Videodeglución: un estudio siempre actual que nunca envejece. Técnica y aplicación en la práctica diaria / Videodeglution: an up-to-date study that never gets old. Technique and application in daily practice

Resumen La videodeglución es un estudio fisiológico y en tiempo real que, al momento, no tiene reemplazo por otra modalidad. Ofrece información relevante sobre el sistema estomatognático del paciente, así como sobre la estructura y la funcionalidad orofaríngea y esofágica. Este estudio cuenta con distintas fases (oral, faríngea y esofágica) en las que se analizan diversas estructuras, así como la funcionalidad de estas a través de degluciones inducidas de diferentes consistencias (semisólido, líquido, sólido). Las patologías que pueden encontrarse son múltiples, siendo algunas de las más frecuentes la disfunción del músculo cricofaríngeo, la penetración/aspiración en la vía aérea, los divertículos y la acalasia. Resulta fundamental su ejecución con una técnica correcta, conociendo previamente la sintomatología, el motivo por el cual fue indicada, la anatomía de las estructuras/cavidades y la fisiología de la deglución. Por lo tanto, una adecuada técnica en la ejecución de la videodeglución y el conocimiento preliminar de la anatomía y la fisiología, así como de los hallazgos y patologías más frecuentes, son fundamentales para una adecuada evaluación del paciente y una correcta interpretación de las imágenes.

Abstract Video swallowing is a physiological and real-time study that, at the moment, cannot be replaced by another modality. It offers relevant information about the patient's stomatognathic system, as well as the oropharyngeal and esophageal structure and function. This study has different phases (oral, pharyngeal and esophageal) where various structures are analyzed, as well as their functionality through induced objects of different consistencies (semi-solid, liquid and solid). The pathologies that can be found are multiple, some of the most frequent being dysfunction of the cricopharyngeal muscle, penetration/aspiration into the airway, diverticula and achalasia. Its execution with a correct technique is fundamental, knowing previously the symptomatology, reason for which it was indicated, the anatomy of the structures/cavities and the physiology of swallowing. Therefore, an adequate technique in the execution of video swallowing and preliminary knowledge of anatomy and physiology, as well as the most frequent findings and pathologies, are fundamental for a correct evaluation of the patient and interpretation of the images.

Multimodal Endoscopic Management of Esophageal Perforations as a Complication of Peroral Endoscopic Myotomy for a Zenker's Diverticulum.

Zenker's diverticulum develops because of a weakness in Killian's triangle, leading to a mucosal and submucosal herniation. Its treatment has evolved from morbid surgical interventions to safer endoscopic techniques such as peroral endoscopic myotomy (Z-POEM). Despite being a safe technique, Z-POEM is not free of complications such as perforations, bleeding, pneumoperitoneum, and pneumothorax, for which new endoscopic techniques have been developed. We present the case of a 53-year-old man taken to a Z-POEM who postoperatively presented dehiscence of the mucosotomy and a mediastinal collection, managed with a vacuum-assisted endoscopic closure device.

Tratamiento quirúrgico del divertículo de Zenker; un caso clínico; Hospital Militar Central de La Paz (COSSMIL) gestión 2022 / Surgical treatment of Zenker's diverticulum, a Clinical Case Central Military Hospital of La Paz (COSSMIL) gestión 2022

Se presenta un caso clínico de una paciente de 66 años de edad masculino que acude a nuestro hospital (COOSMIL), después de hacer una anamnesis donde el paciente manifiestas molestias como tos, regurgitación y mal alientos (halitosis) y se le hace exámenes complementarios y se llega a un diagnóstico de divertículo faringo-esofágico o Zenker. Esta patología no es muy frecuente, pero se presenta en ancianos por una alteración anatomo-funcional que es un debilitamiento del músculo esofágico Hay tres divertículos esofágicos de los cuales el divertículo de Zenker es el más común aunque es relativamente raro que se presente, en la mayoría de las personas en edad seniles. Después de analizar el tamaño y forma del divertículo de este paciente se toma la decisión de una intervención quirúrgica el más acertado por el tamaño que mide es la diverticulectomia este tratamiento quirúrgico actualmente se continúa realizando en esta patología y con buen pronóstico de vida del paciente. Actualmente, el paciente se encuentra en buen estado salud y su recuperación es favorable desde la operación hasta el momento.

