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Figure 17-7 Surgical management of pulsion diverticulum of the lower portion of the esophagus. Placement of left posterolateral thoracotomy incision (inset). Exposure of diverticulum is obtained when the chest is entered through the bed of the unresected left eighth rib. Note that the esophagus has been delivered from its mediastinal bed, tapes have been passed around the esophagus, and the esophagus has been rotated to bring the diverticulum into view. The neck of the mucosal diverticulum has been dissected, identifying the defect in the esophageal muscular wall (A). A TA stapling device is used to transect and close the diverticulum followed by closure of esophageal musculature over mucosal suture line (B). The site of the diverticular incision has been rotated back to the right and is not visible. A long esophagomyotomy, extending from the esophagogastric junction to the aortic arch, has been performed. The musculature of the esophagus has been freed from about 50% of the circumference of the esophageal mucosal tube to allow mucosa to bulge through the muscular incision (C).

Figure 17-7 Surgical management of pulsion diverticulum of the lower portion of the esophagus. Placement of left posterolateral thoracotomy incision (inset). Exposure of diverticulum is obtained when the chest is entered through the bed of the unresected left eighth rib. Note that the esophagus has been delivered from its mediastinal bed, tapes have been passed around the esophagus, and the esophagus has been rotated to bring the diverticulum into view. The neck of the mucosal diverticulum has been dissected, identifying the defect in the esophageal muscular wall (A). A TA stapling device is used to transect and close the diverticulum followed by closure of esophageal musculature over mucosal suture line (B). The site of the diverticular incision has been rotated back to the right and is not visible. A long esophagomyotomy, extending from the esophagogastric junction to the aortic arch, has been performed. The musculature of the esophagus has been freed from about 50% of the circumference of the esophageal mucosal tube to allow mucosa to bulge through the muscular incision (C).

Figure 17-6 Esophagus with huge epiphrenic diverticulum occupying about half of the right thorax. Note the associated sliding esophageal hiatal hernia. (From Payne, W.S.: Esophageal diverticula. In Shields, T. W. [ed.]: General Thoracic Surgery, 3rd ed. Philadelphia, Lea & Febiger, 1983, p. 859, with permission.)

Figure 17-8 Esophagus with traction diverticulum in the middle third of the thoracic portion in relation to subcarinal lymph nodes. Patient was asymptomatic. (From Payne, W.S.: Diverticula of the esophagus. In Payne, W.S., and Olsen, AM. [eds.J: The Esophagus. Philadelphia, Lea & Febiger, 1974, p. 207, with permission.)

Figure 17-9 Traction diverticula of the esophagus occur most commonly in the middle third of the thoracic portion of the esophagus in relation to granulomatous subcarinal lymph nodes. Note how the esophageal wall is tented by inflammatory lymph nodes. (From Payne, W.S., and Clagett, O.T.: Pharyngeal and esophageal diverticula. Curr. Probl. Surg., 1-31, Apr., 1965, with permission of Year Book Medical Publishers.)

inflamed subcarinal nodes

Figure 17-10 Technique for closing acquired esophagobronchial fistula as a complication of a traction diverticulum of the esophagus. Right posterolateral thoracotomy incision (upper left inset). Surgical exposure. Lung has been retracted anteriorly. Note the relationship of the esophagus, right main bronchus, and fistula to neighboring sutures (center). Fistula before division and after division and ligation (upperright and lower left insets). Method of interposing pedicles of mediastinal pleura between esophageal and bronchial closures (lower right inset). (From Payne, W.S., and Clagett. O.T.: Pharyngeal and esophageal diverticula. Curr. Probl. Surg., 1-31, Apr., 1965, with permission of Year Book Medical Publishers.)

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