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Presented by: Date:
Diverticula of the Esophagus
ANZGOSA-2010
John G Hunter MDMackenzie Professor and
Chair, SurgeryOregon Health and Science
UniversityPortland OR
Esophageal Diverticula
• Three types– Pulsion (associated with motor disorders)
• Occur immediately above UES and LES• Zenker’s and Epiphrenic diverticula
– Traction (associated with inflammatory disease)
• Occur in mid-esophagus, near carina• TB, lymphoma (treated) most common
– Iatrogenic• The result of surgical destruction of the muscularis
Management of esophageal diverticula
• Treat the underlying motor disorder– Heller myotomy– Long myotomy– Cricopharyngeal myotomy
• Resect large pulsion diverticula• Leave small pulsion diverticula, traction
diverticula, and iatrogenic diverticula alone
Zenker’s Diverticulum
• Described in 1877 by Friederich Albert von Zenker • First transoral treatment by Mosher in 1917• Technique of Open Cricopharyngotomy and
Diverticulectomy gold standard for years
Transoral TechniquesTransoral Diathermy reported by Dohlman in 1960Carbon Dioxide Laser “septotomy” reported by Van Overbeek in 1981Transoral stapling by Collard and Martin-Hirsch in 1993
Nasogastric tube assists orientation
Stay sutures pull septum into jaws of Stapler
The Transoral Cricopharyngeal
Myotomy Completed
Manometry and Scintigraphy after Transoral Stapling
Peracchia A, Bonavina L, et al. Arch Surg 1998;133:695–700.
Results of Transoral Stapling vs Open Repair
Gutschow CA, Collard JM. Ann Thorac Surg 2002;74:1677–1683
Complications: 5.5% v. 11.8%Oral Diet: 1 Day v. 4.5 days
Zenker’s Management “pearls”
• Small Diverticula (<3 cm) are more amenable to open approaches
• Laser techniques can be performed with flexible endoscopy, but risk perforation
• Stapled transoral cricopharyngotomy has become the gold standard
Recurrence is usually a result of incomplete division of cricopharnygeous
Epiphrenic Diverticula are a heterogeneous lot
Epiphrenic Diverticula-The CommonDenominator
• High Pressures in the Distal Esophagus resulting from– Chronic outflow obstruction (achalasia,
hypertensive LES, peptic stricture)– Spasm (DES)– Peristaltic hypertension (Nutcracker)
• Association recognized in 1833• Mondiere JT, Notes sr quelques maladies de
l’oesophage. Arch Gen Med Paris 1833
Epiphrenic diverticula- Symptoms
• Dysphagia- Most Common• Regurgitation• Weight loss• Chest pain• Aspiration
• A combination of these features
Epiphrenic Diverticula- Evaluation
• Barium Swallow • Esophagagoscopy• Esophageal
Motility Study
Is a Motility Disorder always present?
• U Michigan -82%• USC – 100%
– Achalasia –9 (43%)– Diffuse esophageal spasm -5– Hypertensive LES – 3– Nutcracker esophagus – 2– Non specific motility disorder –2
• Nehra, D; Ann Surg 2002, 235:346-54
It depends on how hard you look!
Epiphrenic Diverticula - Management
• Asymptomatic- Observe• Symptomatic
– Treat Diverticulum– Treat Motility Disorder– Treat Diverticulum and Motility Disorder– Treat Diverticulum, Motility Disorder, and
Perform Fundoplication
Treat the Diverticulum only
• Stapled Diverticulectomy
• Diverticular Suspension
• Diverticular plication
Treat the motility disorder only (small tics)
• Long Myotomy• Heller Myotomy
Treat the Diverticulum and Motor Disorder Laparoscopy
• Diverticulectomy and Myotomy - no Rotation
• Diverticulectomy and myotomy- 90 deg
Treat the Diverticulum and Motor DisorderLeft Thoracotomy
• Diverticulectomy and Myotomy - no Rotation
• Diverticulectomy and myotomy- 90 deg
• Diverticulectomy and myotomy- 180 deg
Treat the Diverticulum, Motility Disorder and Perform Fundoplication
• Heller – Dor– Belsey– Toupet
Laparoscopy, Thoracoscopy or Thoracotomy?
Outcomes of Surgical Management-Open
Institution Case # Techniques Complication MortalityMayo (1993) 33 L T, myotomy and
resection33% ,
Leak - 21%9%
NYC (1993) 17 LT, myotomy, resection, Belsey
Leak -0% 6%
Houston (1999) 15 All known techniques
Leak -6% 0%
USC (2002) 17 LT, myotomy, resection, Belsey
Reop-11%Leak-6%
6%
Michigan (2007) 35 LT, myotomy, resection, Belsey
Leak – 6% 2.8%
Outcomes of Surgical Management -MIS
Institution Case # Techniques Complications MortalityMilan (1998) 11 Lap, resection,
myotomy, DorLeak-9% 0%
Mayo (2003) 11 Lap, resection,myotomy, Dor
Leak -9%Empyema -9%
0%
Naples (2004) 13 Lap, resection, myotomy, R-H
Leak -23% 7%
Pitt (2005) 16 Lap-10, VATS-6
Leak – 20% 5%
ATL/PDX(unpub)
15 Lap -10, VATS-4
Leak- 15% 0%
Management “Pearls”
• Wash out the Diverticulum on table or day before surgery
• LES myotomy may decrease the frequency of staple line leaks
• Treat the staple line with respect– Avoid immediate feeding. Barium study before d/c
• Large mouthed diverticula >5 cm above GEJ may be hard to reach through the hiatus– Perform myotomy with laparoscopy,
diverticulectomy via R thoracotomy
Diverticula of the Esophagus- Summary
Diverticula- when symptomatic- require surgical management
Pulsion Diverticula require myotomy Most diverticula can be treated with
minimally invasive techniques