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

Formación de un divertículo epifrénico como complicación de la cirugía antirreflujo: importancia de la fluoroscopia / Development of an epiphrenic diverticulum as a complication of antireflux surgery: importance of fluoroscopy

En este artículo se muestran los hallazgos radiológicos en el esofagograma del divertículo epifrénico en un paciente con disfagia para sólidos y pérdida de peso, con antecedente de cirugía antirreflujo. Además, se encuentra una plicatura muy apretada y, como consecuencia, la formación del divertículo epifrénico, entidad de rara presentación. Las técnicas de fluoroscopia siguen vigentes para la valoración anatómica y funcional del tracto gastrointestinal

This article demonstrates the radiological findings in the esophagogram of the epiphrenic diverticulum in a patient with solid dysphagia and weight loss with a history of antireflux surgery. In this case, a very tight plication was found and as a consequence the formation of the epiphrenic diverticulum, a rare entity Fluoroscopy techniques are still used for anatomical and functional evaluation of the gastrointestinal tract.

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.

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.

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 Case of Zenker's Diverticulum Mimicking a Right Side Thyroid Nodule

Zenker's diverticulum, a pulsion diverticulum of the hypopharynx, is a rare lesion that commonly occurs in left side of hypopharynx. The incidence of esophageal diverticula is much lower than that of focal lesions or nodules of thyroid. In an ultrasonography, the outpouching just like a focal thyroid lesion, may present as an oval or circular structure. The food remnants or gas bubbles present in the diverticulum may mimic microcalcifications presented in papillary thyroid carcinoma. We reported a case of right side Zenker's diverticulum mimicking a thyroid cancer in thyroid ultrasonography.

Giant esophageal epiphrenic diverticulum: presentation and treatment / Divertículo epifrênico gigante de esôfago: apresentação e tratamento

ABSTRACT Epiphrenic diverticulum is a rare disease associated with esophageal motor disorders that is usually asymptomatic and has a well-established surgical indication. We report a case of giant epiphrenic diverticulum in a 59-year-old symptomatic woman who was diagnosed after underwent complementary exams. Because of her symptoms, the surgical treatment was chosen, and esophageal diverticulectomy was performed along with laparoscopic cardiomyotomy and anterior partial fundoplication.

RESUMO O divertículo epifrênico é uma patologia rara associada a distúrbios motores esofágicos e, frequentemente, assintomática, tendo indicações cirúrgicas bem estabelecidas. Relatamos um caso de divertículo epifrênico gigante em paciente de 59 anos, sexo feminino, sintomática, diagnosticada por exames complementares. Devido à sintomatologia, optou-se por tratamento cirúrgico, sendo realizada a diverticulectomia esofágica com cardiomiotomia e fundoplicatura parcial anterior laparoscópica.

Preliminary results of submucosal tunneling endoscopic septum division in the treatment of esophageal diverticulum / 中华胃肠外科杂志

