zenker’s and epiphrenic diverticula david w rattner, md massachusetts general hospital
TRANSCRIPT
Pathogenesis of Zenker’s Diverticulum
• Cricopharyngeus spasm caused by GER– unclear role, but several studies have described a normal or low pressure at
the cricopharyngeus.
• “Achalasia” of the cricopharyngeus– UES does relax during swallow in Zenker’s patients
• Dyscoordination of cricopharyngeal function
Clinical Presentation
Most patients develop symptoms due to obstruction and retention
• Upper esophageal dysphagia• Regurgitation• Aspiration• Halitosis• Voice change• Weight loss
Diagnosis of Zenker’s Diverticulum• Endoscopy
– laryngoscopy– short rigid esophagoscopy– flexible endoscopy
• High aspiration risk– Keep patients sitting up– Rapid sequence intubations– Rigid suction at hand– Refractory to Selleck’s maneuver
Treatment options: open procedures
• Diverticulectomy with myotomy– best for the large diverticulum– carries risks associated with esophageal repair
• Diverticulopexy with myotomy– may be suitable for smaller (<2cm) diverticula
• Myotomy alone– may prevent progression of mild symptoms associated with a small
diverticulum
Treatment options: open procedures
• Diverticulectomy or diverticulopexy without myotomy– not recommended– fails to address the basic functional abnormality
Diverticulectomy
Mayo Clinic Series (n=888)• Morbidity=3% Mortality=1.2%
• Recurrence=3.6%
• Good or Excellent relief of dysphagia=93%
Diverticulopexy
• May be useful if healing of a suture or staple line is a concern
• Diverticulum is sutured to the prevertebral facia allowing dependent drainage
• Sutures through the diverticulum (5-0 wire) can obliterate the lumen
Treatment options: endoscopic diverticulectomy
• Described by Dohlman (1964)
• Septum between the diverticulum and the esophagus is divided
• 92-98% success rate at palliating dysphagia
– 3% conversion rate to open procedure
– 30% of cases endoscopic repair not attempted
Endoscopic Options
• Moscher 1917– Divided septum with a knife (punch biopsy)– 7 patients- – Abandoned following postoperative death
• Dohlman and Mattsson 1960– 100 patients/fixed laryngoscope (better visualization)– Endoscopic division of the common wall using a diathermy knife – Symptom recurrence rate 7%, no significant complications were observed
Mosher HP. Webs and pouches of the esophagus: their diagnosis and treatment. Surg Gynecol Obstet 25: 1917. 175–187
Dohlman G, Mattsson O. The endoscopic operation for hypopharyngeal diverticula. Arch Otolaryngol 71: 1960. 744–752
Endoscopic Options• Van Overbeek 1982
– 12 patients (as compared to electrocoagulation)– Septum divided with CO2 laser– Several sessions with larger diverticula– Operating microscope
• Collard 1993– 30mm Endo-GIA stapler/eventually modified stapler tip– Video assistance– 6 patients- dysphagia relieved in 5 and improved in 1
van Overbeek JJ, Hoeksema PE, Edens ET.Microendoscopic surgery of the hypopharyngeal diverticulum using electrocoagulation or carbon dioxide laser. Ann Otol Rhinol Laryngol. 1984 Jan-Feb;93(1 Pt 1):34-6
Collard JM, Otte JB, Kestens PJ.Endoscopic stapling technique of esophagodiverticulostomy for Zenker's diverticulum. Ann Thorac Surg. 1993 Sep;56(3):573-6
OperativeConsiderations
• Diverticulum >3 cm in size
• Limitations to mouth opening
• Prominent overbite
• Cervical osteoarthritis/poor neck flexion
Comparative Studies
• UPMC 2007– Dysphagia scores comparable preoperatively (2.78 OS / 2.79
TOS )
– Improved significantly in both groups (1.1 TOS / 1.0 OS)
– Follow up 17 months
Transoral Stapling of Zenker’s Diverticulum
• Transoral treatment employed from beginning of century• Relative advantages
– No incision/OR time/No pain/Short LOS/Earlier POs/
• Procedure of choice for recurrent Zenker’s diverticulum?• Procedure of choice with previous neck surgery?
