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Esophageal diverticulum — Clinical Guidelines

Overview

Esophageal diverticula are protrusions of the esophageal mucosa through weaknesses in the muscular layer, categorized by location such as Zenker (pharyngeal), epiphrenic, and mid-esophageal diverticula. 2 3

Diagnosis

Key Symptoms: Dysphagia, regurgitation, chest pain, and potential aspiration pneumonia. 2

Recommended Tests: Videofluoroscopic swallow studies (VFSS) for confirmation and assessment of aspiration risk. 2

Imaging: Endoscopy and barium swallow studies can identify diverticula and associated complications. 2

Management

First-Line Treatments:

- Behavioral Management: Fluid and food modifications, swallow strategies to reduce aspiration risk. 2 - Speech and Language Therapy: Essential for assessing and managing swallowing difficulties in patients awaiting or unable to undergo surgery. 2

Surgical Interventions:

- Zenker Diverticulum: Endoscopic diverticulectomy (e.g., diverticulotomy) is a common approach. 1 - Epiphrenic Diverticulum: Traditional diverticulectomy via thoracic approach; laparoscopic approaches are emerging alternatives. 3 - Motor Disorder Correction: In some cases, addressing associated motor disorders like gastroesophageal reflux without diverticulectomy may suffice. 4

Special Populations

Elderly: Increased risk of complications; careful consideration of surgical versus conservative management based on symptom severity and aspiration risk. 2 3

Comorbidities: Patients with comorbidities like respiratory issues may require more aggressive management to prevent aspiration pneumonia. 2

Key Recommendations

Utilize videofluoroscopic swallow studies (VFSS) for diagnosing esophageal diverticula and assessing aspiration risk in symptomatic patients. (Evidence: Moderate) 2

Implement speech and language therapy interventions to manage swallowing difficulties and reduce aspiration risk, particularly in patients not suitable for immediate surgical intervention. (Evidence: Moderate) 2

Consider the abdominal laparoscopic approach for epiphrenic diverticula as a feasible alternative to traditional thoracic surgery, though further evidence is needed. (Evidence: Weak) 3

Evaluate the necessity of diverticulectomy in epiphrenic diverticula cases, focusing on correcting associated motor disorders like gastroesophageal reflux when diverticulum resection is not immediately required. (Evidence: Weak) 4

References

1 Wiebracht ND, Giliberto JP, Myer C, Casper K, Johnson KE. Pilot testing of a novel surgical simulator for endoscopic zenker's diverticulotomy. The Laryngoscope 2017. link 2 Holmes E, Kenny C, Samuel M, Regan J, O'Rourke J, McCoubrey C. The Role of Speech and Language Therapy in Assessing and Managing Pharyngo-esophageal Diverticula. Irish medical journal 2015. link 3 Chami Z, Fabre JM, Navarro F, Domergue J. Abdominal laparoscopic approach for thoracic epiphrenic diverticulum. Surgical endoscopy 1999. link 4 Montesani C, D'Amato A, Citone G, Procacciante F, Narilli P, Ribotta G. Surgical treatment of epiphrenic diverticula of the esophagus: is diverticulectomy always necessary? A report of two cases. The Italian journal of surgical sciences 1985. link

Esophageal diverticulum