Editing Oesophageal diverticulum (section)

== '''Zenker diverticulum''' ==

* Anatomy
** False diverticulum (mucosa      and submucosa)
** Forms between oblique fibres      of thyropharyngeus and horizontal fibres of cricopharyngeus (Killian      triangle)
** As the diverticulum      enlarges, it projects down the left side of the oesophagus into the      superior mediastinum, along the paravertebral space
**
* Pathophysiology
** Probably related to loss of      muscle tone and tissue elasticity with age
** ?secondary to impaired      relaxation or fibrosis of the cricopharyngeus component of upper      oesophageal sphincter - sometimes referred to as cricopharyngeal      achalasia
** Most often seen in 60-80      year olds, and mostly men
** Most common oesophageal      diverticulum
* Clinical
** Asymptomatic until it begins      to enlarge
** Dysphagia - most common
** Throat discomfort
** Nagging cough
** Excessive salivation
** Regurgitation of      foul-smelling material
** Halitosis, voice change,      retrosternal pain
** Respiratory infections
** Can lead to weight loss,      malnutrition
** Boyce's sign - cervical      borborygmus in setting of palpable neck mass and emaciation
** Can present with bleeding      ulcer in diverticulum
** Can harbour malignancy
* Diagnosis
** Barium swallow - need a      lateral view
*** 'Cricopharyngeal bar' - the       diverticulum can be seen filled with contrast, resting posteriorly       against the oesophagus
** Gastroscopy and manometry      are unnecessary to diagnose
***

*

* Surgical approaches
** Open options
*** Myotomy + diverticulectomy       (patients with good tissue and sac >5cm)
**** Expose cervical oesophagus
***** Shoulder balloon, head         ring, turn head to right
***** Anterior SCM incision         from thyroid notch to sternum
***** Sub-platysmal flaps
***** Dissect along medial edge         of SCM
***** Divide posterior belly of         omohyoid, or just retract it anteromedially
***** Thyroid medial, carotid         sheath lateral - ligate middle thyroid vein if needed
***** Finger dissection to get         onto spine - identify pre-vertebral fascia, which needs to be         mobilised to access posterior oesophagus
***** Once oesophagus has been         nicely dissected, identify diverticulum
**** Dissect diverticulum free        to base
***** Grasp sac with babcock,         use peanut to bluntly dissect onto base of diverticulum
**** Identify cricopharyngeus
***** Divide over right angle         with some sort of bipolar, to see mucosa underneath
***** Textbook is posterior         midline
***** The mucosa will then         bulge without restriction. This muscle division usually decreases the         upper sphincter resting tone by about 50%.
**** Stapled diverticulectomy
***** TA white 40 or EndoGIA         purple if articulation is required for access
**** If get stuck at any point,        and at the end for a leak test, use the gastroscope
*** Myotomy of proximal and       distal thyropharyngeus and cricopharyngeus alone (generally sufficient       in diverticula <2cm)
*** Myotomy + diverticulopexy
**** Suture the diverticulum to        the posterior pharynx as opposed to the prevertebral fascia to allow        free vertical movement during deglutition
** Endoscopic
*** Harder with smaller/rounder       diverticula
*** Favoured in more frail       patients
*** Shorter post-op course
*** Favoured for diverticula       between 2 and 5cm
*** Endoscopic exclusion       (Dohlman procedure)
*** Endoscopic division of the       common wall between oesophagus and diverticulum (stapler, laser, or       electrocautery)