Z-POEM: ¿Procedimiento ideal para el tratamiento del divertículo de Zenker? / Z-POEM: Ideal procedure for the treatment of Zenker's diverticulum?

Introducción. El divertículo de Zenker es una patología poco frecuente, caracterizada por la presencia de disfagia, halitosis, tos y pérdida de peso, que afectan la calidad de vida de los pacientes. El tratamiento es quirúrgico y las técnicas han evolucionado de forma permanente. El objetivo de este estudio fue evaluar la mejoría de la disfagia en pacientes a quienes se les realizó la técnica de miotomía endoscópica peroral (Z-POEM). Métodos. Estudio descriptivo de una serie de 23 pacientes con divertículo de Zenker diagnosticado por endoscopia y esofagograma, tratados entre mayo de 2018 y noviembre de 2021 en diferentes instituciones de la ciudad de Bogotá, D.C., Colombia, mediante una miotomía endoscópica del cricofaríngeo con la técnica de Z-POEM. Resultados. La mayoría de los pacientes fueron adultos mayores, de sexo masculino. Los síntomas más frecuentes correspondieron a disfagia y regurgitación. El tamaño promedio del divertículo fue de tres centímetros. La estancia hospitalaria fue de un día. Un paciente presentó disfagia postoperatoria en relación con los clips y otro presentó un absceso mediastinal, el cual fue resuelto de manera endoscópica. Actualmente, todos los pacientes se encuentran asintomáticos y no han presentado recurrencia. Conclusiones. El tratamiento endoscópico mínimamente invasivo mediante la miotomía endoscópica peroral (Z-POEM) en el paciente con divertículo de Zenker es una alternativa segura y eficaz, con buenos resultados y poca morbilidad

Introduction. Zenker's diverticulum is a rare pathology characterized by the presence of dysphagia, halitosis, cough, and weight loss, which affect the patients' quality of life. The treatment is surgical and the techniques have evolved permanently. The objective of this study was to evaluate the improvement of dysphagia in patients who underwent peroral endoscopic myotomy technique (Z-POEM). Methods. Descriptive study of a series of 23 patients with Zenker's diverticulum diagnosed by endoscopy and esophagram, treated between May 2018 and November 2021 at different institutions in Bogotá, Colombia, by means of an endoscopic cricopharyngeal myotomy with the Z-POEM technique. Results. Most of patients were older males. The most frequent symptoms corresponded to dysphagia and regurgitation. The average size of the diverticulum was three centimeters. The hospital stay was one day. One patient presented postoperative dysphagia related to the clips and another presented a mediastinal abscess which was resolved endoscopically. Currently, all patients are asymptomatic and have not presented recurrence. Conclusions. Minimally invasive endoscopic treatment by peroral endoscopic myotomy (Z-POEM) in patients with Zenker's diverticulum is a safe and effective alternative, with good results and low morbidity

Zenker Diverticulum: Does Size Correlate with Preoperative Symptoms?

Abstract Introduction Zenker diverticulum (ZD) usually affects adults after the 7th decade of life. Treatment for ZD is indicated for all symptomatic patients, but some patients prefer to defer surgical treatment until symptoms get worse and decrease their quality of life. Objective To evaluate the association of the preoperative symptoms in ZD patients with the size of the ZD. Methods A retrospective study design. Electronic medical records were used to identify patients diagnosed with ZD and treated over 11 years. Data collection included the chief complaints and symptoms, medical history, and findings on radiologic swallow evaluations of the patients. The diverticulum size was stratified into 3 groups: small (< 1 cm), moderate (1-3 cm), and large (> 3 cm). Results A total of 165 patients were enrolled and stratified by diverticulum size (48 small, 67 medium, and 50 large). Dysphagia, cough, and regurgitation were the most prevalent symptoms. Dysphonia was more frequent among patients with a small pouch. Logistic regression analysis showed that dysphagia and choking were associated with large and medium diverticulum size (p < 0.05). Additionally, dysphonia was significantly associated with the presence of a small-sized ZD (p < 0.04). Conclusion Upper gastrointestinal symptoms such as dysphagia and choking may be associated with a ZD > 1 cm and should always be evaluated. Additionally, the presence of dysphonia was found to be correlated with a ZD < 1 cm, suggesting that a prompt and appropriate fluoroscopic evaluation must be considered in those patients in whom no other clear cause of dysphonia is evident.