A case of a male patient of 66 years old was referred to our hospital (COSSMIL), after making an anamnesis in which the patient manifested cough, regurgitation and bad breath (halitosis). After further examination a the diagnosis is pharyngo-esophageal diverticulum or Zenker. This condition is rare, but sometimes it happens in elders due to an anatomical and functional alteration caused by is an esophagus muscle weakening. There are three esophageal diverticula in which the Zenker diverticulum is the most common but relatively rarely to occur in elder people. Before analyzing the size and shape of the diverticulum in this patient, the decision is proceed with surgery, the most recommended solution for measuring the size of the diverticulectomy. is The surgical treatment is still being applied in this pathology, with a high probability of success. Currently, the patient is in good health and the recovery from surgery is favorable so far.

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.

Zenker Diverticulum: Does Size Correlate with Preoperative Symptoms?

Introduction Zenker diverticulum (ZD) usually affects adults after the 7 th 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

Preescolar con divertículo de Zenker y hallazgo intraoperatorio de cuerpo extraño esofágico / Preschool-age child with Zenker's diverticulum and intraoperative finding of an esophageal foreign body

Introducción. El divertículo de Zenker es una evaginación sacular ciega que puede presentarse a nivel faringoesofágico. No se conoce exactamente su incidencia en la edad pediátrica, constituyendo una patología muy infrecuente. La sintomatología es inespecífica, lo que dificulta el diagnóstico precoz y determina un mayor riesgo de complicaciones asociadas. Caso clínico. Paciente preescolar femenina con cuadro recurrente de emesis con deshidratación, posteriormente asociado a disfagia, a quien se le diagnosticó un divertículo de Zenker. Se realizó tratamiento quirúrgico con hallazgo intraoperatorio de dilatación esofágica, un área de estenosis secundaria al hallazgo incidental de un cuerpo extraño y divertículo de Zenker en la región lateral del esófago dilatado. Discusión. Esta patología es extremadamente rara, pero se debe tener en cuenta dentro de los diagnósticos diferenciales en pacientes con sintomatología faringo-esofágica. Conclusión. Se presenta una preescolar sin antecedente de procedimientos esofágicos o malformaciones congénitas asociadas con diagnóstico de un divertículo de Zenker y dilatación esofágica por un cuerpo extraño, tratada quirúrgicamente de forma exitosa.

Introduction. Zenker's diverticulum is a blind saccular evagination that can present at the pharyngoesophageal level. Its incidence in pediatric age is not exactly known, constituting a very infrequent pathology. The symptoms are nonspecific, which makes early diagnosis difficult and determines a higher risk of associated complications.Clinical case. Female preschool patient with recurrent dehydration due to emesis, later associated with dysphagia, who was diagnosed with Zenker's diverticulum. Surgical treatment was performed with intraoperative finding of esophageal dilation, an area of stenosis secondary to the incidental finding of a foreign body, and a Zenker's diverticulum in the lateral region of the dilated esophagus. Discussion. This pathology is extremely rare, but it should be taken into account within the differential diagnoses in patients with pharyngo-esophageal symptoms. Conclusion: We present a preschool female patient with no history of esophageal procedures or congenital malformations associated with a diagnosis of Zenker's diverticulum and esophageal dilation due to a foreign body, successfully treated surgically.

[Manejo quirúrgico del divertículo de Zenker]. / Surgical treatment of Zenker's diverticulum.

INTRODUCCIÓN: Los divertículos de Zenker son los divertículos más frecuentes del esófago. El tratamiento quirúrgico más utilizado es la diverticulectomía con miotomía del cricofaríngeo abierta. En años recientes se ha propuesto el tratamiento endoscópico. OBJETIVO: Presentar la experiencia en el manejo de esta patología en un hospital de referencia. MÉTODO: Fueron revisados los expedientes de los pacientes intervenidos quirúrgicamente por divertículo de Zenker en un periodo de 7 años. Los datos obtenidos incluyeron demográficos, cuadro clínico, abordaje diagnóstico, hallazgos transoperatorios y evolución posoperatoria. RESULTADOS: Fueron intervenidos 10 pacientes durante este periodo, con una edad promedio de 64 años (± 8); siete de ellos eran hombres. Los principales síntomas fueron regurgitación y disfagia, presentes en ocho y siete pacientes, respectivamente. Los estudios diagnósticos incluyeron endoscopia (nueve pacientes), esofagograma (seis pacientes) y manometría esofágica (tres pacientes). El tratamiento utilizado en todos los casos fue diverticulectomía con miotomía del cricofaríngeo. Las complicaciones incluyeron perforación esofágica transoperatoria (un paciente) y fístula esofágica (un paciente). Hubo resolución de los síntomas en nueve pacientes; el paciente restante ameritó nueva miotomía seis meses después, con una adecuada evolución. No hubo ninguna muerte. CONCLUSIONES: La diverticulectomía con miotomía del cricofaríngeo es un tratamiento quirúrgico seguro para los pacientes con divertículo de Zenker. BACKGROUND: Zenker's diverticulum represents the most common diverticulum of the esophagus. The standard surgical treatment consists of open cricopharyngeal myotomy with diverticulectomy. In recent years endoscopic treatment has been proposed. OBJECTIVE: We present the surgical experience of this disease in a referral hospital. METHOD: We reviewed the clinical records of all patients submitted to open surgical treatment for Zenker's diverticulum in a 7-year period. The retrieved information included demographic data, clinical manifestations, diagnostic approach, surgery findings and postoperative evolution. RESULTS: During this period 10 patients were submitted to open surgical treatment; the mean age was 64 (± 8) years and seven of them were male. The main complaint was regurgitation and dysphagia that was present in eight and seven patients respectively. Diagnostic studies included endoscopy (nine patients), esophagogram (six patients) and esophageal manometry (three patients). All underwent open cricopharyngeal myotomy with diverticulectomy. Complications included intraoperative esophageal perforation (one patient) and postoperative esophageal fistula (one patient). Resolution of the symptomatology occurred in 9 patients, the other patient required a new myotomy six months later with good results. There was no mortality. CONCLUSIONS: Cricopharyngeal myotomy with diverticulectomy is a safe option for patients with Zenker's diverticulum.

