Epiphrenic diverticulum
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EPIPHRENIC DIVERTICULUM
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Epiphrenic diverticulum
- 1. Case presentation Georges Khalifeh PGY4 General surgery Lebanese University
- 2. Clinical case History goes back to 12 years prior to presentation, when the patient started complaining from regurgitation, and mild dysphagia The patient has consulted a gastrologist, and a gastroscopy was done
- 4. Clinical case PPIs were prescribed, without a marked amelioration in the symptoms. Upper GI was done.
- 5. Upper GI.
- 6. Upper GI.
- 7. Gastroscopy was repeated, in 2014, with addition of some prokinetic drugs.
- 11. Clinical case Syptoms begun to worsen since 4 years, with added frequent vomiting and regurgitation of undigested foods, with dysphagia to both solids and liquids, assiciated with marked weight loss (about 10 kg in the last few years). A gastroscopy was repeated in 2017, and general surgeon consulted.
- 12. Gastroscopy 2017
- 13. What is an esophageal diverticulum? An esophageal diverticulum is a pouch that protrudes outward in a weak portion of the esophageal lining. This pocket-like structure can appear anywhere in the esophageal lining between the throat and stomach.
- 14. Pathophysiology Upper (pharyngoesophageal, Killian-Jamieson, or Zenker) Middle lower (epiphrenic)
- 15. Congenital vs Acquired Congenital diverticula are diverticula that are present at birth, while acquired diverticula develop later in life. Diverticula of the esophageal body can sometimes be difficult to classify as congenital or acquired
- 16. True vs False True diverticula False diverticula(pseudodiverticula) A special type of pseudodiverticula, believed to represent dilated excretory ducts of esophageal submucosal glands, is observed in the condition esophageal intramural pseudodiverticulosis.
- 17. Pulsion vs Traction Pulsion diverticula Zenker diverticulum Epiphrenic diverticulum Traction diverticula Mid esophageal diverticulum
- 18. Who is affected by esophageal diverticula?
- 19. Epidemiology Age Middle aged adults and elderly people. Infants and children Zenker diverticula ( 50 y ,especially 70- 80 )
- 20. Are there any complications? Aspiration pneumonia Obstruction Squamous cell carcinoma
- 21. Are esophageal diverticula serious? Increasing symptoms : Dysphagia Regurgitation Aspiration pneumonia
- 22. Are esophageal diverticula serious? Obstruction
- 23. Are esophageal diverticula serious? Squamous cel carcinoma
- 24. What are the symptoms of esophageal diverticula? The symptoms of esophageal diverticula include: Dysphagia Pulmonary aspiration (the entry of secretions or foreign material into the trachea and lungs) Aspiration pneumonia (a lung infection caused by pulmonary aspiration) Regurgitation of swallowed food and saliva Pain when swallowing Cough Neck pain Weight loss Bad breath (halitosis) Some people may experience a gurgling sound as air passes through the diverticulum. This is known as Boyce's sign.
- 25. Back to our case…
- 26. Clinical case On physical examination, the patient looks well, thin. Vitals within normal range Abdomen was not distended, with positive bowel sounds, soft, non tender
- 27. Clinical case Upper GI series ordered:
- 28. Clinical case A manometey was ordered
- 29. manometry
- 30. manometry
- 31. manometry
- 32. Clinical case The patient on pre-op examination, he had dyspnea, transferred to ER. A CT chest was ordered for a suspected Pulmonary Embolism. The patient had aspiration pneumonia
- 33. CT chest
- 34. CT chest
- 35. Clinical case Achalasia was diagnosed, with associated epiphrenic diverticulum. He was sckedueled for OR
- 36. Preoperative Planning Review of barium esophagram Defines esophageal anatomy Diet
- 37. Preoperative Planning Rapid induction of anesthesia and intubation Upper endoscopy Prophylactic antibiotics Foley
- 38. Positioning
- 39. Positioning
- 40. After the esophagogastric junction was indentified, the operation started with mobilization of the abdominal esophagus from the diaphragmatic pillars and dissection of the diaphragmatic cruses.
- 41. Once a wide retroesophageal space was created, gentle traction was applied to the esophagus using a retractor. The gastroesophageal junction was then encircled with umbilical tape to aid with traction during the mediastinal dissection. Then, epiphrenic diverticulum of the esophagus was mobilized from the mediastinum about 7 cm above the diaphragmatic cruses
- 42. After preparation of the diverticular pouch was completed, the 4 cm long diverticulum neck was sewn with the endoscopic linear surgical stapler Echelon FLEX 60 under intraoperative esophagogastroscopic control Endoscopy is repeated to check for the adequacy of the myotomy and ruling our mucosal injury.
