Editing Oesophageal diverticulum


== '''General''' ==

* Most diverticula are the     result of a primary motor disturbance, or abnormality of the UOS/LOS
* Pulsion diverticula - false     diverticula that occur because of elevated intraluminal pressures,     generated from abnormal motility disorders
** Zenker
** Epiphrenic
* Traction diverticula -     external inflammatory mediastinal lymph nodes adhering to the oesophagus     as they heal and contract, distorting it
** More common in the      mid-oesophageal region around the carinal nodes

== '''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)

== '''Mid-oesophageal diverticula''' ==

* Anatomy
** Typically seen on the right      due to an overabundance of structures in the mid-thoracic region on the      left
* Pathophysiology
** Traction diverticula
** Historically mostly TB
** Now more commonly caused by      histoplasmosis and resultant fibrosing mediastinitis
** Some may also be caused by a      primary motility disorder
* Presentation
** Mostly asymptomatic
** Often incidentally found
** Can get dysphagia, chest      pain and regurgitation
** Can present with chronic      cough or haemoptysis from a bronchoesophageal fistula
* Diagnosis
** Barium swallow
** CT scan essential
** Gastroscopy as part of      workup to rule out mucosal abnormalities
***
** Manometric studies highly      recommended by Sabiston's to exclude a primary motility disorder -      aetiology will determine treatment
* Management
** Diverticula <2cm can be      observed
** Asymptomatic patients with      inflamed mediastinal lymph nodes - treat underlying cause
** Symptomatic or >2cm      diverticula - surgery
*** Diverticulopexy to thoracic       vertebral fascia if it has a wide mouth and rests close to the spine
*** Diverticulectomy if       anatomically favourable - take care not to narrow oesophageal lumen
** Severe chest pain or      dysphagia and a documented motor abnormality - long oesophagomyotomy
*


== '''Epiphrenic diverticula''' ==

* Anatomy
** Distal third of oesophagus      (within 10cm of GOJ), adjacent to the diaphragm
** Mostly on the right side and      mostly wide-mouthed
* Pathophysiology
** Pulsion diverticula
** Related to thickened distal      oesophageal musculature or increased intraluminal pressure
** Associated with diffuse      oesophageal spasm, achalasia or hypertensive LOS disorders
** Can be seen in EDS or trauma      too
* Presentation
** Mostly asymptomatic
** Can have dysphagia or chest      pain, especially with an underlying motility disorder
* Diagnosis
** Barium swallow - identify      size, position and proximity to diaphragm
** Manometric studies for the      underlying disorder
** Gastroscopy to look for      mucosal lesions including Barrett's, oesophagitis and cancer
* Treatment
** Similar to midoesophageal      diverticula
** Generally, a myotomy is      necessary to treat the underlying pathology
** <2cm diverticula can be      suspended from vertebral fascia without being excised, and perform a      myotomy
** Diverticulectomy - use a      bougie to prevent narrowing the oesophagus, close muscle over excision      site, and perform a myotomy on the opposite oesophageal wall from the      level of the diverticulum to the LOS
** If a large hiatal hernia is      present, excise the diverticulum, perform a myotomy, and repair the      hernia (otherwise high incidence of reflux)
*

[[Category:UGIS]]