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Esophageal Diverticulum Ahmed Hozain, PGY III Kings County Hospital
University Hospital of Brooklyn, Surgery Grand Rounds May 18th, 2017
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Case Presentation
• 53 YOF presented to KCHC with sx of dysphagia for ~ 1 year
• On CT imaging found to have large epiphrenic diverticulum
• Esophogram showed large 5.3cm epiphrenic diverticulum
• No delayed esophageal motility • Small sliding hiatal hernia
• PMH/PSH: Fibromylagia, depression, metastatic breast CA (MRM), RA, DM, HTN
• EGD: bx shows chronic inflammation of stomach with large diverticula
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Procedure: • 3/14: EGD, L thoracotomy with
diverticulectomy • Complicated by post resection stricture on
intraop EGD • Subsequent distal esophagectomy with
esophagogastrostomy and Belsey IV fundoplication.
• Post-op reintubated in SICU secondary to poor respiratory effort
• 2 CT placed
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Post-Op Course • POD2: Extubated • POD 4 CT w/ oral contrast: No
evidence of leak. R loculated collections. Started on tube feeds
• POD 4-5: Fever with tube feeds noted in chest tubes. Made NPO. Started on broad spectrum Abx. CT Scan
• POD 5: Taken back to OR: • Esophageal perforation above staple
line. • Primary repair with pericardial
rotation buttress flap. NGT placed above anastomosis.
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Post-Op Course
• POD 6: TPN started • POD 6-9: persistent fevers,
leukocytosis. CXR shows complete opacification of L. Chest
• Third Chest tube placed – Minimal output
• POD 9: Esophogram negative for leak. Minimal output from chest tubes
• POD 11: Chest tube tPA started for 3 days. Increased drainage from CT.
• POD 9-12: Persistent leukocytosis, fevers. However, clinically appeared well
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Post-Op Course • POD 13: Repeat CT A/P shows apical pleural loculation with
evidence of esophageal leak. • POD 14: Leak confirmed on repeat esophogram on POD 14. • POD 15: Drainage of entire L pleural loculated collection by
IR. AKI secondary to vancomycin toxicity
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Post-Op Course
• POD 18-21: Leukocytosis improving. Dced Abx. Pigtail removed. CXR improving.
• POD 22: Significant SOB, Hypoxia. CTA w/o evidence of PE. Improved collections within the L Chest.
• POD 27: Repeat Esophogram: Controlled Leak
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Post Op Course
• POD28-35: Re-deveoplment of leukocytosis, restarted antibiotics with resolutions of sx. 2 CT removed. Afebrile. NPO/TPN.
• POD 38: Repeat Esophogram: No signs of leak.
• POD 39: NGT removed. Started soft diet. No evidence of leak
• POD 42: Discharged home on soft diet.
• OP Follow-up: Doing well, however complains of reflux. For GI follow-up.
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Esophageal Anatomy
• Divided into 4 parts: • Cervical, upper thoracic, middle thoracic, and lower thoracic
• Length • ~ 25cm - 6th cervical to 11th thoracic vertebra
• Anchored to cricoid cartilage, aorta, right and left pleura, pericardium
• 3 anatomic points of stricture • UES, LES and at ~ 25cm from incisors
• Curvature • Initial left deviation: • Second left deviation: • deviation to the left as it descends to the thoracic inlet
extending
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Anatomy contd.
• Layers Composed of • Mucosa:
• Epithelium • Basement membrane • Lamina propria: • Muscularis mucosa
• Submucosa: • Muscularis propria:
• Outer longitudinal Layer, inner circular layer • Divided into thirds based on muscle content
• Proximal: 100% striated • Middle: Mixture of striated/smooth muscle • Distal: 100% smooth muscle
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Neurovascular Supply
• Blood supply • Cervical • Mid-esophagus • Lower esophagus
• Lymphatics • Neural innervation
• Sympatheic + Parasympathetic function
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Esophageal Sphincters
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Esophageal Diverticulum
• Three most common based on location: • Pharyngoesophageal • Parabronchial • Epiphrenic
• True vs False vs diverticulum • Pulsion vs Traction
• Zenker’s, Epiphrenic, traction
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Zenker’s Diverticulum • Epidemiology:
• Often presents 7th decade of life • Most common esophageal diverticulum • 0.01-0.11% population prevalence • Killian’s Triangle • Often left sided and posterior
• Symptoms • Commonly complaints of “sticking in the throat” • Cough • Excessive salivation • Halitosis • Voice changes • Retrosternal pain • Respiratory infections and aspiration
• Diagnosis • Barium esophagraphy with lateral views
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Zenker’s Diverticulum
• Treatment • Open
• Surgical resection • Fixation • Post op stays in hospital for 2-3 days • Reserved for diverticula > 5cm
• Endoscopic • Reserved for diverticula > 3cm • Stays in hospital • Reserved for diverticula 2-5cm
• Post Op: • Patient’s undergo swallow study
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Transcervical Approach 1. EGD with 36fr boogie placement 2. Left neck incision along SCM 3. Subplatysmal flaps with lateral retraction of the SCM and