- 43. The resected diverticulum was inserted in a retrieval bag. No evidence of esophageal stricture was observed, and the operation continued with esophageal myotomy 5 cm above and 3 cm below the gastroesophageal junction. After myotomy was performed, a test with gas showed no leaks from the staple line. The procedure was completed with Dor fundoplication. Ethibond 3/0 interrupted stitches were used.
- 44. The bottom of the anterior stomach wall was sewn to the myotomy edges with Ethibond 2/0 interrupted stitches from both sides. To close the diaphragmatic lesion the upper stitches The patient tolerated the surgery well. The overall operative time was 180 min.
- 45. On the first postoperative day an esophagogram with Gastrografin swallow (Photo 6) and chest X-ray was performed. It excluded any defects of suture line integrity and pneumothorax. The patient had no complaints of dysphagia or vomiting.
- 48. Pathology The results of histological analysis showed a 7.5 cm × 6 cm esophageal diverticulum with 0.3 cm thickness of the wall. It was covered with stratified squamous cell epithelium, had some focal erosions, and was infiltrated with monomorphic leukocytes. Partial or total atrophy of the muscular layer of the diverticulum was observed.
- 49. A liquid diet was prescribed for 3 days; it was tolerated without any pain, regurgitation or dysphagia. On the 4 day after surgery the patient was discharged from hospital in a good state of health with recommendations for a soft diet for 5 days.
- 50. From the 10 postoperative day the patient resumed a regular diet. Four weeks after the operation the patient had no complaints, symptoms of dysphagia or vomiting.
- 52. DEFINITION Distal 10 cm of the esophagus 20% of all esophageal diverticulum FALSE PULSION
- 53. DEFINITION The underlying pathophysiologic mechanism is a result of increased intraluminal pressure, presumably secondary to an esophageal motility disorder : Achalasia Hypertensive lower esophageal sphincter Distal peptic ulcer Prior fundoplication Any of these processes may lead to herniation of the mucosa and submucosa through an area of weakness in the muscle layers of the esophagus.
- 54. DIFFERENTIAL DIAGNOSIS Hiatal hernia Esophageal webs and strictures Esophageal duplication cyst Esophageal carcinoma
- 55. PATIENT HISTORY AND PHYSICAL FINDINGS symptomatic in only 15% to 20% of cases. Typical symptoms include : Dysphagia regurgitation. Reflux chest pain Pulmonary symptoms Malodorous breath
- 56. PATIENT HISTORY AND PHYSICAL FINDINGS On history, it is important to elicit whether the patient experiences symptoms of GE reflux disease, regurgitation, chest pain, or dysphagia. Additional medical history such as recurrent pneumonia, lung abscesses, or repeated aspiration episodes is pertinent. A history of weight loss is not uncommon. Prior procedures such as esophageal dilations or botulinum toxin injection are also pertinent.
- 57. How is esophageal diverticulum diagnosed? Barium swallow Gastrointestinal endoscopy Esophageal manometry 24-h pHmetry Epiphrenic diverticula are associated with an underlying esophageal motility disorder in most cases. It is imperative to not only assess the size and location of the diverticulum but also to characterize the motor function of the esophagus.
- 58. Imaging Studies Barium radiography (ie, barium esophagography, barium swallow) generally is the diagnostic procedure of choice.
- 60. Imaging Studies Esophageal manometry
- 61. High resolution manometry High-resolution manometry (HRM) is a variant of the conventional manometry in which multiple recording sites are used, thus creating a “map” of the esophageal contractions. This technology allows detection of segmental peristaltic defects, detecting motor defects in a higher number of patients with epiphrenic diverticula.
- 62. Treatment How is esophageal diverticulum treated?
- 63. Nonsurgical treatment Mild esophageal diverticula can usually be managed through lifestyle changes, such as: thoroughly chewing your food eating a bland diet drinking lots of water after you eat to help with digestion. Antacids
- 64. Medical Care Asymptomatic and minimally symptomatic esophageal body diverticula do not require treatment.
- 65. Medication Botulinum toxin has been used successfully as an alternative to surgical myotomy or pneumatic dilation for the treatment of achalasia. OnabotulinumtoxinA (BOTOX®) Botulinum toxin type A is produced by Clostridium botulinum and is responsible for botulism in humans. Botulinum toxin type A produces denervation of affected muscle tissue by irreversibly binding to presynaptic nerve endings and inhibiting the release of acetylcholine. When endoscopically injected into the lower esophageal sphincter (LES), interference with cholinergic transmission of the myenteric plexus leads to smooth muscle relaxation with a subsequent fall of the LES resting pressure. This drug has been used in other fields of medicine to treat spastic torticollis and blepharospasm.
- 66. In many patients with mid esophageal and epiphrenic diverticula, dysphagia is related to underlying dysmotility; thus, treatment should be directed to the motility disorder when feasible. For instance, achalasia can be treated with pneumatic dilation, botulinum toxin injection into the lower esophageal sphincter, or surgical Heller esophagomyotomy.
