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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