Caso clínico-radiológico: divertículo de Zenker / Clinical-radiological case: Zenker's diverticulum

Zenker's diverticulum develops in the hypopharynx, usually between the cricopharyngeus muscle and the inferior pharyngeal constrictor muscle, at the level of the C5 and C6 vertebrae. It often manifests clinically with dysphagia, persistent reflux, and halitosis. Its reference diagnosis is through barium video swallowing observed by fluoroscopy. Management is surgical with a cervical or transoral approach, the latter having a better safety profile

Clinical observation of peroral endoscopic myotomy for mid-esophageal diverticulum in 7 cases / 中华消化内镜杂志

To investigate the effectiveness and safety of diverticular peroral endoscopic myotomy (D-POEM) for mid-esophageal diverticulum. Data of consecutive patients in the prospective database with mid-esophageal diverticulum who received D-POEM in West China Hospital, Sichuan University between April 2014 to September 2019 were collected. The modified Eckardt scoring system for mid-esophageal diverticulum was used to evaluate the severity of diverticular symptoms. The effectiveness and safety of D-POEM were evaluated in terms of clinical success, technical success, complications and recurrence. A total of 7 patients with mid-esophageal diverticulum were included. Clinical and technical success was achieved in all patients with operation time of 16-70 minutes. No serious complications (2 cases with minor complications) or recurrence occurred. The follow-up time was 2-16 months. The median modified Eckardt score decreased from 3 points before operation to 0 points after operation. It is preliminarily believed that D-POEM ensures a complete septotomy between normal esophageal lumen and esophageal diverticulum. It is a safe and effective technique for mid-esophageal diverticulum. The modified Eckardt scoring system is suitable for symptom evaluation before and after treatment of mid-esophageal diverticulum.

Potential threat of pharyngo-esophageal diverticulum to thermal ablation treatment of thyroid nodule and rapid differential diagnosis through swallow contrast-enhanced ultrasonography / 中华超声影像学杂志

Objective To explore the potential risk of misdiagnosis of pharyngeal esophageal diverticulum( PED) for the treatment of thyroid nodules with thermal ablation and its rapid and effective method of diagnosis . Methods The process of diagnosis and treatment were reviewed on 5 cases of PEDs which had been misdiagnosed as thyroid nodules and recommended for thermal ablation therapy . A comprehensive analysis was carried out for the reasons of misdiagnosis ,the timing and clues of the diagnosis as well as the advantage of swallow contrast-enhanced ultrasonography ( sCEUS ) in achieving rapid and correct diagnosis . Results The lack of recognition and vigilance to the acoustic image of PED were the direct causes of misdiagnosis . Five cases of PED misdiagnosed as thyroid nodules were all discovered by the same chief operator before thermal ablation . They were confirmed through sCEUS and mistreatment by ablation were fortunately avoided ,but all true thyroid nodules requiring treatment were safely ablated . Conclusions PED is easily misdiagnosed as thyroid nodule .Improving the recognition and vigilance of the ultrasonic features of PED ,strictly implementing the reconfirming ultrasound examination by the chief operator ,and promptly conducting sCEUS are sensible measures to quickly correct the diagnosis and prevent w rong ablation of PED .

Risk factors predicting development of complications in 72 dogs with esophageal foreign bodies / 대한수의학회지

The aim of this study was to determine predictive risk factors implicated in complications in dogs with esophageal foreign bodies. Medical records of 72 dogs diagnosed with esophageal foreign bodies by endoscopy were reviewed retrospectively. Factors analyzed included age; breed; gender; body weight, location, dimension, and type of foreign body; and duration of impaction. To identify risk factors associated with complications after foreign body ingestion, categorical variables were analyzed using the chi-square or Fisher's exact tests and multivariate analysis, as appropriate. Complications secondary to esophageal foreign body ingestion included megaesophagus, esophagitis, perforation, laceration, diverticulum, and pleuritis. Univariate analysis revealed that the location and duration of impaction after foreign body ingestion were associated with an increased risk of esophageal laceration and perforation. Multivariate analysis showed that age, duration of impaction, and foreign body dimension were significant independent risk factors associated with the development of complications in dogs with esophageal foreign bodies. In conclusion, these results showed that longer duration of impaction and larger foreign body dimensions may increase the risks of esophageal laceration, perforation, and plueritis in dogs.

A Large Epiphrenic Esophageal Diverticulum Communicating with the Left Lower Lobe / 대한흉부외과학회지

Epiphrenic diverticula are known to cause a series of complications. We report the case of a 54-year-old woman who was diagnosed with an epiphrenic diverticulum at a regular checkup in November 2006. Ten years later, she presented with massive hematemesis. Imaging studies revealed an epiphrenic diverticulum measuring 7.8 cm in diameter and a large amount of bleeding inside the diverticulum. Computed tomography showed fistula formation between the diverticulum and the left lower lobe of the lung, leading to the development of a pulmonary abscess. Diverticulectomy and 180° posterior partial fundoplication were performed transabdominally. The pulmonary abscess was treated with antibiotics alone. She was discharged 16 days after the operation without any complications over 7 months of follow-up.