<p><b>OBJECTIVE</b>To evaluate the safety and efficacy of submucosal tunneling endoscopic septum division (STESD) for escophageal diverticulum.</p><p><b>METHODS</b>Clinical data of six consecutive patients with symptomatic esophageal diverticula who received STESD in Endoscopy Center of Zhongshan Hospital, Fudan University from April 2016 to November 2016 were analyzed retrospectively. STESD was performed as following: mucosal entry was made 3 cm from the septum of esophageal diverticulum; submucosal tunnel was created towards the septum; after the satisfactory exposure of the septum, endoscopic division was made down to the bottom of the diverticulum; mucosal closure of the tunnel entry was made. The symptoms were scored using a system modified according to Eckardt score, namely dysphagia, heartburn, regurgitation, weight loss and retrosternal pain with each ranging from 0 to 3 (maximum score 15, minimum score 0, the higher the score, the more severe the symptoms).</p><p><b>RESULTS</b>There were four males and two females with median age of 56.5 (range 50-67) years. Four patients were epiphrenic diverticula, and the other two were Zenker's diverticula. Median duration of disease was 2.5 years (range 5 months-29 years). No previous treatment was attempted. All the patients completed STESD successfully. The median septum division length was 2.5(1-4) cm. The median number of metallic clips for mucosal closure was 5(2-6). The median operation time was 51.5 (33-135) min. No major adverse events, such as perforation or bleeding were found in perioperative period. The median time of hospital stay was 5(3-9) days. All the patients had symptom relief after operation. One patient with Zenker's diverticulum reported foreign body sensation after operation and experienced relief two weeks afterwards. During a median follow-up time of 5(4-10) months, the median symptom score of 6 cases was 4.5 (1-13) before and 0.5 (0-4) after operation. The symptom scores went down to zero in 3 patients (preoperative scores 13, 1, 1, respectively), and down to 1 in 2 patients with main symptom of backflow (preoperative scores 5, 4, respectively). One patient with 29 years history of disease did not report obvious improvement in symptoms (preoperative and postoperative scores 5, 4, respectively).</p><p><b>CONCLUSION</b>Submucosal tunneling endoscopic septum division is efficient and safe to relieve symptomatic esophageal diverticulum in short term.</p>

Manejo del divertículo de Zenker con endoscopia avanzada / Advanced endoscopic management of Zenker´s diverticulum

El divertículo de Zenker es un saco que protruye a través de los músculos constrictor inferior de la faringe y cricofaríngeo (triángulo de Killian); es una alteración que ocasiona disfagia como síntoma principal y se puede manejar con el endoscopio flexible con buenos resultados. Objetivo. Describir la experiencia preliminar en el manejo endoscópico del divertículo de Zenker en el Hospital de San José. Métodos. Se trata de una serie de casos llevada a cabo desde diciembre de 2014 hasta abril de 2016 en el Hospital de San José, en la cual se utilizó el endoscopio flexible para la diverticulotomía en pacientes ambulatorios. Resultados. Se intervinieron seis pacientes, en los cuales se llevaron a cabo nueve procedimientos. El diagnóstico se hizo mediante esofagogastroduodenoscopia y esofagograma. La edad promedio fue de 65 años y cuatro pacientes eran hombres. En todos se practicó el procedimiento bajo anestesia general, usando endoscopio flexible, sonda orogástrica y capuchón. No se usaron antibióticos profilácticos y todos los pacientes se atendieron en forma ambulatora. Conclusión. La diverticulotomía endoscópica con equipo de endoscopia flexible es una técnica que ha sido adoptada por los gastroenterólogos intervencionistas debido a su seguridad y buenos resultados. Por lo anterior, esta técnica se debe tener en cuenta en los pacientes con esta enfermedad

Zenker's diverticulum is a sac that protrudes through the inferior constrictor muscles of the pharynx and cricopharyngeus (Killian triangle), a condition that causes dysphagia as the main symptom and can be managed by flexible endoscopy with good results. Objective: To describe the preliminary experience in the endoscopic management of Zenker's diverticulum at Hospital San José, Bogotá, Colombia. Methods: This is a case series conducted from December 2014 to April 2016 utilizing the flexible endoscope for divericulectomy as an outpatient procedure. Results: Nine procedures were performed in six patients. Diagnosis was made by esophagogastroduodenoscopy and barium swallow. Average age was 65 years, and four patients were men. All the procedure were carried out under general anesthesia using flexible endoscope, orogastric tube and cap. We do not use prophylactic antibiotics and all were outpatients. Conclusion: Endoscopic equipment diverticulectomy with flexible endoscopy is a technique that has been adopted by the interventional gastroenterologists because of its safety and good results. Therefore, this technique should be considered in patients with this pathology

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.

