Epiphrenic diverticulum of the esophagus; a review of its surgical treatment and report of a case.

Articles embracing the incidence, etiology, differential diagnosis, symptoms and complications of epiphrenic diverticulum of the esophagus have appeared not too infrequently in the past.5~9J1J7~ 1 8 , 2 1 ~ 2 7 ~ 2 8 9 3 0 ~ 3 1 However, except for the notable contributions of Janes,13 Adams,' and Harrington,l0 the surgical aspects of this disease have received scant attention. No article has appeared which considers earlier experiences and thoughts on the surgery of such lesions since the contributions of L o t h e i s ~ e n ~ ~ ~ ~ ~ ~ ~ more than two decades ago. For these reasons, it is felt worthwhile to review in some detail the surgery of such diverticula from the historical standpoint as well as present trends in treatment. The first proposal for the surgical extirpation of such lesions appeared in 1901, when Enderlen6 suggested that they be removed through a posterior mediastinotomy, an operation conceived by Nassiloff in 1888 and first performed a decade later by Rehn.a2 On the basis of the few clinical and autopsy cases of such diverticula then known, Enderlen concluded that surgical intervention was rarely indicated and could then be only infrequently attempted, since he considered the following theoretical criteria prerequisites to surgery: 1) The diverticulum must not lie below the level of the ninth thoracic vertebra. 2) I t must be free from adhesions with surrounding structures. 3) The pedicle must not be too large. 4) Carcinoma must not be a complication. 5) Excessive malnutrition must not be present. An alternative procedure suggested by L o t h e i s ~ e n ~ ~ in 1908, proposed anastomosing the fundus of the diverticulum to the cardia of the stomach (marsi, pogastrostomia) through an abdominal approach and incising the diaphragm to gain access to the diverticulum. He also considered the use of the Murphy button in lieu of suture, recognizing the difficulty of esophageal suture. Since diverticula a t a higher level would not be accessible by such an approach, he briefly suggested the possibility of transpleural resection. Although Dessecker5 credits Enderlen as the first to operate for