Dysphagia in middleDysphagia in middleage man age man

Dr Daniela Munteanu Institute of Gastroenterology and Liver DiseaseSoroka University Medical Center

בריא פרט לעישוןבריא פרט לעישון67-67-בן בן ..

..חודשים טרם אשפוזו החל לסבול מדיספגיהחודשים טרם אשפוזו החל לסבול מדיספגיה 9 9

ובהמשך גם לנוזליםובהמשך גם לנוזלים, , דיספגיה בתחילה למצוקיםדיספגיה בתחילה למצוקים ..

גג''''קק17 17 ירידה במשקל ירידה במשקל - - חודש אחרוןחודש אחרון

תקינהתקינה ::בדיקה גופניתבדיקה גופנית

שאר שאר , ,HBHB-12.8, -12.8, albumin-3.1albumin-3.1: : במעבדהבמעבדהפפ..ממ..בב- - בדיקות דם שגרתיותבדיקות דם שגרתיות

What is the diagnosis? What is the diagnosis?

בדיקת גסטרוסקופיה בדיקת גסטרוסקופיה

What to do with the patient?What to do with the patient?

esophagus

vagus

diverticulum

Epiphrenic diverticulaEpiphrenic diverticula

Diverticulum of the distal esophagus, Diverticulum of the distal esophagus, (lower 6-10 cm)(lower 6-10 cm)

The real incidence unknown , The real incidence unknown ,

only 15-20% are symptomatic only 15-20% are symptomatic

Etiology- pulsion diverticulum due to Etiology- pulsion diverticulum due to motility disorder (achalasia, motility disorder (achalasia, diffuse esophageal spasm, hypertensive diffuse esophageal spasm, hypertensive lower esophageal sphincter ).lower esophageal sphincter ).

Clinical presentationClinical presentation

Dysphagia Dysphagia

Regurgitation, Regurgitation, nocturnal cough, nocturnal cough, aspiration aspiration pneumonia pneumonia

Chest pain Chest pain

Weight loss Weight loss

Clinical presentationClinical presentationThe size of diverticulum influence the The size of diverticulum influence the severity of symptoms(1-14cm, median severity of symptoms(1-14cm, median 4-7)4-7)

Epiphrenic diverticulum 5cm or Epiphrenic diverticulum 5cm or greater-100% symptomaticgreater-100% symptomatic

Epiphrenic diverticulum less than 5cm-Epiphrenic diverticulum less than 5cm- 41% symptomatic 41% symptomatic

Fewer than 10% of asymptomatic patients Fewer than 10% of asymptomatic patients will develop symptoms due to diverticulumwill develop symptoms due to diverticulum

85%20Varghese et al.

87%23D’Journo et al.

75%20Fernando et al.

81%21Tedesco et al.

100%13Del Genio et al.

85%13Melman et al.

100%21Nehra et al.

PRIMARY ESOPHAGEAL MOTILITY DISORDER

NUMBER OF PATIENTSAUTHOR

Renato Soares,j Gastrointest Surg(2010)14:2009-2015Renato Soares,j Gastrointest Surg(2010)14:2009-2015

Study-of 21 patients with epiphrenic diverticulum Study-of 21 patients with epiphrenic diverticulum -esophageal motility abnormalities were found in -esophageal motility abnormalities were found in all all patients (stationary esophageal motility study patients (stationary esophageal motility study +ambulatory motility testing )+ambulatory motility testing )

Nehra , et al –An of surgery-2002,vol235Nehra , et al –An of surgery-2002,vol235

Large series from the Mayo Clinic (33 patients) found Large series from the Mayo Clinic (33 patients) found motility abnormality-in 60 % of them, but in the remaining motility abnormality-in 60 % of them, but in the remaining patients-they were unable to pass the manometric probe patients-they were unable to pass the manometric probe into the stomach. into the stomach. Benacci JC,AnnThorac Surgery-1993;55:1109-1113Benacci JC,AnnThorac Surgery-1993;55:1109-1113

Study of 35 patients with epiphrenic diverticulum –found Study of 35 patients with epiphrenic diverticulum –found motility disorder in 82% of patients. Here is supported motility disorder in 82% of patients. Here is supported Belsey’s original teaching that an esophagomyotomy is Belsey’s original teaching that an esophagomyotomy is indicated in the treatment of every esophageal pulsion indicated in the treatment of every esophageal pulsion diverticum.diverticum.Varghese,et al.AnnThorac Surg2007;84:1801-1809Varghese,et al.AnnThorac Surg2007;84:1801-1809

Management of epiphrenic diverticulum Management of epiphrenic diverticulum results of open operations for epiphrenic diverticulumresults of open operations for epiphrenic diverticulum

0%Overall-37.5%

Leak-6%

Resection alone-3

Resection +long myotomy-3

Myotomy of LES alone -10

16Streitz et al.

1992

11%Reflux esophagitis-15%

Reoperation-22%

Leak-0%

Resection alone-10

Right thoracotomy, resection, myotomy,

fundoplication-10

Abdominal myotomy+fundoplivation

-4, other-6

27Feketc et al. 1992

Mortality rate

Complication rate

Technique usedNumber of cases

series

9%Overall-33%

Leak-21%

Left thoracotomy-32

Right thoracotomy-1

Myotomy+resection-22

Resection alone-7

Myotomy alone -1

33Bennaci

Et al.

