Esophageal Diverticulum - SUNY Downstate Medical Center · • Often presents 7. th. decade of life • Most common esophageal diverticulum • 0.0111% population prevalence -0. •

Esophageal Diverticulum Ahmed Hozain, PGY III Kings County Hospital

University Hospital of Brooklyn, Surgery Grand Rounds May 18th, 2017

www.downstatesurgery.org

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


Presenter

Presentation Notes

EGD: negative for H.Pylori

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


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.


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


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


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


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.



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


Presenter

Presentation Notes

Esophagus begins at the level of the 6th cervical rib and is found at the end of the complex muscle found in the larynx and posterior pharynx which consist of three consecutive muscles that begin at the base of the palate and end at the crest of the esophahgus Cervical: lies in neck, bordered superiorly by the hypopharynx, and inferiorly by the thoracic inlet (lies at level of sternal notch) - ~ 15-20 cm from incisors Upper thoracic: supeiroly the thoracic inlet and inferiorly by the lower border of the azygos vein 20-25cm from incisors Middle thoracic: Lower border of the azygos superiorly and inferiorly by the inferior pulmonary veins 25-30cm from incisors Lower thoracic esophagus: superiorly by the inferior pulmonary vein and inferiorly by the stomach – Includes the EGJ and 30-40cm UES – at about 15-17 cm – Composed of dense cricopharngeus muscle that relaxes and it blends into the circular muscles of the esophagus inferiorly LES – At about 38-40 cm – More of a physiologic sphincter than an anatomic one. Area of high hintraluminal pressure and is influenced by aparacrine homrnoe and the intrinsic nervous system. Anterolateral indentation secondary to the L mainstem bronchus at about 25cm Between these areas of narrowing you will find two distinct areas known at the superior and inferior dilations where the esophagus resumes it’s normal size of ~ 2.5cm. Curvature: The cervical esophagus begins as a midline structure that deviates slightly to the left of the trachea as it passes through the neck into the thoracic inlet. At the level of the carina, it deviates to the right to accommodate the arch of the aorta. It then winds its way back under the left mainstem bronchus and remains slightly deviated to the left as it enters the diaphragm through the esophageal hiatus at the level of the 11th thoracic vertebra.

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


Presenter

Presentation Notes

Mucosa: Inner layer – non-keratinized squamous lined epithelium. This is the case for the majority of the esophagus except for the distal 1-2cm where there is a transition to esophageal columnar epithelium at the point known as the Z-line. Lamina propria: Containing blood vessels and nerves. The lymphatics begin here and form saccules just outside the basement membrane that will then extend to the submucosa. Muscularis mucosa: Allows for mucosal crinkling when not distended Submucosa: Loose connective tissue with mucus secreting glands and Meissner’s plexus. Here there is an extensive network Of longitudinal lymphatic and vascular structures as well as mucous glands and Meissner’s neural plexus. Muscularis propria: Composed of 2 layer: deep circular and a superficial thinner longitudinal muscle layers with Auerbach’s plexus in between So the cricopharyngus muscle is basically a continuous band of muscle originating from the cricoid cartilage superior and it blends into the phyrngeal constrictors inferiorly. This layer will then blend into the circular layers of the muscularis propria distally. The longitudinal muscle layer of the muscularis pro-pria originates from the lateral aspect of the cricoesophageal tendon. Posteriorly, these anterior and lateral components converge to meet at the midline and in turn leave the proximaly 1-2 cm of the posterior cervical esophagus is composed only of inner circular muscle, creating a potential for a mirror-image triangular area of weakness called killians triangle. Contraction of the longitudinal muscle fibers of the esophageal body produces esophageal shorten-ing. The inner circular muscle is arranged in incom-plete rings producing a helical pattern. There is a some loose adventitial covering to the muscular coat on the outside of the esophagus, however, there is no true serosal layer