[Divertículo de Zenker. Manejo endoscópico contra técnica abierta. ¿Cuál es mejor? Experiencia en el Hospital General de México Dr. Eduardo Liceaga]. / Zenker's diverticulum: endoscopic versus surgical approach. Which is better? Experience in the General Hospital of Mexico Dr. Eduardo Liceaga.

INTRODUCCIÓN: El divertículo de Zenker es una enfermedad rara en la población general. Su tratamiento puede llevarse a cabo mediante un enfoque endoscópico o quirúrgico. OBJETIVO: Reportar la experiencia en el manejo del divertículo de Zenker en un centro de enseñanza de tercer nivel. MÉTODOS: Estudio retrospectivo, transversal, descriptivo, en el que fueron analizados los expedientes de todos los pacientes con diagnóstico de divertículo de Zenker desde la formación de la clínica de tracto digestivo superior del Hospital General de México Dr. Eduardo Liceaga. RESULTADOS: Se encontraron 14 casos con diagnóstico de divertículo de Zenker, 10 tratados con técnica transoral y 4 por cirugía abierta. Se presentaron tres recidivas en la técnica transoral y ninguna con la técnica abierta. En cuanto a las complicaciones, hubo una lesión dental con la técnica transoral y una fístula esofágica con cirugía abierta, que fue manejada con sonda nasoyeyunal colocada por endoscopia hasta el cierre espontáneo de la fístula. CONCLUSIÓN: El grapado transoral es una técnica con buenos resultados estéticos, pero en nuestra experiencia presenta mayor recurrencia que la cirugía abierta, por lo que debemos realizar un seguimiento a largo plazo de nuestros pacientes. BACKGROUND: Zenker diverticulum is a rare disease in the general population. Its treatment can be carried out by either an endoscopic or surgical approach. OBJECTIVE: To report the experience in the management of the Zenker diverticulum in a tertiary education center. METHODS: Retrospective, cross-sectional, descriptive study in which the files of all patients with diagnosis of Zenker diverticulum were analyzed from the formation of the upper digestive tract clinic of the General Hospital of Mexico Dr. Eduardo Liceaga. RESULTS: We found 14 cases with diagnosis of Zenker diverticulum, 10 treated with transoral technique and 4 for open surgery. Three recurrences in the transoral technique, no relapse with open technique. In terms of complications, one dental lesion was presented in the technique transoral, and one esophageal fistula in open surgery, managed with a nasojejunal tube placed by endoscopy until the spontaneous closure of said fistula. CONCLUSIONS: Transoral stapling is a technique with good aesthetic results. However, in our experience, it has a greater recurrence than open surgery, which is why we must carry out a long-term follow-up of our patients.

