Western definition of esophageal diverticulum: Esophageal diverticulum is a limited centrifugal outgrowth of the esophageal wall with the main symptoms of dysphagia and food reflux, and is one of the common benign esophageal diseases. It can occur singly or in any part of the esophagus. The most common sites are at the junction of the pharynx and esophagus, near the bifurcation of the flat trachea in the middle part of the esophagus, and in the supra-diaphragmatic part of the esophagus. Choke diaphragm in Chinese medicine is defined as a disorder to choke on food or vomit when eating.
Prevalent population: male is more common, and most of the age of onset is older.
The common location of pharyngoesophageal diverticula is slow or other motor abnormalities that cause mucosal expansion and diverticula formation on the basis of the above anatomy.
Supradiaphragmatic diverticulum: It is also a bulging diverticulum, and the diverticulum wall has only mucosal and submucosal layers, very middle esophageal diverticulum, which can be bulging or evolutive, mostly evolutive diverticulum, middle esophageal bulging diverticulum is completely similar to supradiaphragmatic diverticulum in etiology and performance, while evolutive diverticulum is due to scar traction caused by parabronchial lymph node inflammation or tuberculosis, which has the whole layer of esophageal tissue, including mucosa, submucosa It has the entire tissue of the esophagus, including the mucosa, submucosa, and muscle layer, with a wide neck and narrow base resembling a tent. The traction diverticulum occurs mostly in the anterior and right wall of the esophagus at the tracheal bifurcation. Some authors have suggested that some of the mid-esophageal diverticula unrelated to esophageal motility abnormalities are congenital intestinal-derived cysts or pseudoesophageal diverticula, which are rare and of uncertain etiology.
The pathological changes are due to dilated submucosal glandular ducts of the esophagus, and the lesions are confined to the submucosa and do not involve the esophageal musculature. The dilated glandular ducts are cystic in shape, surrounded by chronic inflammation and may have small abscess formation. Inflammatory changes and squamous epithelial metaplasia in the adenohypophyseal duct can narrow or completely obstruct the lumen, leading to proximal dilatation and formation of a pseudodiverticulum. Due to chronic inflammation, fibrosis of the submucosa of the esophagus causes thickening of the esophageal wall, stiffening and narrowing of the lumen. Pseudodiverticula can involve the entire length of the esophagus, but are more commonly found in the upper esophagus, which is consistent with the distribution of submucosal glands in the esophagus. Many patients with pseudodiverticulosis also have diabetes mellitus.
Clinical manifestations of pharyngoesophageal diverticula: early diverticula with only a small portion of mucosa protruding esophageal diverticula
Clinical manifestations of middle esophageal diverticula: Most of the drawn-out diverticula are small and have a wide neck and narrow bottom, which facilitate drainage and are not easy to have food residue, so they are generally asymptomatic and often found in health checkups or intermittently, and do not change over the years. Swallowing difficulties and pain only occur when the esophagus is stretched or narrowed, and when inflammation of the diverticulum occurs. If the diverticulum is inflamed, ulcerated, necrotic and perforated, it can cause bleeding, mediastinal abscess, bronchial fistula and other comorbidities and clinical manifestations of pseudo esophageal diverticulum: patients often complain of mild dysphagia with intermittent episodes or slow progression of symptoms. Esophageal pseudodiverticulosis is most often seen in patients in the age group of fifty to sixty years, with more men than women.
Chinese medicine diagnosis: the disease is commonly seen in the following types of evidence
1, phlegm and qi junction symptoms: phlegm and food choking, sometimes bad breath, spitting, sometimes chest pain, light red tongue, white greasy coating, smooth pulse. Analysis: phlegm and qi intertwine in the esophagus, so phlegm and food choke and spit; qi stagnation, qi and blood do not flow smoothly, and pain when not pass, so chest pain; phlegm and qi long depression, there is the potential to turn into heat, so bad breath; white greasy tongue coating and slippery pulse are also signs of phlegm and qi intertwine.
2, phlegm-heat internal knot symptoms: choking in the throat, chest pain, bad breath, dry throat and bitter mouth, stomach and epigastric fullness, light red tongue, yellowish greasy coating, slippery pulse. Analysis: phlegm-heat internal nodules blocking the esophagus, resulting in choking, bad breath, dry throat and bitter mouth; phlegm-heat blocking the middle, loss of spleen health, resulting in gastric and epigastric fullness; phlegm-heat internal nodules blocking qi flow, loss of harmony between qi and blood, resulting in chest pain; yellowish coating on the tongue and slippery pulse are also signs of phlegm-heat internal nodules.
3. Internal stasis-heat symptoms: difficulty in swallowing food and drink, persistent burning pain behind the sternum, aggravated by eating spicy food, dry and bitter mouth, red tongue with petechiae, yellow greasy moss and stringent pulse. Analysis: Blood stasis is internally knotted in the esophagus, so it is difficult to swallow the food; stasis and heat do not resolve each other, so there is continuous burning pain behind the sternum, dry and bitter mouth; eating spicy food will help heat and make stasis and heat even worse, so the pain behind the sternum is aggravated; the red tongue with petechiae, yellow greasy moss and stringent pulse are also signs of internal stasis and heat.