The Abdominal Approach for Epiphrenic Esophageal Diverticulum as an Alternative to the Thoracic Approach / 대한흉부외과학회지

BACKGROUND: There is no established surgical procedure for the treatment of epiphrenic esophageal diverticulum. The aim of this study was to compare the clinical outcomes of esophageal diverticulectomy using abdominal and thoracic approaches. METHODS: We retrospectively reviewed 30 patients who underwent esophageal diverticulectomy through the thoracic or abdominal approach for an epiphrenic diverticulum at a single center between 1996 and 2018. We compared clinical outcomes, including the postoperative length of stay, time from the operation to oral feeding, leakage rate, and reoperation rate between the 2 groups. RESULTS: The median age was 56 years. Of the 30 patients, 18 (60%) underwent diverticulectomy via the thoracic approach and 12 (40%) underwent the abdominal approach. The median hospital stay was 10 days (range, 5–211 days) in the thoracic approach group and 9.5 days (range, 5–18 days) in the abdominal approach group. The median time from the operation until oral feeding was 6.5 days (range, 3–299 days) when the thoracic approach was used and 5 days (range, 1–11 days) when the abdominal approach was used. In the thoracic approach group, the leakage rate was 16.67% and the reoperation rate was 27.78%. However, there were no cases of leakage or reoperation in the abdominal approach group. CONCLUSION: The abdominal approach for esophageal diverticulectomy is a feasible and appropriate alternative to the thoracic approach.

Imágenes en divertículos del tubo digestivo: localizaciones infrecuentes. serie de casos / Imaging in infrequent digestive diverticula: case series

Los divertículos se pueden localizar en todo el tubo digestivo (TD): esófago, estómago, duodeno, yeyuno, íleon, apéndice, colon. Son infrecuentes, salvo en colon. Sus manifestaciones clínicas son inespecíficas, con difícil diagnóstico y mayor riesgo de complicaciones. Se presenta una serie de divertículos digestivos atípicos, mostrando las características imagenológicas multimodalidad y describir los hallazgos claves. Es una revisión retrospectiva en el archivo computacional de nuestra institución. Selección de casos de divertículos de presentación inhabitual por sus características, localización u origen. En esófago los divertículos de Zenker y Killian-Jamieson. En estómago los divertículos gástricos infrecuentes. Los divertículos en intestino delgado tienen baja prevalencia, el más frecuente en duodeno. Los divertículos colónicos pueden tener una localización o presentación atípica. Los divertículos apendiculares y Meckel presentan baja prevalencia. Los divertículos digestivos son infrecuentes, excepto los colónicos. El radiólogo debe estar familiarizado con las diferentes ubicaciones de ellos, para reconocerlos y poder diagnosticarlos.

Diverticula may occur in any segment of the digestive tract: esophagus, stomach, duodenum, jejunum, ileum, appendix, and colon. Its clinical manifestations are nonspecifi which may turn diffiult an early diagnosis, leading to a higher risk of complications. We present a cases serie of atypical digestive diverticula and to describe the fidings on the different imaging techniques. We performed a retrospective review on the imaging computer archives of our institution. The atypical diverticula were selected. Zenker and Killian-Jamieson's diverticulums in esophagus. In stomach ocasionally gastric diverticula. Diverticula in small intestine have a low prevalence, the most common location is duodenum. Colonic diverticula may present a atypical location or presentation. The appendicular and Meckel diverticuli are uncommon. The digestive diverticula are uncommon, except the colonic ones. The radiologist must be familiar with it's different locations in order to be able to recognize it and diagnose it properly.

A Case of Paratracheal Air Cyst Mimicking an Upper Esophageal Diverticulum

Paratracheal air cyst (PTAC) is a small air collection in the right paratracheal area and mainly diagnosed by computed tomography (CT). Increased with ultrasonographic (US) screening of the thyroid, PTAC can be detected incidentally. However, the US findings of PTAC have not been well described. Herein, we report our experience with a rare instance of a PTAC. A 64-year-old female was referred to our hospital for fine-needle aspiration (FNA) cytology of a thyroid nodule. The lesion was identified as an ovoid, hypoechoic lesion with internal hyperechoic foci, abutting on the inferior pole of the right thyroid lobe. The margin was smooth without hypoechoic rim, which is typical in upper esophageal diverticula. US-guided FNA suggested a benign bronchial epithelial lining cyst. If a hypoechoic neck mass containing air without a thick hypoechoic rim is observed, especially at the right side of the trachea, the possibility of PTAC should be considered.