Neurovascular Supply

• Blood supply • Cervical • Mid-esophagus • Lower esophagus

• Lymphatics • Neural innervation

• Sympatheic + Parasympathetic function


Presenter

Presentation Notes

Arterial supply: Cervical branches of the ITA, a branch of the thyrocerical trunk. Smaller branches can come off the pharyngeal, Subclavian, common carotid Midesophagus: this happens at the level of the tracheal bifurcation, is supplied by branches of the bronchial artery or directly off the aorta Lower third and the stomach portion of the esophagus are both supplied by branches of theh L gastric artery and possibly branches from the L inferior phrenic artery. Venous supply: There is a rich subepithelial venous plexi in the lamina propria which runs longitudinally along the whole length of the esophahgus, receiving blood from adjacent capillaries and drains into theh submuousa plexus. From here this drains into an extrminic esopphhgeal venous plexus and thereon into nearby larger veins. Drainage generally follows the arterial supply. Lymphatics: Extnesive and consists of two interconnecting lymphatic plexuses The submucosa plexus penetrates theh msucularis propria and drains into the plexus that runs longitudinally in the esophageal wall which then drains into regional lymph node beds In the upper 2/3 thoax, the drainage is upwards, whereas in the distal 1/3, the flow is downwards The intricate lymphatic network of the esophagus allows for rapid spread of infection and tumor into three body cavities. It stands to reason that the rich arterial supply to the esophagus makes it one of the more durable organs in the body with respect to surgical manipulation, whereas its comprehensive venous and lymphatic drainage create an oncologic challenge to controlling cellular migration. Sympathetic: Both parasympathetic and sympathetic nerves innervate the esophagus. Branches of the vagus nerve supply parasympathetic fibers that are motor to the muscle coat and secretomotor to the submucosal glands. The cervical and thoracic sympathetic chain and the celiac plexus provide sympathetic fibers that promote contraction of sphincters and relaxation of the esophageal body muscle, increase peristaltic and glandular activity, and cause vasoconstriction.

Esophageal Sphincters


Presenter

Presentation Notes

UES spincter remains at constant state of 60mmhg of tone presenting air transfer inot the esophahgus LES: constant pressure at 24 which prevents just enough material from refluxing back up into the esophahgus.

Esophageal Diverticulum

• Three most common based on location: • Pharyngoesophageal • Parabronchial • Epiphrenic

• True vs False vs diverticulum • Pulsion vs Traction

• Zenker’s, Epiphrenic, traction


Presenter

Presentation Notes

True: involves all layers of the esophahgeal wall (mucosa/submucosa False: consists of the mucos and the submucosa only Pulsion: false diverticula that occur b/c of elevated intraluminal pressure – often 2/2 abnormal motility disorders. This leads to the mucosa/submucosa herniating through the muscular layer. Traction: these are true diverticula which arise 2/2 to external inflammatory mediastinal lymph nodes adhering to the eesophahgus as they heal and contract, pulling the esophaphgus during the process. thi

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


Presenter

Presentation Notes

Killian’s triangle: between the oblique fibers of the thryopharyngeus muscle and the horizontal fibers of the cricopharyngeus muscle

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


Presenter

Presentation Notes

Both resection and pexy open procedure take about 1 hour to complete under general anesthesia. Both require a Myotomy of the proximal and distal thyropharyngeus and cricopharyngeus muscles. Endoscopic technique also requires full extension of the neck and can be difficult in pts’ w/ cerbical stensosi. Takes about 1 hour to complete.

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


Presenter

Presentation Notes

Anatomically, the closing muscles of UES are composed of inferior pharyngeal constrictor, cricopharyngeus muscle and cervical esophagus. Important to note that w/ diverticula < 2cm, often times the myotomy alone will lead to disappearsnce of the sac.

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


Presenter

Presentation Notes

The difference between the Stapler and laser is that it is suspected that there is less rate of recurrence when you laser as there is no chance that you are leaving behind any criopharyngeus muscle

• Comparative analysis of 164 patients undergoing operation for zenker’s diverticulum

• Open n=27, Laser n=68, endoscopic stapler n= 69


Presenter

Presentation Notes

Study at t theh unveristy of Miami


Haun Y, Zhao Y. Surgical treatment of Zenker’s Diverticulum. Digestive Surgery 2013;30:207-218


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


Presenter

Presentation Notes

They are often incidentally found during a workup fro some other complaint CT is helpful to determine mediastinal lymphadenopathy and lateralerize the sac EGD important to r/o mucosal abnormalities that may be hidden w/I the sac.

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


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%)


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


Presenter

Presentation Notes

Important to note that there is no correlation between the size and the sx that develop

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


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?


• 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.


Presenter

Presentation Notes

Out of the 41 pts w/ sx needing surgery, 3 were high risk and 5 refused surgery) Out of the 33 pts requiring surgery, 5 had antireflux procedures performed. Long term follw up was performed in 29/30 surviors and ranged from 4 months to 15 years. They did this through telephone calls, or letters. There were 6 late death, not related to esophaphgeal procedure (pneumonia, CHF , Cancer, RA). All able to tolerate diet after theh procedure. Weight game from 11-23kg in the patients who presented w/ weight loss prop. 17% (5)had dysphagia had symptoms post op, 4 of these pt had preoperative dysmotility. All 5 required post operative dilation. Non-Op patients. Of theh 71, 27 were lost to follow up.

• 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


Presenter

Presentation Notes

All patients underwent Anti-reflux procedure, 29 had belsey and 4 nissen fundoplication.


Presenter

Presentation Notes

These studies here are all published and represent the biggest studies looking at results following esophahgeal surgery for epiphrenic diverticula. In general, these reports reflect a relatively high morbidity and mortality compared with other surgical intervnetions for benign esophageal disease.

• 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



Thank You


Documents

Esophageal Diverticulum - SUNY Downstate Medical Center · • Often presents 7. th. decade of life • Most common esophageal diverticulum • 0.0111% population prevalence -0. •