1993

5.9%Leak-0%Lt.thoracotomy approach for all; myotomy,

resection+Belsey-13

Myotomy,pexy+Belsey-1

Myotomy, resection+Nissen-1

17Altorki et al.

1993

Mortality

rate

Complication

rate

Technique usedNumber of cases

series

..

2.8%Leak-6%Open transthoracic operation : resection of the diverticulum, long esophagomyotomy, and antireflux operations

35Varghese

Et al.

2007

6%Reoperation-11%

Leak-6%

Lt. thoracotomy ,resection,myotomy-13

Lt.thoracotomy, pexy+ myotomy-4

Antireflux procedures:

Dor-2,Modified Belsey-14, Nissen-1

17Nehra

Et al.

2002

Mortality

rates

Complication ratesTechnique usedNumber of

cases

series

5%5%Overall Overall --45%45%

LeakLeak--20%20%

Laparoscopic Laparoscopic diverticulectomydiverticulectomy--,myotomy ,myotomy and partial fundoplicationand partial fundoplication

1616FernandoFernando

Et al. Et al.

20052005

7%7%LeakLeak--23%23%Laparoscopic transhiatal Laparoscopic transhiatal diverticulectomy, myotomy, diverticulectomy, myotomy,

NissenNissen--Rosetti fundoplicationRosetti fundoplication

1313Del Del GenioGenio

Et al.Et al.

20042004

0%0%Conversion Conversion to open to open operationoperation--11

Leak9%,Leak9%,

empyemaempyema--9%9%

Laparoscopic Laparoscopic diverticulectomy, myotomy,diverticulectomy, myotomy,

partial fundoplicationpartial fundoplication

1111Klaus et Klaus et al .al .

20032003

0%0%LeakLeak--9%9%Laparoscopic transhiatal Laparoscopic transhiatal diverticulectomy, myotomy,diverticulectomy, myotomy,

partial fundoplicationpartial fundoplication

1111Rosati Rosati

Et al.Et al.

20012001

Mortality Mortality ratesrates

ComplicatioComplication rates n rates

Technique usedTechnique usedNumber Number of casesof cases

seriesseries

5%5%Overall Overall --45%45%

LeakLeak--20%20%

Laparoscopic Laparoscopic diverticulectomydiverticulectomy--,myotomy ,myotomy and partial fundoplicationand partial fundoplication

1616FernandoFernando

Et al. Et al.

20052005

7%7%LeakLeak--23%23%Laparoscopic transhiatal Laparoscopic transhiatal diverticulectomy, myotomy, diverticulectomy, myotomy,

NissenNissen--Rosetti fundoplicationRosetti fundoplication

1313Del Del GenioGenio

Et al.Et al.

20042004

0%0%Conversion Conversion to open to open operationoperation--11

Leak9%,Leak9%,

empyemaempyema--9%9%

Laparoscopic Laparoscopic diverticulectomy, myotomy,diverticulectomy, myotomy,

partial fundoplicationpartial fundoplication

1111Klaus et Klaus et al .al .

20032003

0%0%LeakLeak--9%9%Laparoscopic transhiatal Laparoscopic transhiatal diverticulectomy, myotomy,diverticulectomy, myotomy,

partial fundoplicationpartial fundoplication

1111Rosati Rosati

Et al.Et al.

20012001

Mortality Mortality ratesrates

ComplicatioComplication rates n rates

Technique usedTechnique usedNumber Number of casesof cases

seriesseriesResults of minimally invasive operations for epiphrenic diverticulum

To operate only symptomatic patients with To operate only symptomatic patients with epiphrenic diverticulumepiphrenic diverticulum

The laparoscopic approach is considered The laparoscopic approach is considered today as the surgical treatment of choice today as the surgical treatment of choice

The transthoracic approach should be The transthoracic approach should be used for patients who have giant or very used for patients who have giant or very high diverticula, or when the technical high diverticula, or when the technical expertise with minimally invasive expertise with minimally invasive techniques is not available.techniques is not available.

Alternative treatmentAlternative treatment

Botulinum toxin injectionBotulinum toxin injection -decrease LES by -decrease LES by 33%, improves dysphagia in 66% of patients for 33%, improves dysphagia in 66% of patients for a six month period (for older adults or individuals a six month period (for older adults or individuals who are poor risks for definitive treatmentwho are poor risks for definitive treatment((

Pneumatic dilatation Pneumatic dilatation –clinical efficacy range –clinical efficacy range from-32% to 98%. Incidence of perforation from-32% to 98%. Incidence of perforation 1-5%(3%)1-5%(3%)

רקערקע70 , 70 , בן בן - -hypertensionhypertension

אובחן כסובל מאכלזיה של הושטאובחן כסובל מאכלזיה של הושט2002- 2002- משנת משנת עם עם

Epiphrenic diverticulum Epiphrenic diverticulum גדולגדול . .

ממ""ממ30 30 עבר הרחבה פנאומטית עם בלון עבר הרחבה פנאומטית עם בלון 2004- 2004- בב. . שגרם להקלה ניכרת בכל התסמיניםשגרם להקלה ניכרת בכל התסמינים

בשל קושי בליעה מינימאלי עבר הרחבהבשל קושי בליעה מינימאלי עבר הרחבה2005- 2005- בבמ מ ""ממ35 35 עם בלון עם בלון

,,אך עדיין סימני רגורגיטציהאך עדיין סימני רגורגיטציה, , אין קושי בבליעהאין קושי בבליעה--מאזמאז . .שיעול לילי שיעול לילי