ESOPHAGEAL DIVERTICULA

Is a completely epithelial-lined blind pouch or pocket leading from the main lumen of the esophagus

Classification

type protrusion of mucosa and submucosa Traction type pulling outward of the esophageal wall
Pulsion

I.
Pharingoesophageal (ZENKER) diverticulum

Clinical Findings
A.Symptoms and signs - dysphagia - undigested food regurgitation - manually massage of the neck to empty the sac - gurgling sound in the neck - halitosis, metallic taste

Clinical Findings
B. Imaging study - barium - endoscopy - manometry and ph studies - CT scan

Radiology

Endoscopy

CT scan

Manometry

Essentials of diagnosis
Dysphagia,

pressure symptom and gurgling sound in the neck Regurgitation of undigested food, halitosis. Manual emptying of the diverticulum by the patient

Differential Diagnosis
Malignant

lesions Achalasia of the cricofaringeus muscle Cervical esophageal webs

Complications
tracheobronchial irritation and pneumonitis Perforation mediastinitis, paraesophageal abcess Bleeding
Aspiration

Treatment

Surgery is the treatment of choice

cricopharyngeal miotomy diverticulectomy

RESULTS
Postoperative

complications - are rare recurrent nerve palsy esophagocutaneus fistula Able to eat day after surgery

II.
Thoracic diverticulum

General considerations

Lower

third localisation Associated with motility disturbance Frequently lunch

Clinical findings

A. Symptoms and signs B. Imaging studies -dysphagia -radiology -regurgitation -manometry -aspiration -pulmonary symptoms

Epiphrenic diverticulum

Epibroncheal diverticulum

Epiphrenic diverticulum

Essentials of diagnosis
Dysphagia

and pressure sensation in the lower esophagus after eating Vomiting, substernal pain Radiology Disturbed motility of the lower esophagus Associated hiatal hernia on occasion

Differential diagnosis
Achalasia Hiatal

hernia Benign or malignant stenosis

Complications
Esophagitis Periesophagitis Bleeding Perforation - rarely

Surgical treatment

Prognosis

Successful in 80 90 % of cases

Laparoscopic aproach

Traction diverticulum

Appears to parallel that of specific inflamatory disease Symptmatology occasionally

ACHALASIA

General consideration
Neuromuscular

disorders with esophageal dilatation without organic stenosis Cardiospasm Sir Cooper Perry, Thomas Willis

Ethiopatogeny
Abscense, atrophy, disintegration of the ganglion cells of Auerbachs myenteric plexuses Two theories - degenerative disease of the neurons - infection Chagas disease Peak years 3060; affects more males

Clinical Findings
Dysphagia Retention Pain Regurgitation Aspiration

of ingested food

Imaging studies

Radiology

Endoscopy
Manometry

Manometry

Endoscopy

Essentials of diagnosis
Dysphagia Retention of ingested food Radiology - absent primary peristalsis - dilated body of esophagus - conically narrowed cardioesophageal junction Manometry absent primary peristalsis

Differential diagnosis
Benign

strictures Cardioesophageal junction carcinoma Epiphrenic diverticulum

Complications
Mucosal Bleeding Aspiration

ulcerations

- pneumonitis, - tracheobronchitis Malnutrition mild to moderate Malignant degeneration 3-5% squamous cell

Treatment
Surgery Heller myotomy Open laparatomy or thoracotomy Laparoscopy Thoracoscopy Dilatation Medical calcium channel blockers

Laparoscopic Heller procedure

Technique

Technique

Technique

Prognosis

85-90% good results