brief presentation of mid & distal esophageal diverticula management mainly focusing on treatment aspects

1. Surgical Management of Mid- &
Distal Esophageal Diverticula
Dr ROHAN NU
MCh Resident
Institute of SGE & LTx
5.5.2022

2. Introduction
• Defined as focal outpouching of one or more layers of esophageal wall
• Described by their location : pharyngoesophageal, mid-esophagus & epiphrenic
• Usually false diverticulum; true variety occurs in mid-esophagus & is rare
• Often asymptomatic; common among elderly with multiple comorbidities, careful surgical planning
necessary

3. DISTAL ESOPHAGEAL (EPIPHRENIC) DIVERTICULUM

4. Introduction
 A pulsion diverticulum most often found in the distal 10 cm of the esophagus, usually false variety
(outpouching of mucosa & submucosa only); m/c on RIGHT side
 almost always secondary to an underlying esophageal motility disorder (achalasia > DES)
 Other proposed causes – distal stricture, prior fundoplication, hiatus hernia
 Dysmotility  uncoordinated contraction between the distal esophagus and LES  increased
intraluminal pressure  subsequent herniation through a weakened area of the esophagus

5. Diagnosis
 Usually asymptomatic; dysphagia m/c symptom
(90%), followed by regurgitation; repeated aspiration
in 30%
 Initial study is BS; HRM & OGD also in evaluation
before surgical planning
 CT scan of the chest for determining the true
proximal extent of the diverticulum.
 Decision to offer Rx based on presence & SEVERITY of
symptoms

6. BARIUM SWALLOW OGD HRM
 Allows measurement of length
and size of diverticulum
 Orients diverticulum (right/left)
 Identifies other pathology such
as hiatal hernia, stricture
 Provides information about
esophageal motility
 Defines anatomy of
diverticulum, including precise
location relative to GEJ
 Assesses for concomitant
pathology such as ulceration
malignancy
 Used to treat bleeding, place
manometry catheter, feeding
tube
 Defines underlying motility
disorder
 May need to be placed
endoscopically or under
 fluoroscopy
 Potentially guides length of
myotomy

7. Sx
 The decision to offer treatment is based on the patient’s symptoms & SEVERITY of those
symptoms
 Asymptomatic patients can be managed conservatively; continued follow-up is necessary
because of the development of worsening symptoms
 Surgical principles
• Delineation of the entire diverticulum at the mucosal level
• Definition of the “neck” of the diverticulum
• Resection of the diverticulum
• Closure of the overlying muscle with or without buttress
• Distal myotomy with or without partial fundoplication

8.  Approaches
 Open Transthoracic
 Video-assisted thoracic surgery (VATS)
 Laparoscopic
 combined VATS + Lap
 endoscopic approach
 Choice of approach depends mainly on location & size of diverticulum
 Assess the location of the diverticulum based on the location of the upper border of the
diverticulum in relation to endoscopically identified GEJ.

9.  Diverticula <5 cm above the GEJ, a lap transhiatal approach
 Diverticula >5 cm above the GEJ or above the inferior pulmonary vein, a combined thoracoscopic-
laparoscopic minimally invasive approach
 Reasons for need for an esophagomyotomy
 Most diverticula are associated with an underlying motility disorder & a distal obstruction or high
pressure zone increases the risk for staple line dehiscence and subsequent leak
 myotomy creates the potential for GERD, which requires a fundoplication and/or the need for PPI

10. TRANSTHORACIC APPROACH
 7th or 8th ICS LEFT thoracotomy
 Entire distal esophagus mobilized including hiatus
 overlying muscle is split along the length of the diverticulum taking care to avoid the vagus nerve
 muscle dissected away to expose the superior & inferior margins of the diverticulum
 Define the “neck” / “waist”, till the mucosal level
 Intra-op endoscopy can be used

11.  Stapler division of diverticulum; adjacent muscle edges approximated with pleura
 Buttress of pleura / intercostal muscle can also be added
 The esophagogastric myotomy on contralateral side, at the location of the inferior aspect of
diverticulectomy
 Distally extended onto the stomach for 2 cm; proximal extent depends on surgeon
 +/- partial fundoplication

