Esophageal diverticula can be divided into true and false diverticula. True diverticulum includes mucosa, submucosa and muscle layer, while false diverticulum only includes mucosa and submucosa. According to the mechanism of occurrence, esophageal diverticulum can be divided into pulsion and traction. Traction diverticulum(TD) is a true diverticulum, which is usually caused by mediastinal inflammation. The middle esophageal diverticulum is a true diverticulum and a traction diverticulum, which usually has a wide base.
Most esophageal diverticula are asymptomatic. However, the development of the disease to a certain degree of esophageal diverticulum can affect the quality of life of patients, and there are risks such as aspiration and suffocation and Oral drug retention in it affects the effect of the drug, and it may become cancerous.Therefore, intervention measures should be taken after the esophageal diverticulum has obvious clinical symptoms.It has been reported that surgery is recommended for patients with clinical manifestations such as severe dysphagia, aspiration pneumonia .It has been thought that the treatment of esophageal diverticulum needs to be performed under thoracoscopy or laparoscopy. Since esophageal diverticulum is more common in the elderly, patients usually have underlying diseases or cannot tolerate surgical operations. Therefore, more and more scholars have proposed the use of endoscopic minimally invasive treatment of esophageal diverticulum to improve the feasibility and safety of surgery and reduce surgical complications and some adverse events.
The focus of the treatment of esophageal diverticulum is to cut off the diverticulum spine under the mucosa, but this operation has a high probability of repeated symptoms. The cause of diverticulum is often abnormal or absent esophageal muscle layer, which cannot repair itself. Therefore, complete surgical resection can achieve better therapeutic effect. In this paper, a case of esophageal diverticulum underwent endoscopic resection of the weak area of the bottom muscle layer of the diverticulum, and the circumferential muscle of the diverticulum was cut off. Two titanium clips and nylon rope were sutured in the middle of the diverticulum wound, and then the wound was completely closed with the titanium clip. It had a similar effect as surgery and preserved the physiological function of the esophagus. The complications of pleural effusion were related to the limitation of endoscopic suture methods. The treatment goal was achieved by combining the treatment with a fully covered metal stent. In addition, Long-term chronic stimulation of esophageal diverticulum mucosa can induce tumor formation. Therefore, the possibility of developing into cancer of esophageal diverticulum is reduced to some extent.
The choice of treatment for esophageal diverticulum is mainly determined by comprehensive factors such as the anatomical structure of the diverticulum, the size of the diverticulum, the general condition of the patient, the patient's wishes, and the local medical level.We believe that the reason for the success of this operation is mainly related to the following factors. First, the weakened area of the muscular layer at the bottom of the diverticulum is removed, which provides sufficient operating space for subsequent operations . It facilitates the flow of food from the diverticula into the esophageal cavity and avoids the discomfort caused by repeated food stimulation for a long time. Ultimately, the probability of recurrence of esophageal diverticulum decreases. Second, the use of titanium clips, kiss sutures and metal stents. It can reduce the tension of the kiss suture, which is stronger than direct suture. Due to the excessive tension, the titanium clip fell off and was later covered with a self-expanding fully covered metal stent , which eventually formed a tight scar to connect the wound, thereby changing the residual condition of the weakened esophageal muscle layer of the traditional endoscopic treatment. The implantation of a recyclable full-membrane esophageal stent prevents food and secretions from irritating the surgical wound, which is conducive to shortening its healing time. Third, long-term fasting and enteral nutrition support. According to some scholars , the time to start eating after esophageal diverticulum resection should be greater than 5 days, because this is the time required for the formation of granulation tissue. Under tolerable conditions, most patients can carry out enteral nutrition through nasogastric tube. In this case report, the patient had good compliance and half a month of enteral nutrition, which was an important factor in the success of this operation. Third, rational use of antibiotics.
The selection of treatment for esophageal diverticulum needs to refer to many factors. For the middle esophageal diverticulum, especially those with large diverticulum sacs and small mouths, they can be located by esophageal barium meal X-ray and gastroscopy. If it is clear that the diverticulum sacs are large and the mouth is small, you can try endoscopic diverticulectomy and crestectomy. It has no esophageal stricture and postoperative recurrence. This can not only reduce surgical trauma, but also reduce the symptoms of patients and improve the quality of life. It is a bold attempt and breakthrough in the treatment of the original diverticulectomy. The feasibility, effectiveness and safety of this surgical method require more practical experience and accumulation of cases. This may provide a new idea and reference for the treatment of esophageal diverticulum, and it also provides more choices for patients.