Esophageal Diverticulum. Ahmed Hozain, PGY III Kings County Hospital University Hospital of Brooklyn, Surgery Grand Rounds May 18 th, 2017

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1 Esophageal Diverticulum Ahmed Hozain, PGY III Kings County Hospital University Hospital of Brooklyn, Surgery Grand Rounds May 18 th, 2017

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.

2 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

3 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

Started on tube feeds POD 4-5: Fever with tube feeds noted in chest tubes. Made NPO.

4 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.

5 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

POD 14: Leak confirmed on repeat esophogram on POD 14.

6 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

7 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

8 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 followup.

Esophageal Anatomy Divided into 4 parts: Cervical, upper thoracic, middle thoracic, and lower thoracic Length ~ 25cm - 6 th cervical to 11 th thoracic vertebra Anchored to cricoid cartilage, aorta,

10 Esophageal Anatomy Divided into 4 parts: Cervical, upper thoracic, middle thoracic, and lower thoracic Length ~ 25cm - 6 th cervical to 11 th 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

11 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

12 Neurovascular Supply Blood supply Cervical Mid-esophagus Lower esophagus Lymphatics Neural innervation Sympatheic + Parasympathetic function

13 Esophageal Sphincters

14 Esophageal Diverticulum Three most common based on location: Pharyngoesophageal Parabronchial Epiphrenic True vs False vs diverticulum Pulsion vs Traction Zenker s, Epiphrenic, traction

Zenker s Diverticulum Epidemiology: Often presents 7 th decade of life Most common esophageal diverticulum 0.01-0.

15 Zenker s Diverticulum Epidemiology: Often presents 7 th decade of life Most common esophageal diverticulum % 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

16 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

17 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

18 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

19 Comparative analysis of 164 patients undergoing operation for zenker s diverticulum Open n=27, Laser n=68, endoscopic stapler n= 69

21 Haun Y, Zhao Y. Surgical treatment of Zenker s Diverticulum. Digestive Surgery 2013;30:

Midesophageal Diverticula Etiology: Historically: Tuberculosis Historically Today: Histoplasmosis Sarcoidosis, carcinoma, chronic lymphadenopathy Motility disorders

22 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

23 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

24 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%)

25 Eiphrenic Diverticulum Diagnosis: Esophagraphy and CT EGD rules out Manometry Characteristics: Average size of 7cm Often right sided (68%) Common in 6 th decade of life Treatment: Generally reserved for symptomatic patients

Thoracic Approach Open Transthoracic approach: 1. EGD with 50-54 fr placement of bougie 2. Left posterolateral thoracotomy 7 th intercostal space 3. Isolation of esophagus 4.

26 Thoracic Approach Open Transthoracic approach: 1. EGD with fr placement of bougie 2. Left posterolateral thoracotomy 7 th 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

27 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

28 Retrospective review 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.

Retrospective review of 35 patients from 1979 2005. All received transthoracic triple threat procedure Median age 71 Average 6.

29 Retrospective review of 35 patients from 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

31 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

33 Thank You

Gastroesophageal reflux disease Principles of GERD treatment Treatment of reflux diseases GERD

Esophagus Anatomy/Physiology Gastroesophageal reflux disease Principles of GERD treatment Treatment of reflux diseases GERD Manometry Question 50 years old female with chest pain and dysphagia. Manometry