Diagnosis and diagnostic criteria of pharyngoesophageal diverticulum
There are not many positive clinical physical examination signs, and some patients can hear loud sounds after swallowing a few mouthfuls of air and repeatedly pressing the anterior border of the sternocleidomastoid muscle at the level of the cricopharyngeal muscle.
The main means of diagnosis is X-ray examination, and the fluid plane is occasionally seen on plain film, and the diverticulum at the back of the esophagus can be seen by taking barium, and if the diverticulum is huge and obviously compresses the esophagus, a barium shadow can be seen after the barium enters the diverticulum, and then a barium shadow flows from the opening of the diverticulum to the esophagus below. Repeated changes in position during imaging are beneficial to the filling and emptying of the diverticulum, facilitating the discovery of small diverticula and observing whether the mucosa within the diverticulum is smooth, except for early malignant changes.
Endoscopy has certain risks, so it is not a routine examination, but only when malignancy is suspected or combined with other malformations, such as esophageal webbing or esophageal stricture. Before endoscopy, the patient is asked to swallow a black silk thread as the guide line of endoscope, which can increase the safety of the examination.
Diagnosis of pseudo esophageal diverticulum and diagnostic criteria
Pseudodiverticula cannot be found on X-ray examination, but barium contrast can reveal multiple long-necked flask-like or small button-like pouches in the lumen of esophagus, ranging from 1 to 5 mm in size, with scattered or limited distribution, and there are more pseudodiverticula in the obvious stenosis of esophagus, so it is believed that esophageal stenosis is related to inflammation around pseudodiverticula.
Endoscopic examination of the esophagus shows chronic inflammatory changes, and pseudodiverticulosis is only seen in a very small number of patients, and biopsy is not easy to confirm the diagnosis.
Many patients with pseudodiverticulosis often have Candida infection, which may be secondary, especially in diabetic patients.
Treatment of pharyngoesophageal diverticula
The condition is mostly progressive and non-surgical conservative therapies are ineffective, so elective surgery should be performed as soon as possible after the diagnosis is clear and before comorbidities arise.
Very few patients need intravenous rehydration to correct malnutrition, and comorbidities should be treated actively, and surgery can be performed after the disease is controlled.
If the nasogastric tube can be sent into the diverticulum under fluoroscopy before surgery, and repeatedly rinse and aspirate the residue, it is helpful to prevent misaspiration during induction of anesthesia. The treatment of diverticula retained in the diaphragm should be surgical treatment of symptomatic large diverticula or diverticula that gradually increase in size during follow-up, as well as diverticula with signs of retention or combined with other malformations such as esophageal hiatal hernia and pancreatic atelectasis. Special attention should be paid to correct the combined deformities at the same time, otherwise complications or recurrence may occur.
1, preoperative preparation is basically the same as pharyngoesophageal diverticulum, but preoperative gastrointestinal preparation should be performed: oral metronidazole 0.4g, 3 times a day for 3 days. After gastric lavage the night before surgery, oral streptomycin 1g and enema, these measures are conducive to preventing the occurrence of esophageal fistula.
2, anesthesia with pharyngeal esophageal diverticulum surgery, the use of endotracheal intubation of general anesthesia.
3.Surgical method of supradiaphragmatic diverticulum mostly uses the left side of the 7th rib bed into the chest, although sometimes the diverticulum is located on the right side, is also the left chest approach to facilitate surgical operations.
After opening the chest, hold the lung to the front, cut open the mediastinal pleura to reveal the esophagus, pay attention to preserve the vagus plexus. Touch the gastric tube inside the diverticulum or ask the anesthesiologist to inject gas through the gastric tube to help identify the diverticulum, if the diverticulum is located on the right side of the esophagus, the esophagus can be freed and rotated to facilitate the exposure of the diverticulum. The diverticulum is often herniated from a gap in the muscular layer of the esophagus. After identifying the interface between the esophageal circular muscle and the esophageal mucosa, the muscle layer is cut about 3 cm distal to the esophagus and about 2 cm proximal to the esophagus to fully expose the diverticulum neck. If the diverticulum is huge, the diverticulum can be excised, and the mucosal and muscular layers can be incised, with the proximal end reaching the level of the inferior pulmonary vein and the distal end reaching 1 cm of the gastric wall. The site of myocardial incision should be lateral to the suture repair of the diverticulum neck to reduce the occurrence of fistula. Routinely perform closed drainage of the chest cavity.
4, postoperative treatment after surgery routine fasting, gastrointestinal decompression intravenous rehydration, intestinal sounds after the recovery of gastrointestinal decompression to stop, the next day to eat through the mouth. After good lung expansion and no chest drainage, remove the chest drainage tube.
Treatment of pseudo-esophageal diverticulum
The aim of treatment is to alleviate symptoms and manage the associated lesions. Esophageal dilatation can reduce dysphagia and antacid therapy can reduce the symptoms of esophagitis. However, the x-ray presentation of pseudodiverticula is usually unchanged and occasionally disappears on its own.