Uso seguro y eficaz del IT-Knife-2 en el manejo endoscópico del divertículo de Zenker (DZ) / Efficacy and safety of the endoscopic management of Zenker diverticulum with IT-Knife 2 device

Objetivo: Evaluar la eficacia y seguridad del manejo endoscópico del DZ con IT-knife 2. Materiales y métodos: Estudio prospectivo, multicéntrico (Hospital Nacional Edgardo Rebagliati Martins y la Clínica El Golf). Se incluyeron todos los pacientes con DZ sintomáticos desde setiembre 2013 a agosto 2016, los cuales fueron sometidos a miotomía cricofaringea endoscópica. Técnica: se afrontó el septo del DZ con un cap y luego se seccionó con el IT-Knife 2 (ENDOCUT Q Efecto 3-2-5) hasta su base. Se comparó la escala de disfagia antes y después del procedimiento, al 1er mes y luego de los 3 meses. Resultados: Se incluyeron 20 pacientes (11 varones; edad promedio: 71 años). El tamaño promedio del DZ fue de 40,5 mm. El tiempo promedio de la miotomía cricofaringea fue de 13,75 minutos. El éxito clínico fue del 100%, presentando un descenso estadísticamente significativo (p<0,001) en el score de disfagia de 2+/-0,86 pre-tratamiento a 0,05+/-0,22 al primer mes post- tratamiento. La recurrencia clínica a partir del tercer mes fue de 15%, resolviendo por completo con un segundo tratamiento endoscópico. No se presentó ningún caso de perforación ni sangrado. Dos pacientes cursaron con neumonía. Conclusión: El tratamiento endoscópico del DZ mediante el uso del IT-knife 2 es altamente eficaz y seguro, y de menor complejidad que la experiencia previa

Objective: To evaluate the efficacy and safety of the endoscopic management of Zenker Diverticulum with IT-Knife 2 device. Materials and methods: prospective and multicenter study (Edgardo Rebagliati Martins National Hospital and Golf Clinic). We included all patients with sintomatic Zenker Diverticulum that were treated with endoscopic cricopharyngeal miotomy from september 2013 until august 2016. Technique: the diverticulum septum was faced with a cap, and then it was cut by the IT-Knife 2 (ENDOCUT Q, effect 3-2-5) until its baseline. Disphagia score was compared before and 1 and 3 months after the procedure. Results: 20 patients were included (11 men; average age: 71 years). The median size of Zenker Diverticulum was 40.5 mm. The median duration of the cricopharyngeal miotomy was 13.75 minutes. Clinical success was 100%. There was a significative decrease (p<0.001) in the disphagia score from 2+/-0.86 before the procedure to 0.05+/-0.22 one month after it. Recurrence after 3 months was 15% and it was completely solved after a second endoscopic treatment. Niether perforation nor bleeding was reported. Two patients had pneumonia. Conclusion: the endoscopic management of Zenker Diverticulum with IT-Knife 2 is highly effective, safe and less complex than previous technique experience

Septotomía endoscópica del divertículo de Zenker / Endoscopy septotomy in zenker diverticulum

Introducción: La Diverticulotomía o Septotomía endoscópica en el divertículo de Zenker, es una alternativa a otros abordajes terapéuticos. El presente estudio muestra nuestra experiencia de esta técnica endoscópica. Pacientes y Métodos: Análisis retrospectivo, entre el 2009 y 2017 en pacientes con divertículo de Zenker. La septotomía se realizó utilizando videoendoscopio flexible, esfinterótomo aguja, electrobisturi para DSE tipo Hibridknife, mediante una técnica ya estandarizada. Resultados: Se trataron 25 pacientes con edad promedio de 71 años (rango etario de 45 a 84 años). En una paciente su mejoría fue muy poca, por lo que se sometió a intervención quirúrgica, donde tampoco hubo resultados consistentes. Veintiún pacientes mostraron un alivio completo de la disfagia. Tres pacientes que tuvieron recurrencia sintomática fueron tratados con el mismo método endoscópico entre 2 y 4 sesiones evolucionando de forma satisfactoria. Conclusiones: La septotomía endoscópica del divertículo de Zenker es un método eficaz y seguro, por lo tanto representa una alternativa real a la cirugía.

Introduction: Diverticulotomy or Endoscopic septotomy in Zenker's diverticulum is an alternative to others therapeutics approaches. The present study shows our experience of this endoscopic technique. Patients and methods: Retrospective analysis between 2009 and 2017 in patients with Zenker's diverticulum. The procedure was performed using a flexible video endoscope and a needle knife, Erbe hybrid knife probe, using an already standardized technique. Results: Twenty-five patients with an average age of 71 years (age range 45-84 years) were treated. In one patient his improvement was very little, therefore surgical procedure was performed, nevertheless this procedure had not consistent results. Twenty-one patients showed complete relief of dysphagia. Three patients who had symptomatically relapsed were retreated with the same endoscopic method between 2 and 4 sessions with good results. Conclusions: Zenker's endoscopic septotomy of the diverticulum is an effective and safe method; thereby it represents a real alternative to surgical treatment.