A Case of Killian-Jamieson Diverticulum in the Esophagus

A Killian-Jamieson diverticulum (KJD) is an unfamillar and unusual cervical esophageal diverticulum. This diverticulum originates on the anterolateral aspect of the esophagus through the Killian-Jamieson's area that is formed between cricopharyngeal muscle and the lateral to longitudinal esophageal muscle. Recently, we experienced a patient who was found outpouching lesion on lateral side of left esophagus on the duodenoscopy. Then, a barium esophagography performed and in left lateral position demonstrated a left-sided diverticulum with a frontal projection, highly suggestive of a KJD. There are two ways of surgical approach to manage the KJD. First is external approach, another one is endoscopic approach. In common, external approach has been recommended for the treatment of KJD because of concern of nerve injury. We present a case of KJD that underwent external approach and sternocleidomastoid muscle flap in the management of KJD.

Clinical Characteristics and Incidence of Thyroid Nodule in the Male Population for Health Check-up / 대한내분비외과학회지

PURPOSE: Thyroid nodules are a common disease in clinical practice. The prevalence of thyroid nodules has recently increased according to the development of thyroid ultrasonography. Thyroid nodules are more commonly found in women, but the potential for malignant nodules is much higher in men. The purpose of this study was to assess clinical characteristics and the incidence of thyroid nodules and malignancy in the adult male population. METHODS: Clinical characteristics and incidence of thyroid nodules was examined by screening ultrasonography targeting 6,968 male patients over the age of 40 who visited the National Police Hospital from January 2012 and April 2015. RESULTS: Among 6,968 male patients, 2,481 (35.6%) showed abnormal findings on ultrasonography. Of the 2,481 patients, 2,370 patients (34.01%) had a thyroid nodule and 111 patients (4.47%) had thyroiditis without a thyroid nodule, previous thyroidectomy, lymphadenopathy, esophageal diverticulum, parathyroid cyst, and benign calcification. Of the 2,481 patients, 958 patients (38.6%) had abnormal TFT and 204 patients (8.22%) had thyroiditis with or without a thyroid nodule. Thyroid nodules were benign in 1993 (80.33%) cases, indeterminate in 313 (12.61%) cases, and suspicious in 64 (2.56%) cases. Among the 2,481 subjects, thyroid cancer was detected in 37 subjects (1.49%). CONCLUSION: The incidence of thyroid nodules has recently increased according to the development of thyroid ultrasonography.

Esophageal Cancer in Esophageal Diverticula Associated with Achalasia

The simultaneous occurrence of achalasia and esophageal diverticula is rare. Here, we report the case of a 68-year-old man with multiple esophageal diverticula associated with achalasia who was later diagnosed with early esophageal cancer. He initially presented with dysphagia and dyspepsia, and injection of botulinum toxin to the lower esophageal sphincter relieved his symptoms. Five years later, however, the patient presented with worsening of symptoms, and esophagogastroduodenoscopy (EGD) was performed. The endoscopic findings showed multifocal lugol-voiding lesions identified as moderate dysplasia. We decided to use photodynamic therapy to treat the multifocal dysplastic lesions. At follow-up EGD 2 months after photodynamic therapy, more lugol-voiding lesions representing a squamous cell carcinoma in situ were found. The patient ultimately underwent surgery for the treatment of recurrent esophageal multifocal neoplasia. After a follow-up period of 3 years, the patient showed a good outcome without symptoms. To manage premalignant lesions such as achalasia with esophageal diverticula, clinicians should be cautious, but have an aggressive approach regarding endoscopic surveillance.

The Role of Transnasal Esophagoscopy in ENT Office: A Prospective, Multicenter Study in Korea

