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epiphrenic diverticulum is a rare disease that presents with the primary symptoms of dysphagia and regurgitation ( 1 - 3 ) .
esophagitis is the most frequent complication , and bleeding may also occur ( 4 , 5 ) .
we report here a patient with perforated epiphrenic diverticulum who was diagnosed 3 days after spontaneous rupture and had a primary repair of his perforation .
there are no prior reports of delayed primary repair of a perforated epiphrenic esophageal diverticulum in korea .
a 68-yr - old man was transferred to the emergency room because of sudden postprandial chest pain , which had been aggravated during the previous two days .
he had a history of stroke , hypertension and diabetes mellitus for 3 yr , during which time he had been taking antihypertensive , antiplatelet , and antidiabetic medications .
blood pressure was 110/70 mmhg , pulse 120 bpm , and temperature 39. physical examination demonstrated a subcutaneous emphysema in the neck .
laboratory data included white blood cell count of 16,400/l , hemoglobin value 11.3 g / dl , and platelet count 27310/l .
chest computed tomography showed periesophageal fluid collection in the lower esophagus , more prominent air collection at the left lateral aspect of the lower esophagus , and bilateral minimal pleural effusion ( fig .
the esophagogram revealed a perforation with a bulge of 2.5 cm in width in the lower thoracic esophagus ( fig .
the patient was emergently operated on , with primary closure for perforation , and proper drainage with insertion of thoracostomy tubes . at the time of surgery , after esophageal dissection and debridement ,
a perforated esophageal diverticulum was identified and the perforation was revealed in the borderline between mucosal protrusion and muscular fiber ( fig .
the mucosal edge of the perforation was identified and approximated using interrupted 4 - 0 vicryl sutures , and the muscular edge was closed using interrupted 3 - 0 silk sutures .
the closure was reinforced by stripping a large flap of pleura from the posterolateral thoracic cavity and stitching it to the muscular coat of the esophagus all round the sutured perforation .
the chest was closed with two thoracostomy tubes . despite the use of broad spectrum antibiotics
postoperatively , the patient 's condition deteriorated and follow - up radiography revealed markedly aggravated pulmonary edema , cardiomegaly , and widened mediastinum ( fig .
the patient was improved his symptom and radiography . a gastrographin swallow study obtained on the 14th postoperative days showed the disappearance of the diverticulum , although there remained small and confined leak from the esophagus ( fig .
the patient was managed with non - surgical treatments , such as intravenous hyperalimentation and broad - spectrum antibiotics .
a gastrographin swallow study performed on the 42nd postoperative day showed the absence of leaks , and the patient was discharged 2 months after the operation .
esophageal diverticula are divided into those in the transition zone between the pharynx and the esophagus ( zenker 's diverticula ) , midesophageal diverticula , and those in the lower third of the esophagus ( epiphrenic diverticula ) .
pulsion diverticula of the epiphrenic portion of the esophagus are not as common as those occurring in the cervical portion .
an epiphrenic diverticulum is generally believed to represent a form of pulsion diverticulum caused by markedly increased intraluminal esophageal pressures associated with underlying esophageal motility disorders such as diffuse esophageal spasm ( 1 , 2 , 6 , 7 ) . in some studies ( 6 , 8) , however , diverticula occurred in the absence of esophageal motor disorders and failed to enlarge when low esophageal sphincter pressures were elevated .
these studies suggested that epiphrenic diverticula were not always dependent on an esophageal motor disorder . in the present study esophageal motility was normal on gastrographin study .
an epiphrenic diverticulum should be operated on if symptoms and complications are related to the diverticulum .
dysphagia and regurgitation are the most common symptoms , and bleeding ulceration may also occur .
spontaneous perforation is an extremely rare and serious complication of epiphrenic diverticulum , which has a high mortality and morbidity rate . in esophageal perforation
, the gastric contents are expelled into the mediastinum and the pleural cavity as a resulting esophageal injury .
the combination of gastric acid and digestive enzymes cause mediastinitis and sepsis , which is fatal in most untreated cases .
esophageal perforation is not common and has a variety of symptoms , none of which are diagnostic , therefore , there is often a delay in diagnosis .
when the esophageal perforation is more than 24 hr old , its treatment remains controversial .
unfortunately , these methods have a high mortality and the disadvantage of needing further reconstructive surgery ( 9 , 10 ) . in 1975
, however , grillo and wilkins ( 11 ) recommended that primary repair should be undertaken for esophageal perforation , regardless of the time interval between perforation and operation .
however , postoperative morbidity , including postoperative leakage is a common occurrence after primary repair .
these complications can be treated with aggressive and intensive nursing care , early nutritional support , and a proper antibiotic regimen .
therefore , the overall high morbidity rate does not correlate with a high morbidity rate and recently there is increasing evidence that primary repair affords the patient the best probability of survival , regardless of the time interval between esophageal perforation and repair ( 12 , 13 ) most benign strictures or motility disorders may not contraindicate primary closure .
however , delayed primary repair of the esophageal perforation is not advisable in all situations .
in addition to malignant disease , an esophagus that is severely damaged from certain benign intrinsic conditions ( scleroderma , previous caustic burn ) or extrinsic trauma ( acute lye ingestion , blast injury ) may not be primarily repairable ( 13 , 14 ) .
a number autologous tissue flaps have been described to reinforce the repaired esophageal perforation , such as pleural flap , pericardium , diaphragm or muscle flaps ( 15 , 16 ) .
it has been suggested that reinforced primary repair should be performed for most thoracic esophageal perforations . in conclusion ,
a 68-yr - old man complaining of sudden , postprandial chest pain visited the emergency room . 
 his symptom had been aggravated during the preceding two days . 
 upper gastrointestinal contrast study with gastrographin showed leakage of dye from the epiphrenic diverticulum in the lower third of the esophagus . 
 the primary repair was urgently carried out . 
 upper gastrointestinal contrast study 14 days after operation revealed an esophageal leakage which was small and confined . 
 the patient was managed with conservative treatments such as intravenous hyperali - mentation and broad - spectrum antibiotics . 
 forty - two days after the operation , a gastrographin swallow study showed the absence of leaks . 
 this is the first report - ed case of a perforated epiphrenic esophageal diverticulum repaired by delayed primary repair in korea .