esophageal diverticula - suny downstate medical center diverticula.pdf · case presentation • 68...

Esophageal Diverticula

Daniel Kim Kings County Hospital Center

July 10, 2014

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Case Presentation

• 68 year old male • PMH: Achalasia, Hyperlipidemia, Anxiety • PSH: Umbilical hernia repair • Symptoms:

– Dysphagia and early satiety – Regurgitation of food and liquids – Halitosis – Weight loss of 30 lbs over 6 months

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Preoperative Workup

• Physical Examination: – Halitosis

• Laboratory: – Unremarkable

• CXR: – Dilated esophagus with retained material

• EKG: – Normal sinus rhythm

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CXR www.downstatesurgery.org

Preoperative Workup

• Esophageal Manometry – Lack of peristalsis – Incomplete evaluation of LES

• EGD – 2.5 Liters of masticated food in the esophagus evacuated – Wide-mouthed diverticulum 4cm from the gastric cardia

• Barium Swallow Study – Sigmoid esophagus – Epiphrenic diverticulum 10cm in diameter

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Barium Swallow Study

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Barium Swallow Study

Sigmoid Esophagus Diverticulum

Stomach

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Barium Swallow Study

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Operation

• Procedure: – Laparoscopic esophageal diverticulectomy – Heller myotomy – Anterior fundoplication – EGD

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Operative Details

• Liver retracted away to the anterior and right side • Gastrophrenic ligament is incised exposing the esophagus • Incision of the phrenoesophageal membrane • Dissection of the right and left crus of diaphragm • Esophagus encircled with a Penrose drain • Mediastinal dissection performed close to esophagus until the

diverticulum was found • EGD performed and transillumination of the diverticulum

successful • Adhesiolysis performed to release the diverticular sac from

the pleura

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Operative Details

• Endo-GIA used to transect the diverticulum at the diverticular neck while the tip of the EGD scope placed in the stomach

• Myotomy of the longitudinal and circular muscle fibers performed along the esophagus opposite the side of the diverticulectomy

• Myotomy extended cranially to the proximal limit of the diverticular neck and caudally to the gastric cardia

• Anterior fundoplication

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Postoperative Course • POD #0

• Transferred to the SICU

• POD #1 • NGT removed

• POD #2

• Extubated

• POD #3 • Gastrograffin swallow negative for leak • Barium swallow negative for leak • Clear liquid diet • Patient left against medical advice

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Questions ?

• …Patient was contacted on POD #10 but refused to come back to clinic…

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Esophageal Diverticula

• Anatomy • Overview of Esophageal Diverticula • Clinical presentation • Diagnostic workup • Treatment • Follow-up

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Anatomy

• Cervical Esophagus – The retroesophageal space extends from the skull base to the

posterior mediastinum which offers the potential for cervical infections to travel deep into the posterior mediastinum

• Thoracic Esophagus – At the level of T8, the aorta crosses behind the esophagus, leaving the

left side covered only by parietal pleura which explains why this location is the most common site of perforation in Boerhaave syndrome

• Abdominal Esophagus – In 50% of patients, the esophageal hiatus is bound on both the left

and right by the right crus, which is both longer and thicker than the left crus

– The phrenoesophageal membrane surrounds the esophagus as it descends from the hiatus

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Points of Narrowing www.downstatesurgery.org

Arterial Blood Supply • Once arteries enter the wall of the

esophagus, they branch in a characteristic "T" pattern and create a network of collaterals

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Venous Drainage

• In the setting of portal venous obstruction, portal blood can drain to the superior vena cava via this network and the azygos vein

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Physiology

• Upper Esophageal Sphincter • High-pressure zone at the origin of the cervical esophagus • 3 cm in length • Basal pressures 30 mm Hg

• Esophageal Body • Contraction wave travels at about 2 to 5 cm per second. The wave is

initiated by voluntary swallowing, but the remainder of the contraction is not under voluntary control.

