VCOM Louisiana Research Day Program Book 2024

Case Studies

Rebecca Peters, MS; Bakeer Mohamed, MD; William Liles, MD; Savannah Newell, PhD VCOM-Louisiana; St. Francis Medical Center 56 OPEN PHARYNGOESOPHAGEAL DIVERTICULECTOMY IN THE TREATMENT OF A LARGE ZENKER’S DIVERTICULUM

Background: A Zenker’s Diverticulum is a rare condition, occurring in 0.01% to 0.11% of the population. This condition most commonly affects middle-aged or elderly individuals, and commonly presents as dysphagia, halitosis, cough, regurgitation of food, and weight loss. What differentiates a Zenker’s Diverticulum specifically within the esophagus is its location in the hypopharynx between the cricopharyngeus muscle and the pharyngeal constrictor muscles. These diverticulae can range in size up to 15cm but most commonly present at less than 4 cm in size. The most common treatment for this condition is an endoscopic diverticulectomy. Objective: The purpose of this case report is to describe the case of a 93-year-old female with an abnormal presentation, found to have a large Zenker’s Diverticulum after thorough investigation. This case also describes the use of open surgical repair, due to comorbidities preventing the patient from undergoing endoscopic repair. This report contributes to the field of surgery by providing knowledge on an a rare pathology with a somewhat uncommon presentation, a large size, and an open surgical repair. Methods: I observed/Assisted on the open surgical repair of a large Zenker’s Diverticulum in

our patient, and assisted with the management of her postoperative care. In addition, I spoke with the family to obtain informed consent for the use of the patients images to be used for the purposes of medical education. After the surgery, I conducted a thorough review of the literature regarding this pathology. The surgical repair entailed: The patient was originally placed in the supine position, and the neck and abdomen were prepared in sterile fashion. An endoscope was placed originally to verify the position of the diverticulum, and then was passed to the stomach. A transverse incision was made above the sternal notch, and Bovie electrocautery was used to dissect through the subcutaneous tissue and platysma. Sub platysmal flaps were created superiorly and inferiorly. The strap muscles were then divided at the raphe revealing the thyroid gland. Due to the large size of the diverticulum and the left lobe of the thyroid, we elected to perform a left thyroid lobectomy tying off the superior and inferior poles taking down the left lobe at the isthmus which was sent for specimen. The esophagus was bluntly dissected off of the spine and the diverticulum was identified a cricopharyngeal myotomy was performed , taking down the muscle superiorly and inferiorly releasing the diverticulum down to the base at the esophagus

this portion was stapled off and due to the thin nature of the staple line it was oversold with 3-0 vicryl suture the strap muscles and platysma were re approximated using 3-0 vicryl sutures the skin was then reapproximated using 4-0 monocryl due to concern for passing the endoscope and G drove through the esophagus and the staple line we elected to perform an open gastrostomy tube placement. Results: The patient is a 93 year-old female who presented to the emergency department due to lethargy and disorientation after multiple falls with a decrease in responsiveness and appetite, malnutrition, and a productive cough. The patient has a past medical history of HTN, atrial fibrillation (on Eliquis), hypothyroidism, arthritis, and GERD. The patient presented with vitals WNL (T 97.7 F, P 65, RR 15, BP 131/78, SPO2 94%), and increased liver enzymes (AST 126, ALT, 150). CBC and CMP were WNL except for Sodium (128 (L), PT 16.7 PTT 11.1, and mild anemia. The patient was ill-appearing upon admission. Physical exam demonstrated a regular heart rate and rhythm rales present bilaterally, but worse in the lower left lung fields. Her abdomen was flat with no lower extremity edema. An upper abdominal ultrasound returned normal results, but following chest XR, there was evidence of multifocal pneumonia and

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