- 67. Endoscopic treatment of an epiphrenic diverticulum using a fully covered self-expanding metal stent
- 69. SURGICAL MANAGEMENT The need for surgical resection of epiphrenic diverticula largely depends on the patient’s symptoms. Small, asymptomatic diverticula (less than 3 cm) often do not require intervention. Symptomatic patients with small diverticula may benefit from myotomy (with concomitant partial fundoplication) to correct the underlying motility disorder. Larger diverticula require diverticulectomy in addition to myotomy (with concomitant partial fundoplication).
- 70. OPEN THORACIC APPROACH The operative steps for an open transthoracic epiphrenic diverticulum resection are similar to those described earlier for the minimally invasive approach. A 7th interspace thoracotomy is used. An open left thoracic approach is ideal when a fundoplication is to be performed from the chest (Belsey Mark IV). Use of a thoracoabdominal (TA) stapler or resection and hand-sewn closure of the mucosa are commonly used techniques for resection of the diverticulum when an open approach is used.
Editor's Notes
- Esophageal diverticula are classified by location in the esophagus.
- Diverticula also may be classified on the basis of histopathology. True diverticula contain all layers of the intestinal tract wall. False diverticula, also known as pseudodiverticula, occur when herniation of mucosa and submucosa through a defect in the muscular wall occurs (eg, Zenker diverticulum). A special type of pseudodiverticula, believed to represent dilated excretory ducts of esophageal submucosal glands, is observed in the condition esophageal intramural pseudodiverticulosis.
- acquired diverticula of the esophagus and hypopharynx also may be classified according to their pathogenesis as pulsion diverticula or traction diverticula. Pulsion diverticula form as a result of high intraluminal pressures against weaknesses in the GI tract wall. Zenker diverticulum occurs due to increased pressure in the oropharynx during swallowing against a closed upper esophageal sphincter. An epiphrenic diverticulum occurs from increased pressure during esophageal propulsive contractions against a closed lower esophageal sphincter. In contrast, traction diverticula occur as a consequence of pulling forces on the outside of the esophagus from an adjacent inflammatory process (eg, involvement of inflamed mediastinal lymph nodes in tuberculosis or histoplasmosis).
- Most esophageal diverticula occur in middle-aged adults and elderly people. Presentation in infants and children is rarely seen. Zenker diverticula typically present in people older than 50 years and especially present during the seventh and eighth decades of life
- Over time, an esophageal diverticulum can lead to some health complications. Aspiration pneumonia. If an esophageal diverticulum causes regurgitation, it can lead to aspiration pneumonia. This is a lung infection caused by inhaling things, such as food and saliva, that usually travel down your esophagus. Obstruction. An obstruction near the diverticulum can make it hard, if not impossible, to swallow. This can also cause the pouch to rupture and bleed. Squamous cell carcinoma. In very rare cases, ongoing irritation of the pouch can lead to squamous cell carcinoma.
- Typically, esophageal diverticula are nuisances that enlarge slowly over many years, gradually producing increasing symptoms, such as dysphagia, regurgitation and aspiration pneumonia, caused by breathing in regurgitated diverticula content. Regurgitation caused by a diverticulum often occurs at night when lying down, which can lead to choking, aspiration pneumonia (a lung infection caused by pulmonary aspiration, the entry of secretions or foreign material into the trachea and lungs), and lung abscesses.
- When symptoms of esophageal diverticula worsen, a person may be unable to swallow due to an obstruction near the diverticulum; rarely, the esophagus may rupture. An obstruction or rupture caused by an esophageal diverticulum is dangerous, and both complications require immediate attention.
- Although rare, squamous cell carcinoma can develop in 0.5 percent of those with diverticula. This is thought to be caused by chronic irritation of the diverticula by prolonged food retention. It is important to note that the fear of cancer is not a reason to surgically treat diverticula.
- A review of the barium esophagram is helpful to confirm the size and location of the diverticulum relative to the diaphragm and GE junction. It also defines the esophageal anatomy in terms of degree of esophageal dilation and presence of megaesophagus or sigmoid appearance in the setting of achalasia. The patient’s diet should be restricted to clear liquids for 2 days prior to surgery to minimize the accumulation of food debris in the diverticulum prior to operation.
- The anesthesiologist must be informed that rapid sequence induction is needed to minimize risk of aspiration. After induction of anesthesia, upper endoscopy should be performed to delineate esophageal anatomy, rule out malignancy, and remove debris from the pouch. Esophagogastroduodenoscopy (EGD) should also evaluate for the presence of a “pop,” which is consistent with achalasia. Prophylactic antibiotics should be administered prior to skin incision, with consideration given to covering for oral flora, anaerobes, and yeast. Standard procedures such as sequential compression devices and Foley catheter are employed.