• Lower Esophageal Sphincter • Also has a high resting tone; 20 mm Hg • The degree of basal tone is highly variable. The lower esophageal

sphincter relaxes with swallowing and distention of the esophagus, as well as with distention of the gastric fundus

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Peristalsis www.downstatesurgery.org

Esophageal Diverticula

• Pulsion (False – protrusion of mucosa) – Likely secondary to dysmotility

• Zenker • Epiphrenic

• Traction (True – protrusion of all layers)

– Likely secondary to extramural inflammation from mediastinal lymph nodes

• Midesophageal

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Zenker Diverticulum

• Pulsion – type diverticulum • Most common type (3:1, Male:Female) • Age > 60 years • Affects 0.11% of the US population

• Secondary to poor coordination between the pharynx and the

UES; or from a hypertensive UES

• Diverticulum originates from the Killian triangle – Usually deviates to the left as it enlarges

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Diagnosis of Zenker Diverticulum

Crycopharyngeus

Inferior constrictor

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Diagnosis of Zenker Diverticulum

• Esophageal manometry – Calculates intraluminal pressures, esophageal length, and

sphincter lengths

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Diagnosis of Zenker Diverticulum

• High resolution manometry – Uses more electrodes and records 360 degrees of

data at each electrode – Provides a more accurate map of sphincter length

and position

• Cine - Esophagography – Dynamic contrast-based study focused on the

cervical esophagus and swallowing mechanism. This is performed in fluoroscopy

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Treatment of Zenker Diverticulum

• Open excision of the diverticulum and myotomy of the cricopharyngeus muscle and the upper 3 cm of the posterior esophageal wall

• For small diverticula (< 2 cm), the myotomy alone is sufficient

• Transoral endoscopic approach can be used for diverticula between 3 and 6 cm in size. A stapler is used to resect the diverticulum

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Open Zenker Diverticulectomy

Esophagus Diverticulum

Common Carotid Artery Internal Jugular Vein

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Open Zenker Diverticulectomy www.downstatesurgery.org

Endoscopic Zenker Diverticulectomy www.downstatesurgery.org

Epiphrenic Diverticula

• Pulsion – type diverticulum • Arise in the distal 10 cm of the thoracic

esophagus • Associated with a motility disorder such as

achalasia • Symptoms are similar to Zenker diverticula but

may also complain of chest pain • Affects 0.015% of the US population

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Diagnosis of Epiphrenic Diverticula

• Barium Swallow study • EGD • CXR

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Epiphrenic diverticula www.downstatesurgery.org

Treatment of Epiphrenic Diverticula

• Symptomatic and large (>5cm) epiphrenic diverticula should be surgically resected

• When diverticula are associated with esophageal motility disorders, esophageal

myotomy should be performed with partial fundoplication

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Laparoscopic Esophageal Diverticulectomy

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• Retrospective Literature review searching for the phrases: Esophageal diverticula and Epiphrenic

• Goal was to show that laparoscopic and thoracoscopic approaches to epiphrenic diverticulectomy were safe compared to open approach

• 85 patients in 10 studies; • 86% underwent Laparoscopy; 14% Thoracoscopy • 1 patient converted to open • 1 patient mortality from MI • 12% cumulative leak rate • Complication rate 9-50% (Leak, PNA, empyema, PTX, perforation, sepsis)

• Conclusion: compared to data from 1993, minimally invasive technique offers

shorter hospital stay, decreased mortality and similar symptom relief compared to open diverticulectomy

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Mid-esophageal Diverticula

• Traction – type diverticula • Not typically associated with dysphagia • True diverticulae • From extraesophageal inflammation, most

often granulomatous disease in subcarinal LNs • Treatment is focused on the underlying

inflammatory process.

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Summary

• Esophageal Diverticula are rare • Two classes are described: traction vs pulsion • Three types are described: Zenker, mid-esophageal and

epiphrenic • Symptoms, if present, will be similar: halitosis, regurgitation,

chest pain, dysphagia • Workup includes physical examination, barium swallow, EGD

and manometry if motor dysfunction suspected • Treatment of pulsion diverticula is usually surgery whereas

traction diverticula are usually asymptomatic • Epiphrenic diverticulectomy may be safely performed

laparoscopically but will be more difficult in the presence of inflammation or fibrosis

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Questions?

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• 1. Choose all true diverticula – A. Meckel’s – B. Zenker – C. Mid-Esophageal – D. Epiphrenic – E. Colonic

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