Miomectomía endoscópica del divertículo esofágico de Zenker: técnica modificada / Myomectomy endoscopic of Zenker’s esophageal diverticulum: modified technique

El divertículo de Zenker, también llamado divertículo faringoesofágico, es un tipo de divertículo de la mucosa de la faringe, que se ubica en la parte superior del músculo cricofaríngeo, es decir, por encima del esfínter esofágico superior. Es un falso divertículo en el sentido que no compromete todas las capas de la pared faríngea. Los mecanismos de formación aunque controversiales son por pulsión y tracción. Los divertículos de Zenker pueden causar halitosis, regurgitación de alimento no digerido, disfagia orofaríngea e incluso una obstrucción completa por compresión. Como complicaciones puede provocar broncoaspiración, formación de fístulas entre el divertículo y la tráquea, hemorragia intradiverticular y más raro, carcinoma epidermoide dentro del divertículo. Una serie esofágica con trago de bario normalmente detecta el divertículo. El tratamiento establecido del divertículo de Zenker consiste en la miotomía quirúrgica del músculo cricofaríngeo asociada a diverticulectomía o diverticulopexia y, como alternativa, la diverticulostomía o miomectomía endoscópica. El objetivo del presente estudio es presentar un caso clínico, describir el procedimiento endoscópico usando cápsula distal acrílica dentada y disección de capas posterior a esclerosis de solución de adrenalina. Se presentan fotos de este procedimiento que ofrece más firmeza en el corte porque evita el desplazamiento de la punta del endoscopio, ningún sangrado, mejor exposición de las capas musculares y mejor visibilidad para el corte. Debe ser validada con una serie de casos

Zenker's diverticulum, also called pharyngoesophageal diverticulum, is a type of diverticulum of the mucosa of the pharynx, which is located at the top of the cricopharyngeal muscle, ie above the upper esophageal sphincter. It is a false diverticulum in the sense that it undertakes all layers of the pharyngeal wall. The formation mechanisms are controversial even drive and traction. Zenker diverticula can cause halitosis, regurgitation of undigested food, oropharyngeal dysphagia and even complete obstruction by compression. As complications may cause aspiration, fistula formation between the diverticulum and trachea, hemorrhage and rarest intradiverticular, epidermoid carcinoma in the diverticulum. A number esophageal barium swallow normally detects the diverticulum. The established treatment of Zenker's diverticulum is surgical myotomy of the cricopharyngeal muscle associated with diverticulectomy or diverticulopexy and, alternatively, the diverticulostomía or The objective of this study is to present a case, describe the endoscopic procedure using acrylic capsule toothed distal dissection layers sclerosis after epinephrine solution. We present photo of this procedure provides more firmly in the court because it prevents the displacement of the endoscope puna, no bleeding, better exposure of the muscle layers, and better visibility for cutting. Validity must be a number of cases

Divertículo de Zenker: tratamento endoscópico versus cirúrgico / Zenker diverticulum: surgical versus endoscopic treatment

OBJETIVO: Revisar a evidência da segurança e efetividade dos tratamentos endoscópico e cirúrgico do divertículo de Zenker. MÉTODOS: pesquisa no MEDLINE, LILACS e SciELO por "Zenker's diverticulum or pharyngoesophageal diverticulum", e seleção de estudos para avaliação da qualidade e extração dos dados para uma metanálise. RESULTADOS: a pesquisa não localizou nenhum ensaio clínico randomizado. Encontramos cinco estudos comparativos não randomizados com grupo controle, com um total de 630 pacientes, 339 no braço endoscópico e 291 no cirúrgico. Os valores para segurança foram uma mortalidade de 0,29 por cento e morbidade 7 por cento para o tratamento endoscópico, e mortalidade 0,34 por cento e morbidade 5 por cento para o tratamento cirúrgico. O valor para efetividade foi 84 por cento e 85 por cento, respectivamente. O efeito das abordagens endoscópica e cirúrgica para o tratamento do divertículo de Zenker foi comparável, a odds ratio para morbidade foi 1,24 (0,56-2,74), e a odds ratio para o sucesso foi 0,66 (0,41-1,05). CONCLUSÃO: os estudos sobre o tratamento do divertículo de Zenker têm baixo nível de evidência e não são capazes de definir qual o melhor tratamento em termos de segurança e efetividade.

