Case Conference 2502451 醫五 Clerk ⚫ K07132 施翰琳 患者主訴： Suffer from swallow difficulty, recurrence esophageal diverticulum, admitted for VATS diverticulectomy. ⚫ 現在病史： This 55-year-old female, who denied any systemic disease such as hypertension or diabetes mellitus, complained of difficulty swallowing. According to her statement, she accepted surgical intervention with thoracoscopic excision of esophageal diverticulum at 20181128, and regularly follow up at our OPD, but loss follow up after one year. Recently, she suffered from difficulty swallowing, so she came to our GI OPD for help, so on 20220812 Esophagography was arranged and showed recurrent esophageal diverticulum. Then, on 2022/08/29 Upper G-I panendoscopy reveal: 1. Gastroesophageal reflux disease, LA Grade A. 2.Esophagus diverticulum, 4-4.5 cm, middle to lower esophagus. 3.Gastric polyps, body, GCS, r/o fundal gland polyps. Then she was referred to CS Dr. Chen OPD for further operation management. Under impression of esophageal traction diverticulum, she was admitted for further survey and surgical management. ⚫ 過去病史： 嚼檳榔：無 吸菸(含電子菸)：無 旅遊史：無 職業別：其它 接觸史：無 群聚：無 Allergy History: contrast (whole body skin rash) Past Medical History: nil Surgical Medical History: Caesarean section on 1987, thoracoscopic excision of esophageal diverticulum at 20181128 Social and Personal History: denied alcohol drinking, denied smoking, denied betel nut chewing Family History: father- gout hyperuricemia ⚫ 系統評估： General： Fever(-) , Sweating(-), Irritability(-),Fatigue(-) ⚫ 入院診斷： 1. Esophagus diverticulum, 4-4.5 cm, middle to lower esophagus 2. Hypertension ⚫ 治療計畫： 1. Arrange chest CT for pre-op survey 2. Full lab survey 3. Post OP care Discussion: Esophageal diverticulum ⚫ Classification According to their location 1. Zenker’s diverticulum (pharyngoesophageal): is the most common type of diverticulum of the esophagus. Zenker’s diverticulum are usually located in the back of the throat, just above the esophagus 2. Midthoracic diverticulum: in the mid-chest 3. Epiphrenic diverticulum: above the diaphragm According to the mechanism of formation 1. Traction diverticulum: occurs secondary to pulling forces on the outer aspect of the esophagus 2. ⚫ Pulsion diverticulum: occurs secondary to increased intraluminal pressure Pathology 1. True diverticulum: include all esophageal layers 2. False diverticulum: contain only mucosa and submucosa herniating through the muscular layer ⚫ Symptoms 1. Dysphagia (difficulty swallowing, characterized by a feeling of food caught in the throat) 2. Pulmonary aspiration (the entry of secretions or foreign material into the trachea and lungs) 3. Aspiration pneumonia (a lung infection caused by pulmonary aspiration) 4. Regurgitation of swallowed food and saliva 5. Pain when swallowing 6. Cough 7. Neck pain 8. 9. Weight loss Bad breath (halitosis) ⚫ Diagnosis 1. Barium swallow 2. Gastrointestinal endoscopy 3. Esophageal manometry ⚫ Treatment Minor symptoms: lifestyle changes, such as eating a bland diet, chewing food thoroughly, and drinking plenty of water after meals. Severe symptoms →Surgery: 1. Cricopharyngeal myotomy 2. Diverticulopexy with cricopharyngeal myotomy 3. Diverticulectomy and cricopharyngeal myotomy 4. Endoscopic diverticulotomy ⚫ Images Zenker’s diverticulum Mid-esophageal diverticulum Epiphrenic diverticulum ⚫ 心得： 進醫院的第一天就來到胸腔外科，面對陌生的環境心中滿懷著不安，還記 得剛到核醫 14 樓時，PGY 邱學長就把我推入病房問診，內心充滿了慌 亂，卻還是硬著頭皮努力搜尋腦中的知識，最後終於順利問完 LQQOPERA 及病史，而這位病人就是食道憩室的病患；原本覺得胸外大部分應該都是 處理肺癌，這次卻剛好讓我遇到了相對少見的病例，因為對於食道憩室較 為陌生，當天回家就遵照陳副院長的指示，好好查詢了一番食道憩室的相 關資料。隔天是人生第一次進刀房，第一次跟刀就是食道憩室切除，黃主 任與陳副並肩執刀，而這時 CR㚽芸學姐轉過身來詢問我們食道憩室的分 型，幸好昨晚有事先查詢資料，勉強回答得出問題；手術結束後，陳副把 切下的憩室打開來給我們看，憩室內類似豆皮的食糰露了出來，而它散發 出的惡臭讓我永生難忘。這個病人是我人生中第一個 care 的病人，在她身 上我累積了許多經驗及知識，在胸外各位老師、學長姐的引導下，讓我獲 益匪淺。