illustration (Fig. i), the obliquely passing fibers of the cricopharyngei form a triangular space bounded above by the lowest fibers of the inferior constrictor and on each side by the oblique fibers of the cricopharyngei. This is known as the pharyngeal dimple and is the weak place in the posterior wall at the pharyngo-esophageal junction. The neuromuscular co6rdination which brings about propulsion of food from the pharynx into the esophagus acts normally when with contraction of the constrictors the cricopharyngei relax to permit propelled food to pass into the esophagus. When there is any incoordination in this neuromuscular effort, the pressure from the constrictors and the obstruction below from the unre- laxed cricopharyngei will obviously result in a bulge at the point known as the pharyngeal dimple (see Fig 2 a, the first stage of the esophageal diverticulum). As this co6rdination continues to produce recurring pressure upon this weak point, what was originally a bulge soon becomes a sac since the bulging pharyngeal wall is made up, in this, a false diverticulum, only of mucosa and submucosa and is covered by but a few of the remaining fibers of the cricopharyngei. As the bulge converts itself into a sac the course of the sac as it enlarges is in the downward direction under the few enveloping fibers of the cricopharyngei, and as the sac becomes more frequently distended with food, and has for its walls only the readily stretched mucosa and submucosa, this sac *Read before the American Surgical Association, April 2-4, I946, Hot Springs, Virginia. 617 FRANKFRANKH.H.LAHEY ~~~October,Annalo of SurgeryIV46 progressively increases in size until it is in a dependent position parallel with the esophagus, with a true sac body, a true neck, and a small aperture in the midline opening into the true esophagus. This is well illustrated by Figure 2 b, the second stage of the development of a pulsion pharyngo-esophageal diverticulum. With further passing of time and the accumulation of greater amounts of food within the sac and so greater distention of the sac, together with the effect of ascending and descending with swallowing, further enlargement of the sac is in the downward direction into the superior mediastinum until the size of the sac can reach good-sized proportions, illustrated as the third and final stage of the development of pharyngo-esophageal diverticulum (Figs. 1 c 6 / ~~~~~~2and io). We have learned from this experience with these cases that each stage of this disease has with it a group of symptoms brought about by the stage of development of the diverticulum. For example, in stage i (Fig. 2 a), that is, when there is merely a bulge, i2- ,> Ie~nferlor Corm of t.t there are no symptoms except those Thyrotl CartUa¶. related to the occasional lodging of a Po;nt of Or,gtn Of dry piece of bread or cereal within l LvertLculum this bulge, which results in recurring attempts of the patient to dislodge it by hawking. There are no other symptoms related to this stage of the diverticulum, and because there is no FIG. i.-Diagrammatic illustration of neck to the sac and it is only a bulge, aniatomy at the point of origin of the operation is neither necessary nor ad- diverticulum. visable. The symptoms related to the second stage (Fig. 2 b) are merely those associated with the presence of a sac and to the fact that this sac constantly has contents made up of food mixed with air and mucus. It is to be remem- bered that an esophageal diverticulum is a sac placed in front of the preverte- bral fascia and behind the pretracheal fascia, that it ascends and descends with swallowing, and that its contents are variable in amount so that the degree of distention within the sac is variable. It is to be recalled also that the sac rests posteriorly upon a rigid structure, the vertebral bodies, and is covered in front by the sternomastoid, omohyoid, sternothyroid, and the overlying thyroid gland. With this anatomy in mind, one can realize how, with changes in position of the neck and chin, there are changes in pressure on the fluid and air filled sac by these overlying structures against the nonresistant posterior boundary. This produces unpredictable expulsion of food and mucus which can come up into the mouth anytime during the day or night. In addition to 618 Volume 124 Number 4 PHARYNGO-ESOPHAGEAL DIVERTICULUM this, as a result of pressure upon the sac as it ascends and descends with swallowing, the mixture of air with food and mucus can produce gurgling noises which are audible to friends of the patient who eat at the table with him and which at times occasion embarrassment for the patient, since inquiries are frequently made as to the causes of obvious noises in the patient's throat as he swallows. Since with change in position the contents of the sac can be unexpectedly expelled into the pharynx, it is also obvious that changes in position at night b FIG. 2.-a, Note that this is the first stage of esophageal diverticulum, shown diagram- matically by the bulge in insert Iand by the roentgenogram. Note absence of any sac. b, In this illustration is shown the second stage of esophageal diverticulum with a true sac. Note that the opening into the esophagus at this stage is longitudinal while the opening into the sac is lateral. c, This illustration graphically demonstrates why obstructive symptoms occur at the third stage of development of a diverticulum. Note that the direct opening is now into the sac of the esophagus, its opening being transverse, while the opening into the true esophagus is now lateral (see insert 3). The thin stream of barium can be seen overflowing from the sac through the laterally placed opening into the true esophagus. with the head and neck at various angles on the pillow, can bring about unpredictable expulsion of the sac contents into the pharynx with occasional inspissation of the contents, strangulation, and the danger of lung abscess. Many of these patients have come to us seeking operation because of some of these above stated features, because they are so embarrassed with the noise they make in their throat when swallowing, because they have so frequently been awakened at nigh-t by the expulsion of food that it interferes with their sleep, and because in four cases the inspissation of food has produced lung abscesses. All of the symptoms associated with the second stage of the development of this condition just spoken of can be associated with the third stage (Fig. 2 c) of the development of pharyngo-esophageal diverticulum, that is, the stage with the large sac. This stage is, however, distinguished by the fact that it is only at this stage that obstructive symptoms occur. I wish particularly to discuss the cause of obstruction at this stage in order that anyone dealing with a patient with a large pharyngo-esophageal diverticulum of the third 619 Annals of Surgery FRANK H. LAHEY October, 1946 stage will understand its cause and its management, particularly as relates to attempting to pass an esophagoscope or attempting to introduce a feeding tube preoperatively before the sac has been freed and completely dissected and especially because of the danger of attempting to pass a bougie at this stage. When we first began to operate upon patients with large esophageal diverticula who had obstruction, it was my impression that the obstruction was FIG. 3.-A further excellent illustration of stage 2. Note the well formed sac with a neck, the lateral opening and the true esophagus outlined by dots. probably due to the pressure of the very large, filled sac against the lateral esophagus. It was some time before I realized that this was not the case. In stage two when the sac is first developed and is of only moderate size, it will be seen, as illustrated in Figures 2 b and 3, that the opening into the sac is on the lateral wall of the esophagus and that the opening into the true esophagus is in the normal transverse position. However, as this sac enlarges, and as a result of its enlargement together with the weight of its contents, descends into the mediastinum it drags the lateral wall of the esophagus down- 620 Volume 124 Number 4 PHARYNGO-ESOPHAGEAL DIVERTICULUM ward with it and, as shown in Figure 2 c, converts the opening into the diverticulum sac into a semitransverse one and the opening into the true esophagus into a semilateral one (Fig.

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