OBJECTIVE: To review the evidence of safety and effectiveness of endoscopic and surgical treatment of Zenker's diverticulum. METHODS: Searches of MEDLINE, LILACS and SciELO by "Zenker's diverticulum" or "pharyngoesophageal diverticulum," and selection of studies for quality assessment and data extraction to a meta-analysis. RESULTS: The study did not find any randomized clinical trial. We found five comparative, non-randomized studies, with a total of 630 patients, 339 in the endoscopic arms and 291 in the surgical ones. The values for safety were a 0.29 percent mortality and 7 percent morbidity for the endoscopic treatment, and 0.34 percent mortality and 5 percent morbidity for surgical treatment. The values for effectiveness were 84 percent and 85 percent, respectively. The effect of endoscopic and surgical approaches for the treatment of Zenker's diverticulum was comparable, the odds ratio for morbidity was 1.24 (0.56 to 2.74), and the odds ratio for success was 0.66 (0.41 -1.05). CONCLUSION: The studies on the treatment of Zenker's diverticulum have a low level of evidence and are not able to establish the best treatment in terms of safety and effectiveness.

Massive bleeding in epiphrenic esophageal diverticulum: A case report.

Esophageal diverticulum is an outpouching of the esophageal wall. Approximately 65% of diverticulum is asymptomatic. Although bleeding from esophageal diverticulum is a rare symptom, it is a life-threatening complication. The authors report a 45-year-old man with massive upper gastrointestinal bleeding and hypovolemic shock. Esophago-gastro-duodenoscopic examination revealed bleeding from a large epiphrenic esophageal diverticulum. The bleeding point was stopped by endoscopic adrenaline injection therapy. Radiographic examination revealed two esophageal diverticula. The larger one, a wide-mouth diverticulum of the epiphrenic type, was the cause of bleeding. An esophageal diverticulectomy with cardiomyotomy was performed via video-assisted thoracoscopic surgery (VATS). There was no esophageal leakage or post-operative morbidity or mortality. The patient had no recurrent bleeding during 24 months after operation.

Massive Upper Gastrointestinal Bleeding from a Traction Type of Diverticulum in the Midesophagus / 대한소화기내시경학회지

The common sites of esophageal diverticula are the pharyngoesophageal junction, midesophagus and epiphrenic. The pathophysiological mechanisms of acquired esophageal diverticula are traction and pulsion forces. Traction diverticula of the midesophagus are usually asymptomatic, and found incidentally on an esophagogastroduodenoscopy or barium contrast esophagogram. Midesophageal traction diverticula are caused by inflammatory processes between the external wall of the esophagus and the adjacent structure. Pneumonia, bronchoesophageal fistula and gastrointestinal bleeding can occur due to an extension of inflammatory process into the lung or blood vessels. There are a few reports of midesophageal diverticular bleeding. We present a case of massive upper gastrointestinal bleeding from a traction diverticulum of the midesophagus that was successfully managed by endoscopic treatment.

Endoscopic Treatment of a Giant Mid-Esophageal Diverticulum / 대한소화기내시경학회지

Most patients with esophageal diverticula are asymptomatic and treatment should be reserved only for the symptomatic patients. The mainstay of treatment is surgery. Recently, in cases of Zenker's diverticula, endoscopic diverticulotomy has become increasingly popular. In lower esophageal diverticula, minimally invasive surgery (i.e. laparoscopic approach) has been successful. However, treatment with flexible endoscope has not been reported yet in mid- esophageal diverticulum. We present a case with a giant symptomatic mid-esophageal diverticulum, which was successfully treated by clip and cut technique through a flexible endoscope without general anesthesia.

Congenital bronchoesophageal fistula associated with esophageal diverticulum in the adult

Congenital bronchoesophageal fistula is a rare clinical entity in adults. This anomaly may cause various symptoms such as respiratory infections, coughing bouts when eating or drinking, and even hemoptysis. The fistula can cause symptoms in childhood but may not appear until adulthood. We recently experienced a case of congenital bronchoesophageal fistula associated with esophageal diverticulum in an adult. A 63-year-old woman was admitted to our hospital due to chest discomfort, sore throat and coughing bouts when eating. An empyema with lung abscess had occurred eight years previously. Results of the physical examination were unremarkable. A Barium swallowing revealed a medium-sized diverticulum at the right anterior aspect of the esophagus, which had developed a fistulous connection with the right lower lobe bronchus. The patient was treated by fistulectomy and lobectomy of the right lower lobe. The postoperative course was smooth and uneventful.