Pulsion Diverticulum Research Articles

Diverticulum of the Esophagus

THE first record of diverticulum of the esophagus was made in 1764 by Ludlow, a surgeon in England. He reported it as a case of obstructed deglutition from a prenatal dilatation, and later similar lesions were reported by the Italian and German writers. In 1877 Zenker and Von Ziemissem made a careful study and corrected many erroneous ideas and made the proper classification of pulsion and traction diverticula. This same classification still obtains with the majority of writers. Under the pathological classification they are spoken of as simple cylindrical and sacculated dilatations. The simple cylindrical dilatations are usually the result of long-continued stenosis of the esophagus or at the cardiac end of the stomach. The dilated portion shows thickened walls, with sometimes polypoid growths which may later ulcerate. The sacculated dilatations are classified into groups of pulsion and traction diverticula: pulsion due to pressure from within; traction due to traction from without. The pulsion diverticula are more commonly found in the upper portion of the esophagus on a level with the cricoid cartilage and arising from the posterior wall, varying in size from that of a pea to a large sausage-shaped dilatation, hanging down between the esophagus and the vertebral column. When located on the posterior wall, we find that the muscle tissue is not so strong at this point. The longitudinal fibers of the esophageal muscles are inserted above the cricoid cartilage, so that, in order to reach these other fibers, they become divided to the right and left before reaching the cricoid. The area between these fibers must be filled in with others, called transverse fibers. These are thin, so that when the muscles contract to force down a bolus of food, the upper longitudinal and transverse fibers pull on this thin point or area; then with an added traumatism, due to a large mass of imperfectly masticated food, the area gives way and a dilatation is formed. While small at first, it gradually becomes larger, due to a repetition of the same force, until food accumulates in the sac, ferments, and a more rapid dilatation results. We must bear in mind that the physiology of deglutition plays a rather important part in the etiology of esophageal diverticula. The bolus of food on the upper surface of the tongue is compressed by the tongue against the soft palate, assisted by esophageal-pharyngeal muscles, and is shot rapidly down the pharynx into the upper esophagus. No doubt, there is considerable force brought against the poorly supported region. This added insult does not by any means help the strength at that point. Some writers think it is a congenital defect. Diverticula of the pulsion type are nearly always found in the cervical region, and generally on the left side. Those of small size are spherical in form, but become oblong or pear-shaped, increasing in size until sometimes they become large enough to hold eight ounces or more.

ENDOSCOPIC TREATMENT OF PULSION DIVERTICULUM: A FURTHER REPORT

A method of inverting pulsion diverticulum through the endoscope and ligating it, was presented before this society last year. Three cases in which operation was performed by this method were reported at that time. Since then, four other cases with pulsion diverticulum have been studied. One patient who was operated on by the method of inversion of the sac and ligation, unfortunately died from lobar pneumonia five days later. A mediastinitis did not seem to be present, but as autopsy was not performed, this fact cannot be proved. It was felt, moreover, that if a patient with a pulsion diverticulum is past middle life, the safest methods of operation should be employed. If this apparently simple procedure can cure a patient of his symptoms, it should be used, but only after a proper explanation of its possibilities and limitations. Because of the danger of esophageal trauma and the possibility of

Successful Operation in Eight Cases of Pulsion Diverticula of the Esophngus

Successful Operation in Eight Cases of Pulsion Diverticula of the Esophngus

Successful Operation in Eight Cases of Pulsion Diverticula of the Esophagus

Successful Operation in Eight Cases of Pulsion Diverticula of the Esophagus

CARDIOSPASM AND CONCOMITANT ESOPHAGEAL DIVERTICULUM

As the occurrence of either cardiospasm or diverticulum of the esophagus is relatively infrequent, the existence of the two conditions in the same individual is rather unusual. Dessecker1states that, in eight cases of diverticulum of the lower third of the esophagus, cardiospasm was found in five; and he believes that even when it is absent, a careful history may reveal symptoms of spasm at some time. The accumulation of food in a spot weakened congenitally, or by traction from cicatrices, is thought to be a causative factor. A further contributing factor, he believes, is the negative pressure of air in the thorax as affecting that in the esophagus. Vinson2has reported two cases of diverticulum of the middle third of the esophagus associated with cardiospasm. The case here reported presents the very unusual condition of pulsion diverticulum of the upper end of the esophagus with concomitant cardiospasm.