OBJECTIVES: The purpose of study was to report the current role of transnasal esophagoscopy (TNE) in Korea. METHODS: One hundred thirty-seven patients who underwent TNE at Soonchunhyang University Bucheon Hospital (n=69) and Korea University Anam Hospital (n=68) from July 2007 to February 2009 were prospectively analyzed. Laryngopharyngeal reflux disease (LPRD) patients without any response to proton-pump inhibitor (n=102), and patients with complaints that require esophagoscopy as part of their evaluation (n=35) were included in this study; investigation of metachronous lesions or routine follow-up screening of head and neck cancer patients, n=17; dysphagia, n=9; blood tinged saliva, n=4; to determine the cause of vocal fold paralysis as screening tool, n=4; suspicious esophageal foreign body, n=1. RESULTS: Fifty-three patients (38.7%) had positive findings on TNE. Positive finding ratio was highest in group of dysphagia (7 among 9 patients, 78%). Forty-two patients (41.1%) were found to have pathology (esophagitis, n=41; esophageal diverticulum, n=1) during the screening examination for LPRD. There were no significant complications in any of the patients. CONCLUSION: TNE is a high-yield diagnostic and therapeutic modality available to otolaryngologists for use on awake patients in the office setting.

Resultados del tratamiento quirúrgico de la patología esofágica benigna con cirugía mínimamente invasiva: experiencia en 483 pacientes / Minimally invasive surgery for benign esophageal diseases: experience in 483 patients

Background: Minimally invasive surgical techniques are increasingly used for the treatment of benign esophageal diseases. Aim: To report the results of minimally invasive surgical techniques among patients with benign esophageal diseases. Material and Methods: Four hundred eighty three patients aged 37 to 81 years (184 males), were studied. Of these, 278 had a Barret esophagus, 125 had a hiatal hernia, 75 had achalasia and five had esophageal diverticula. All patients were studied using standard protocols, operated using minimally invasive techniques and followed, registering postoperative complications and recurrence of symptoms. Results: Among patients with esophageal reflux, 85 percent had successful results on the long term. Among patients with hiatal hernia and subjected to laparoscopic surgery, 12 percent had complications and 12 percent had recurrence of symptoms which increased to 17 percent if a mesh was not used. The recurrence rate among patients with achalasia is less than 5 percent. There was no recurrence among patients with esophageal diverticula. Conclusions: Minimally invasive surgery for esophageal diseases has good success rates, with a lower incidence of complications than open surgery.

Introducción: En este artículo se presenta la experiencia de nuestro grupo de trabajo de los resultados obtenidos en el tratamiento quirúrgico con técnicas mínimamente invasivas en patología esofágica benigna. Material y Método: Se analizan los resultados en pacientes sometidos a cirugía antirreflujo por enfermedad por reflujo gastroesofágico, esófago de Barrett, tratamiento de las hernias hiatales, acalasia esofágica y diver-tículos esofágicos. Resultados: Los resultados obtenidos por nuestro grupo son comparables a los que señala la literatura internacional, con mínima morbilidad y sin mortalidad. En pacientes con reflujo gastroesofágico, los resultados a largo plazo presentan una tasa de éxito en el 85 por ciento de los casos. En pacientes con hernia hiatal operados por vía laparoscópica las complicaciones son cercanas al 12 por ciento y la recurrencia es de un 12 por ciento en promedio, pero se eleva al 17 por ciento cuando no se usa malla. En Acalasia por otro lado, la tasa de recurrencia es menor a un 5 por ciento. Los pacientes operados por divertículos esofágicos no presentan recidiva. Conclusiones: Las técnicas de cirugía mínimamente invasiva diseñadas para el abordaje de los diversos tipos de patologías que afectan al esófago, resultan por lo general, altamente factibles de realizar por cuanto reproducen los resultados de la cirugía abierta pero con menor tasa de complicaciones.

Subphrenic Esophageal Diverticulum Associated with Esophageal Dysmotility and Leiomyoma / 대한내과학회지

Lower esophageal diverticula are frequently related to esophageal motor disorders. An epiphrenic esophageal diverticulum can also have a mechanical cause, such as an esophageal web, benign stricture, or leiomyoma. For a good therapeutic outcome, symptomatic patients with an esophageal diverticulum require a tailored approach. Therefore, it is important to evaluate motor disorders and other associated diseases in a patient with an esophageal diverticulum before devising a therapeutic strategy. We report a case of subphrenic diverticulum associated with an esophageal leiomyoma and motility disorder in a 58-year-old man who had suffered from intermittent regurgitation of food and epigastric soreness.