Complications
Due to the accumulation of food, the diverticulum will continue to increase and gradually fall, which is not conducive to the discharge of the accumulated materials inside the diverticulum, resulting in the opening of the diverticulum is facing the lower pharynx, the food swallowed first into the diverticulum and reflux occurs, then there is dysphagia, and is progressively aggravated, some patients also have bad breath, nausea, loss of appetite and other symptoms. Some of them have malnutrition and weight loss due to difficulty in eating. In the absence of treatment, if the diverticulum gradually increases in size, the accumulated food and secretions begin to increase, sometimes automatically returning into the oral cavity, occasionally causing aspiration. The result of misaspiration will lead to comorbidities such as pneumonia, atelectasis or lung abscess. Complications such as bleeding and perforation are less common.
Treatment of pharyngoesophageal diverticula
The disease is mostly progressive and non-surgical conservative therapies are ineffective, so elective surgery should be performed as soon as possible after the diagnosis is clear and before the emergence of comorbidities.
Very few patients need intravenous rehydration to correct malnutrition, and comorbidities should be treated actively, and surgery can be performed after the disease is controlled, so there is no need to wait for a long time.
If the nasogastric tube can be sent into the diverticulum under fluoroscopy before surgery, and repeatedly rinse and aspirate the residue, it is helpful to prevent misaspiration during induction of anesthesia. The gastric tube retained in the diverticulum is conducive to intraoperative search and dissection of the diverticulum, facilitating surgical operation.
2, anesthesia endotracheal intubation general anesthesia, can control breathing to prevent misaspiration, facilitate surgical operation.
3.Surgical method pharyngeal esophageal diverticulum is mostly located in the posterior left side of the midline, surgery often uses the left neck approach, but must be decided according to the preoperative imaging, such as diverticula to the right side of the right neck approach should be used.
Supine position, head turned to the healthy side, take the sternocleidomastoid muscle anterior edge incision, from the level of the hyoid bone to 1 cm above the clavicle, cut the broad cervical muscle, in front of the trachea, separate the sternocleidomastoid muscle and surrounding tissues and muscles and traction to the side, reveal the scapulolingual muscle, resection or retraction, resection is more conducive to the exposure of diverticula. The diverticulum is more favorable to be revealed by traction to the side and resection. Pull away the carotid artery laterally, cut off the inferior thyroid artery and the middle thyroid vein, pull the thyroid toward the midline, pay attention to protect the laryngeal recurrent nerve in the tracheoesophageal groove, carefully identify the diverticulum wall, you can touch the gastric tube inside the diverticulum, or ask the anesthesiologist to slowly inject gas into the diverticulum through the gastric tube to make the diverticulum expand, so that it is easy to identify. The diverticular sac is lifted with a rat-tooth clamp and the diverticular neck is dissected along the wall of the sac. Below the diverticulum neck is the upper edge of the cricopharyngeal muscle, above is the lower edge of the pharyngeal constriction muscle, along the median line from top to bottom to cut the transverse fibers of the cricopharyngeal muscle and esophageal muscle layer about 3 cm, and the esophageal mucosa layer and muscle layer of the diverticulum neck to the left and right to separate up to half of the circumference of the esophagus, so that the mucosa expansion, do not need to deal with. If the diverticulum is very large, it should be removed, the original gastric tube in the diverticulum is sent into the esophageal lumen, the neck of the diverticulum is clamped with vascular forceps equally on the longitudinal axis of the esophagus, the wall of the diverticulum is removed, the esophageal mucosa is sutured, and the knot is tied in the lumen, note that the removal should not be too much, so as not to cause esophageal stricture. Put drainage strips to drain, and suture the neck incision layer by layer.
4.Post-operative treatment can be eaten through the mouth on the second day after surgery, and drainage strips can be removed when there is not much drainage in 48-72h after surgery.
The main surgical complication is injury to the recurrent laryngeal nerve, and most of them can recover on their own. The second is the formation of leakage or fistula at the repair site, which can be healed by local drug exchange. If esophageal stricture occurs, esophageal dilatation is feasible.
The treatment of esophageal diverticula does not require village treatment for the asymptomatic evolutive esophageal diverticula, and those with mild symptoms can also be observed for years, and surgery is required only when the symptoms gradually worsen and the diverticula gradually increase in size or when complications such as inflammation, foreign body perforation and bleeding occur.
During surgery, the cause of the evolutive diverticulum should be removed, and any possible combination of esophageal dysmotility or obstruction, such as pancreatic dystonia, diaphragmatic hernia, hiatal hernia, etc., should be corrected to avoid recurrence or complications.
Preoperative preparation and anesthesia are the same as for supradiaphragmatic diverticula.
The surgery is usually performed using a right thoracic approach, where the mediastinal pleura is cut behind the pulmonary hilum to confirm the esophagus. The diverticulum is often surrounded by enlarged lymph nodes and closely adherent fibrous tissues, so it is difficult to free the diverticulum, so careful and patient removal of enlarged lymph nodes is required. In combination with abscesses and fistulas, we need to remove and repair them together, pleura, intercostal muscle and pericardium can be used as additional solid tissue.