medial retraction of the strap muscles and thyroid 4. Transection of the omohyoid +/- 5. Ligation of the middle thyroid vein 6. Lateral retraction of the carotid sheath 7. Identification of the RLN and medial retraction of the
trachea 8. Isolation of the diverticulum 9. Contralateral cricopharyngeal myotomy – 4cm distal to
neck of diverticulum 10. Diverticulectomy 11. Water-leak test 12. Closure with JP placement
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Endoscopic Approach 1. Use of diverticuloscope to
identify the common channel 2. Placement of 2 sutures to
secure common channel 3. Stapling vs CO2 laser device
to divide the common channel – Specifically the Criopharyngeus muscle
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• Comparative analysis of 164 patients undergoing operation for zenker’s diverticulum
• Open n=27, Laser n=68, endoscopic stapler n= 69
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Haun Y, Zhao Y. Surgical treatment of Zenker’s Diverticulum. Digestive Surgery 2013;30:207-218
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Midesophageal Diverticula • Etiology:
• Historically: Tuberculosis – Historically • Today: Histoplasmosis • Sarcoidosis, carcinoma, chronic lymphadenopathy • Motility disorders
• Symptoms: • Incidentally found • Can present as:
• Dysphagia • Chest pain • Regurgitation • Chronic cough • Hemoptysis
• Location: • Commonly Right sided
• Diagnosis: • Esophagraphy and CT • EGD • Manometry
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Treatment
• Motility disorders • Similar to epiphrenic with Right
thoracotomy approach • Reports diverticulectomy, myotomy, or
diverticulopexy all have been used
• Inflammation • Diverticulectomy, excision of inflammatory
lymph nodes and interposition muscle pad
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Eiphrenic Diverticulum • Etiology:
• Often associated with dysmotility disorder (43-100%)
• Hiatal hernia (29%) • Symptoms:
• Often symptomatic • Regurgitation (81%) • Chest pain (62%) • Heart burn (57%) • Intermitted aspiration overnight (48%)
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Eiphrenic Diverticulum
• Diagnosis: • Esophagraphy and CT • EGD – rules out • Manometry
• Characteristics: • Average size of 7cm – Often right sided
(68%) • Common in 6th decade of life
• Treatment: Generally reserved for symptomatic patients
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Thoracic Approach Open Transthoracic approach: 1. EGD with 50-54 fr placement of bougie 2. Left posterolateral thoracotomy – 7th
intercostal space 3. Isolation of esophagus 4. Mobilization of diverticula and isolation 5. Diverticulectomy – Stapler 6. Esophagomyotomy – Contralateral
1. Carries onto the stomach and proximally though areas of dysmotility
7. +/- Anti-reflux procedure • Belsey Mark IV procedure
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Alternative Surgical Approach
• Transabdominal vs Transthoracic approach • Open vs Laparoscopic approach –
• Lap/Transabdominal approaches reserved for very distal diverticula.
• > 4cm • Close to GE junction
• Area of debate: • When to operate? • Are myotomies required? To what
length?
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• Retrospective review 1975 – 1991
• 112 patients (42% Female) • Thoracotomy surgical repair in
33 patients (41 required surgery)
• Divertictectomy and esophagomyotomy – 22 patients
• Diverticulectomy – 7 patients • Esophageal resection – 3 patients • Esophagomytomy – 1 patients
• Results: • Median - 13 days hospital • 11 (33%) morbidity rate
• Leak 18% • Pneumonia (6%), A-fib (6%), central line
sepsis (3%) • 3 (9%) mortality
• 2 in pts with esophageal leaks • All three patients had preoperative
dysmotility • Non-Op Patients:
• 47 Asymptomatic • 27 lost to follow up:
• 24 minimal symptoms (9 had regurgitation)
• 9 lost to follow up • Medial 6.9 follow up. • No patients had clinical progression of
symptoms.
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• Retrospective review of 35 patients from 1979 – 2005. • All received transthoracic triple threat procedure • Median age 71 • Average 6.4cm diverticulum size and duration of 3 years of symptoms • Advocate for proximal esophagomyotomy to level of aortic arch • Results:
• 2.8% mortality (1 perioperative death) – Plicated diverticulum leak, mediastinitis • 2.8% Non-fatal suture line leak. Total 5.7% • Median hospital stay of 7 days • 74% w/o residual symptoms • 20% required post operative esophageal dilatation for dysphagia
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• Retrospective review of 20 patients (5 years) • 16 epiphrenic and 4 midesophageal
diverticula. • Avg age 70.5 with similarly described
presenting symptoms • Results:
• Laparoscopy – 10 Patients • VATS – 7 patients • VATS/Laparosocpy – 2 • Laparoscopy/Thoracotomy – 1 • 12 patients had triple threat procedure. • Overal 45% complication rate
• 20% esophageal leak rate. • 5% mortality (Leak) • Significant improvement in dysphagia
postoperatively at 18 months follow up
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Thank You
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