Treatment of Middle Esophageal Diverticulum with Esophageal Motility Disorders
Mid-thoracic pulsion esophageal diverticula frequently develop in the context of an underlying esophageal motility disorder. In this setting, addressing the diverticulum in isolation is not sufficient — the associated motility dysfunction must be incorporated into any treatment plan.
Clinical Scenario
This protocol covers middle (mid-thoracic) pulsion esophageal diverticulum occurring in association with an esophageal motility disorder — including achalasia, nutcracker esophagus, segmental esophageal spasm of the middle third, and nonspecific motility disorders (NSMD). The type and extent of intervention depends on which motility subtype is present.
Treatment Approach — Overview (partial)
Management combines diverticulectomy with an extramucosal myotomy performed on the contralateral esophageal wall, sized according to the specific underlying motility disorder. An endoscopic route via flexible endoscopy is also an established option for this type of diverticulum.
The complete protocol specifies how myotomy extent and approach are determined for each motility subtype, and when endoscopic alternatives apply.
References
- In the case of pulsion midthoracic diverticula, strictly diverticular interventions are no longer sufficient to resolve the underlying symptoms and pathology.
- Motility disorders such as achalasia, nutcracker esophagus, segmental esophageal spasm in the middle third, and nonspecific motility disorders (NSMD) are recorded in 92% of the patients.
- It is necessary to associate with extra mucosal myotomy, which is performed on the contralateral esophageal wall.
- For common cases, caused by NSMD, a segmental myotomy extended proximally and distally to the diverticulum by 3–4 cm is sufficient; some surgeons limit the length of the myotomy strictly to the length of the aberration described manometrically.
- Endoscopic treatment through flexible endoscopy and POEM is used successfully for this type of diverticulum.
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