- Positioning of the patient varies with surgical approach. When approaching epiphrenic diverticula from the abdomen, the patient is positioned supine. Surgery was performed under general anesthesia with orotracheal intubation, by the laparoscopic approach. The patient was placed in a reverse Trendelenburg (30-degree) supine position with legs spread. The surgeon stood between the patient's legs.
- A Veress needle was inserted 5 cm above the umbilicus. To form the pneumoperitoneum, CO at 10 mm Hg was used. The trocar and video laparoscope were placed. Under the control of the laparoscope, two trocars (10 mm and 12 mm) on the left side of the abdomen and two 10 mm trocars on the right side of the abdomen were inserted
- Epiphrenic diverticula are those that occur in the distal 10 cm (lower third) of the esophagus. They constitute approximately 20% of all esophageal diverticula. Epiphrenic diverticula are thus false, or pulsion, diverticula.
- Most commonly, epiphrenic diverticula occur in the setting of achalasia or diffuse esophageal spasm. A high-pressure environment in the esophageal lumen is potentially created by some form of distal functional or mechanical obstruction, such as a non relaxing, hypertensive lower esophageal sphincter (LES); repetitive normal to high amplitude simultaneous contractions; or a distal peptic stricture. A prior fundoplication for the treatment of reflux may also lead to epiphrenic diverticula in the setting of an esophageal motility disorder.
- The differential diagnosis of epiphrenic diverticula includes hiatal hernia, esophageal webs and strictures, esophageal duplication cyst, and esophageal carcinoma.
- Epiphrenic diverticula are estimated to be symptomatic in only 15% to 20% of cases. Typical symptoms include dysphagia and regurgitation. Reflux and chest pain may also commonly occur. Pulmonary symptoms may include chronic cough, productive or purulent sputum, or chronic dyspnea. Malodorous breath may also be present.
- The tests most commonly used to diagnose and evaluate esophageal diverticulum include: Barium swallow: The patient swallows a barium preparation (liquid or other form) and its movement through the esophagus is evaluated using X-ray technology. Gastrointestinal endoscopy: A flexible, narrow tube called an endoscope is passed through the gastrointestinal tract and projects images of the inside onto a screen. Esophageal manometry: This test measures the timing and strength of esophagus contractions and muscular valve relaxations. 24-h pHmetry: A test to check for the presence of gastroesophageal reflux disease (GERD).
- A barium esophagram is the initial test performed to define the anatomy of the diverticulum and esophagus. Size, location, and right or left sidedness can be determined from the esophagram. This provides a “road map” for operative planning, as diverticula more than 7 to 10 cm above the diaphragm are not easily through the transhiatal route and may be better approached from the chest. Barium esophagrams may also offer information about motility.
- Preoperative upper endoscopy is necessary to examine the esophagus and stomach for the presence of Barrett’s, esophagitis, and to exclude malignancy.2 In addition, the presence of a pop upon passage of the scope across the LES may further confirm the diagnosis of achalasia. Lastly, it is important to remove debris from the diverticulum on the day of surgery.
- manometry is helpful to better define underlying motility disorders. can be helpful to evaluate lower esophageal sphincter pressure, lower esophageal sphincter relaxation, and esophageal body function in symptomatic patients if achalasia or another esophageal motility disorder is suspected or if surgery is being considered. It can also demonstrate the incoordination between the buccal squirt and relaxation of the cricopharyngeus, although special manometric techniques are usually required.
- High-resolution manometry, the current gold standard, is necessary to evaluate for an underlying esophageal motility disorder. In the setting of achalasia, manometry demonstrates aperistalsis with a nonrelaxing LES. Other manometric patterns seen in the setting of epiphrenic diverticula include diffuse esophageal spasm (80% or more simultaneous contractions of normal amplitude), nonspecific motility disorder, nutcracker esophagus, or hypertensive LES. Failure to identify and treat the underlying motility disorder during diverticulum resection has been associated with high rates of recurrence and leak along the suture line in the range of 10% to 20%.1 Specifically, failure to perform an adequate myotomy in such patients has yielded leak rates exceeding 25% when diverticulectomy alone is performed.
- Cases of esophageal diverticulum that cause minor symptoms can be treated through lifestyle changes, such as eating a bland diet, chewing food thoroughly, and drinking plenty of water after meals. Over-the-counter antacids can also help with mild symptoms.
- SURGICAL MANAGEMENT The need for surgical resection of epiphrenic diverticula largely depends on the patient’s symptoms. Small, asymptomatic diverticula (less than 3 cm) often do not require intervention. Symptomatic patients with small diverticula may benefit from myotomy (with concomitant partial fundoplication) to correct the underlying motility disorder. Larger diverticula require diverticulectomy in addition to myotomy (with concomitant partial fundoplication).