• Requires general anesthesia• Small diverticulum – contraindication• Introduction of scope/stapler limited in some patients• Residual spur• Individualized approach
Transoral Stapling of Zenker’s Diverticulum
Transoral Stapling of Zenker’s Diverticulum
Conclusions• The presence of a Zenker’s diverticulum is an indication
for surgery– Symptoms frequently progress
• Routine use of myotomy favored
• Management of diverticulum after myotomy depends on size of residual pouch and patients condition– Rare contraindications to surgery
FEATURES• Least common esophageal diverticulum• Occurs within 10cm from the EG jxn and almost
always of pulsion type• Acquired diverticulum later in adult life • Prevalence difficult to quantitate
– Asymptomatic patients not discovered
• Majority of patients have some form of esophageal dysmotility with functional esophageal obstruction
PATHOPHYSIOLOGY• Increase intraluminal pressure against a
relative obstruction causes mucosal herniation false diverticulum
• Altorki, Orringer, DeMeester suggest all patients have esophageal dysmotility
• Some association with:– Achalasia– Diffuse esohageal spasm– Connective tissue diseases– Hypertensive LES– Reflux strictures
SIGNS AND SYMPTOMS
• Dysphagia
• Regurgitation
• Halitosis
• Chest, epigastric pain
• Cough, hoarseness
• Aspiration pneumonia
• No correlation between size and severity of symptoms
PREOPERATIVE EVALUATION
• Barium esophagram
• Esophagoscopy to rule out achalasia or neoplasm
• Esophageal manometry – Endoscopic placement
– *24hr ambulatory study increased diagnostic yield
• 24hr pH probe if GERD suspected
*Nehra D, DeMeester TR et al., Ann Surg, 2002.
CONTROVERSYShould asymptomatic patients undergo
repair?
Does diverticulum size matter?
Length of esophagomyotomy
? Anti-reflux procedure
TREATMENT• Symptom severity
– Minimal conservative management– Altorki recommends Rx in all patients– Moderate to Severe surgical repair
• Left transpleural approach most common– Diverticulectomy– Long myotomy over 50-54 bougie– Antireflux procedure controversial
• Minimally invasive approach– Thoracoscopy– Laparoscopy found similar to open
TRANSPLEURAL APPROACH Left thoracotomy Diverticulectomy Long myotomy
– Opposite the diverticulum – Including the length of the motor
abnormality
± Anti-reflux procedure– Incomplete Fundoplication– Dor, anterior 180°– Toupet, posterior 270°– Belsy thoracic, posterior 240°
TREATMENTMayo Clinic Series16yr Retrospective study - 112 Patients • 71 pts. no symptoms
• 35 followed long term with no sequelae @ 7yrs
• 41 pts. symptomatic• 33 underwent repair • 90% dysphagia, 82% regurg, 30% aspiration• 50% hiatal hernia
• 9% mortality• 33% major complication (18% leak rate)• Fair or poor long term function in 24%
Benacci JC et al., Ann Thor Surg, 1993.
CORNELL EXPERIENCENEW YORK HOSPITAL
• 21 Patients– Size 3-10cm– 17/21 (81%) Transthoracic diverticulectomy with esophageal
myotomy and anti-reflux procedure– 24% pulmonary symptoms– 52% dysphagia and regurgitation– 43% achalasia – All had abnormal esophageal motility– 26% pulmonary complications
Altorki NK, Skinner DB, J Thorac Cardiovasc Surg, 1993.
REVIEW OF SURGICAL SERIES
Series N D M DM DMA Other Morbidity Mortality
Outcome Excellent
Fekete 1992 27 10 0 1 10 6 9 (2 leak) 11% (3) 77%
Streitz 1992 16 3 13 0 0 0 1 leak 0% 62%
Altorki 1993 17 0 0 0 15 2 NA 6% (1) 88%
Benacci 1993 33 7 1 16 6 3 11 (6 leak) 9% (3) 82%
Nehra
2002
18 0 0 0 13 5 2(bleeding,leak)
5.5% (1) 88%
Varhgese 2007
35 0 0 1 33 1 1 leak 2.8% (1) 76%
Reznik 2007 44 3 0 0 32 9 22 (1 leak) 0% 68%
D = diverticulectomy, M = myotomy, A = antireflux, DMA = combined treatment
MINIMALLY INVASIVE APPROACH• Many small series ( leak rate)
• Found feasible and safe*– Laparoscopic transhiatal approach and
thoracoscopic approach– Diverticulum divided with linear stapler– Myotomy on opposite esophageal side– Anti-reflux procedure
• Potential difficulty with a long myotomy via laparoscopic approach
*Rosati R, et al. Laparoscopic treatment of epiphrenic diverticula. J Laparoendosc Adv Surg Tech A. 2001 Dec;11(6):371-5
ASYMPTOMATIC PATIENTS
• Over a 12 yr period, enlargement was noted in 16%, significance unclear*
• High risk of aspiration found in 46%#
• Overall < 10% will develop sx’s
• Regular clinical and radiologic review once identified
*Bruggeman LL, Seaman WB. Epiphrenic diverticula. An analysis of 80 cases. Am J Roentgenol Radium Ther Nucl Med, 1973; 119:266-276.
#Altorki NK, Skinner DB, J Thorac Cardiovasc Surg, 1993.
CONCLUSIONS• Epiphrenic diverticulae are always associated with esophageal
motor disorders• Symptomatic diverticulae should be repaired• Operative repair in asymptomatic patients controversial
– Food or contrast retention potential indication Castrucci– Series complications occur in 45% pts. Altorki, DeMeester
• Diverticulectomy, diverticulopexy, long myotomy yield a good result in 90% of pts.
• Anti-reflux repair as part of management prevails in more recent series (partial fundoplication, loose Nissen)