13. VATS ± LAP MYOTOMY /
FUNDOPLICATION
 placement of double-lumen endotracheal tube,
patient placed in the left lateral decubitus position
 4 ports
1. seventh intercostal space [ICS] posterior axillary line
for surgeon’s left hand, stapler
2. ninth ICS in the line of the scapular tip for the
camera
3. fourth ICS posterior axillary line for retraction and
suctioning
4. seventh ICS just inferior & posterior to the scapular
tip for the surgeon’s right hand
4th ICS
Assistant
port
7th ICS
9th ICS - Camera
7th ICS

14.  VATS only approach difficult to perform distal myotomy; access to proximal stomach limited
 So lap approach used for completion of myotomy with/without a partial fundoplication
 To ensure the proper extent of the myotomy, the distal end of the diverticulum is marked with a
clip on the anterior surface of the esophageal wall at the completion of the VATS portion

15. LAP TRANSHIATAL APPROACH
 low lithotomy with placement of 5 ports.
 Identification of both vagi, max mobilization till distal
extent of divertivculum & complete circumferential
dissection
 Dissection at neck of diverticulum till mucosa
exposed
 Stapler used over an endoscope / bougie & stapler
line reinforced
 Myotomy performed along the left anterior wall of
the esophagus just to the left of midline
 diverticula >5 cm from the GEJ will be inadequately
addressed; higher propensity for incomplete
resection or a staple line leak at the superior-most
aspect of the diverticulectomy

17. ENDOSCOPIC APPROACH
 At experimental stage; GE reflux is a potential complication
 Khashab MA. Thoughts on starting a peroral endoscopic myotomy program. Gastrointest Endosc.
2013;77(1):109-110.
 Liu B-R, Song J, Fan Q. 899 endoscopic esophageal epiphrenic diverticulum inversion by using the
submsubmucosal tunneling technique. Gastrointest Endosc. 2015;81(5):AB180.
 submucosal tunnel created to facilitate a distal esophageal myotomy (as done during POEM for
achalasia)
 diverticulum is inverted into the lumen & an endoscopic snare placed around the neck of the
diverticulum; mucosa eventually sloughs and the defect heals over time
 A channel is created between the diverticulum and the gastric body by means of a
transdiverticulum-to-gastric puncture and subsequent dilation of the channel and placement of an
endoscopic stent

18. COMPLICATIONS
 Surgery specific complications - staple line leak, incomplete myotomy, vagal nerve injury
(manifested by delayed gastric emptying), and pleural effusion
 Staple line leaks are best avoided by careful and meticulous dissection, re-approximation of the
esophageal muscle, and complete myotomy
 If occurs NPO, broad-spectrum antibiotics, alternate form of nutrition support; OGD very
important for early Mx
 When feasible options are endoscopic stenting, clips, or suturing to control leakage
 if not successful OPEN wide drainage, control of contamination & +/- diversion

19. OUTCOMES

20. OUTCOMES continued…

21. MIDDLE ESOPHAGEAL DIVERTICULUM

22. Introduction
 True diverticula; found in the middle one-third of the esophagus within 4 to 5 cm of the
tracheal carina
 A traction diverticula that occur due to mediastinal inflammation pulling on the esophageal
wall to create the diverticulum in the middle third of the esophagus [Sarcoidosis, TB,
Histoplasmosis]
 congenital component related to an incomplete trachealesophageal fistula or foregut
duplication
 In addition to the traction etiology, there is most likely a pulsion component, as motility
disorders are present in over 80% of patients

23. Diagnosis
 Typically asymptomatic, due to their wide-mouth
opening and dependent drainage; diagnosed
incidentally
 Symptoms include intermittent dysphagia and some
with occasional retrosternal pain, heartburn, and/or acid
reflux
 Ongoing inflammation  erosion  fistula between
airway & diverticulum  bleeding 2* to erosion
bronchial artery branch
 The initial test that identifies the diverticulum is a CT
scan of the chest during evaluation for mediastinal
adenopathy or for chronic cough
 HRM in the absence of obvious chest pathology
 Bronchoscopy along with OGD

24. Sx
 Best approached with a right thoracotomy through 5th ICS (ease of access to the carina,
mediastinal nodes, and esophagus)
 Extensive inflammation, extensive scarring & distorted anatomy expected
 separate the esophagus and diverticulum from the adjoining mediastinal nodes
 diverticulum should be isolated, and the mucosa should be evaluated and repaired or resected
depending on the degree of damage
 overlying muscle layers should be re-approximated over top with an interposition graft usually
intercostal muscle – prevents recurrence
 Distal myotomy for underlying motility disorder

25. Thank You