Les diverticules de l’œsophage

Service de Chirurgie Digestive, Hôtel-Dieu, Boulevard Léon Malfreyt, F-63058 Clermont-Ferrand, France
Acta Endoscopica (Impact Factor: 0.16). 08/2006; 36(4):605-615. DOI: 10.1007/BF03003763

ABSTRACT Les diverticules de l’œsophage sont rares, souvent asymptomatiques et découverts de façon fortuite. Ils sont l’expression
d’un trouble de la motricité œsophagienne sous jacent responsable d’une augmentation de la pression intra-œsophagienne. Les
diverticules asymptomatiques ne doivent pas être traités, à l’inverse des diverticules symptomatiques, compliqués ou volumineux.
La chirurgie est le traitement de choix, par myotomie longitudinale œsophagienne éventuellement associée à une diverticulectomie
ou une diverticulopexie. Pour les diverticules pharyngo-œsophagiens (de Zenker), la diverticulostomie endoscopique par pince
mécanique ou électrocoagulation est devenue une alternative à la chirurgie, notamment chez les patients âgés.
Diverticula of the oesophagus are rare and often asymptomatic or discovered incidentally. They are symptomatic of an ongoing
oesophageal dysmotility process, resulting in abnormal intraluminal pressure. Asymptomatic diverticula can remain untreated,
unlike of symptomatic, complicated or giant diverticula. Surgery is the treatment of choice and consists in longitudinal oesophageal
myotomy eventually associated with diverticulectomy or diverticulopexy. In pharyngoesophageal (Zenker’s) diverticulum, endoscopic
diverticulostomy with stapler, laser or coagulation, has become an alternative to surgery, particularly in elderly patients.

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    ABSTRACT: Incomplete symptomatic relief of pharyngoesophageal (Zenker's) diverticulum after endoscopic stapling or laser division has been reported by some authors. The clinical relevance of cricomyotomy, although supported by experimental data, remains controversial. Operative procedures consisted of transcervical resection (n = 34, group I), transcervical resection plus cricomyotomy (n = 12, group II), transcervical cricomyotomy (n = 8, group III), transcervical cricomyotomy plus diverticulopexy (n = 47, group IV), endoscopic stapling division (n = 31, group V), and endoscopic laser division (n = 55; group VI). The percentage of totally asymptomatic patients was significantly (p < 0.004) higher after open procedures (combined groups I to IV) than after endoscopic treatment (combined groups V and VI) regardless of the size of the pouch (< 3 cm, 85% versus 25%; > or = 3 cm, 86% versus 50%). The percentage of patients with no or occasional (ie, fewer than twice a week) symptoms was significantly (p < 0.001) higher after open procedures (98%) than after endoscopic treatment (57%) for less than 3-cm diverticula whereas it was not higher (p = 0.409) for 3-cm or greater pouches (open, 97%; endoscopic, 88%). Furthermore, this percentage was similar (p > 0.286) after endoscopic stapling division and after endoscopic laser division (< 3 cm, 50% versus 58%; > or = 3 cm, 96% versus 80%). It was also similar (p > 0.197) after resection alone (group I) and after open operations including myotomy (combined groups II to IV) (< 3 cm, 100% versus 98%; > or = 3 cm, 92% versus 100%). Unlike endoscopic stapling and division, laser division was complicated by mediastinitis (2 patients), and 1 patient was referred because of cervical esophageal disruption during laser division. Five of six postoperative fistulas after resection occurred in patients who did not have myotomy, and 4 patients were referred 12 to 49 years after resection without myotomy for true recurrence of the pouch. Open techniques afford better symptomatic relief than endoscopic techniques, especially in patients with small diverticula. Endoscopic stapling and division is safer than laser division. Although very effective at midterm, resection without myotomy predisposes to the development of postoperative fistula and to recurrence of the pouch after many years.
    The Annals of Thoracic Surgery 11/2002; 74(5):1677-82; discussion 1682-3. DOI:10.1016/S0003-4975(02)03931-0 · 3.85 Impact Factor
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    ABSTRACT: The aim of our study was to identify the presence of associated functional disorders (dysmotility or gastro-esophageal reflux, GER), to select patients who need surgery and to plan a tailored surgical treatment in patients affected by esophageal body diverticula. We report on 51 consecutive patients with esophageal body diverticula, observed at our department, who underwent a thorough functional evaluation by means of radiology, endoscopy and manometry; 24 h pH-monitoring was performed in 11 patients who complained of symptoms of GER. The treatment of choice was planned in each patient on the basis of the following elements: the need of diverticulum excision and correction of esophageal body dismotility, LES dysfunction or GER. An esophageal motor dysfunction was detected in 73% (37 patients) of our total cases with an impaired LES function in 53% (27 patients); GER was identified in nine out the 11 patients submitted for 24 h pH-monitoring. On the overall series, we observed dysmotility or GER in 49/51 patients (96%). Sixteen patients did not require surgical treatment and eight patients refused it; 27 patients underwent tailored surgery. The overall complication rate was 11% (two esophageal fistulae, one acute coronary disease) with 7% mortality rate (one septic shock from esophageal leakage and one myocardial infarction). At follow up (average 47 months; range 6-103 months) 92% satisfactory results (Visick I and II) and only 8% of poor results were observed in our series. None of 13 patients who underwent conservative management had major complications at mean follow-up of 64 months. Based upon our experience, we believe that any case of diverticulum of the esophageal body deserves a complete physiopathological evaluation because an underlying functional disorder is associated in most cases. The evidence that the diverticulum per se can be considered as the ultimate phenomenon of an underlying functional disease determined the need for a tailored surgery, planning treatment of the functional disorder as the primary goal, not necessarily associated with a diverticulectomy. In our experience a tailored surgical treatment provided best results.
    European Journal of Cardio-Thoracic Surgery 11/1998; 14(4):380-7. DOI:10.1016/S1010-7940(98)00201-2 · 3.30 Impact Factor
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    ABSTRACT: Oesophageal pulsion diverticula, excluding pharyngeal types, are uncommon sequelae of oesophageal dysmotility. Current opinion favours myotomy as effective therapy, but the role of diverticulectomy, myotomy selection and placement, and the need for fundoplication remain unresolved. A Medline search and review of references identified relevant English language articles. Data on epidemiology, aetiology, oesophageal motility, pathology, symptomatology, investigations, surgical management and outcome were examined. Data were largely retrospective. Significant morbidity and mortality were associated with pulmonary aspiration and diverticulectomy site leaks. Surgical outcome was similar whether or not a diverticulectomy was added to a myotomy, but a myotomy clearly reduced the risk of leaks. Fundoplication reduced the incidence of postcardiomyotomy reflux symptoms. Results from minimally invasive techniques were similar to those of open surgery. Surgery should be reserved for symptomatic patients; asymptomatic patients may benefit from surveillance. Pulmonary aspiration mandates surgical intervention. Myotomy remains the mainstay of treatment and an adequate subdiverticular extension is crucial in relieving obstruction. A partial fundoplication is preferred in selected patients. Minimally invasive techniques should become the routine approach for oesophageal pulsion diverticula.
    British Journal of Surgery 06/2001; 88(5):629-42. DOI:10.1046/j.1365-2168.2001.01733.x · 5.54 Impact Factor
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