ASSESSMENT OF MECHANICAL AND MANUAL SUTURE IN THE SURGICAL TREATMENT OF THE PHARYNGOESOPHAGEAL DIVERTICULUM / AVALIAÇÃO DA SUTURA MECÂNICA E MANUAL NO TRATAMENTO CIRÚRGICO DO DIVERTÍCULO FARINGOESOFÁGICO

Background: The occurrence of the pharyngoesophageal, or Zenker diverticulum is not frequent in the national scenario, and the technique of the diverticulectomy with cricomyotomy in medium and great dimension diverticula is still the most indicated. Because the resection of the diverticulum requires the suture of the pharynx, dehiscence can occur, thereafter delaying swallowing. Hence, the idea is to accomplish this surgical procedure, comparing the manual and mechanical suture, in order to evaluate the real benefit of the mechanical technique. Aim: To evaluate the results of the pharyngoesophageal diverticulectomy with cricomyotomy using manual and mechanical suture with regard to local and systemic complications. Method: Fifty-seven patients with pharyngoesophageal diverticula diagnosed through high digestive endoscopy and pharyngeal esophagogram were studied. The applied surgical technique was diverticulectomy with myotomy of the cricopharyngeal muscle, done in 24 patients (42.2%) the mechanical suture (group A) with the mechanical linear suture device and in 33 (57.8%) a manual closure of the pharynx (group B). Results: In the postoperative period, one patient of group A (4.1%) presented fistula caused by dehiscence of the pharyngeal suture, and three of group B (15.1%) presented the same complication, with a good outcome using a conservative treatment. In the same group, three patients (9.0%) presented stenosis of the suture of the pharynx, with good outcome and with endoscopic dilatations, and no patient from group A presented such complication. Lung infection was present in five patients, being two (8.3%) of group A and three (9.0%) on B, having good outcomes after specific treatment. In the late review, done with 43 patients (94.4%) of group A and 22 (88.0%) on B, the patients declared to be pleased with the surgical procedure, because they were able to regain normal swallowing. Conclusion: The diverticulectomy with myotomy and pharyngeal closure using mechanical suture was proven appropriate, for having restored regular swallowing in most of the patients, and the mechanical closure of the pharynx proved to be more effective in comparison to the manual one, because it provided a lower index of local post-surgical complications.

Racional: A ocorrência do divertículo faringoesofágico, ou de Zenker, é pouco frequente no cenário nacional, sendo que a técnica da diverticulectomia com cricomiotomia em divertículos de média e grandes dimensões ainda é a mais indicada. Devido à ressecção do divertículo necessitar de sutura da faringe ocorre possibilidade de deiscência, o que retarda o retorno da deglutição. Daí a ideia de realizar este procedimento cirúrgico, comparando a sutura manual com a mecânica, para avaliar o real benefício da técnica mecânica. Objetivo: Avaliar os resultados da diverticulectomia faringoesofágica com cricomiotomia utilizando à sutura manual e mecânica em relação às complicações locais e sistêmicas. Métodos: Foram estudados 57 pacientes com divertículos faringoesofágicos diagnosticados através da endoscopia digestiva alta e faringoesofagograma. A técnica cirúrgica empreendida foi a diverticulectomia com miotomia do músculo cricofaríngeo, sendo a sutura mecânica realizada em 24 pacientes (42,2%, grupo A) com o aparelho linear e em 33 (57,8%, grupo B) a manual para o fechamento da faringe. Resultados: Na avaliação do pós-operatório precoce, um paciente do grupo A (4,1%) apresentou fístula consequente à deiscência da sutura da faringe e três do grupo B (15,1%) ambos com boa evolução com tratamento conservador. Neste mesmo grupo, três pacientes (9,0%) apresentaram estenose da sutura da faringe, com boa evolução com dilatações endoscópicas sendo que nenhum do grupo A apresentou esta complicação. A infecção pulmonar esteve presente em cinco pacientes, dois (8,3%) do grupo A e três (9,0%) do grupo B, com boa evolução com tratamento específico. Na avaliação tardia, realizada em 43 pacientes, 17(94,4%) do grupo A e 22 (88,0%) do grupo B, os pacientes referiram estarem satisfeitos com o procedimento cirúrgico, pois conseguiram resgatar a deglutição normal. Conclusões: A diverticulectomia com a miotomia do cricofaríngeo demonstrou ser procedimento cirúrgico ...

Comparison of electrical current and ultrasonic device for incision of the septum of the pharyngoesophageal diverticulum in a pig model.

BACKGROUND: Complications of endoscopic treatment of pharyngoesophageal diverticulum (PED) such as bleeding and perforation occur in up to 15 % of cases. Our objective was to compare incision of the PED septum using the ultrasonic device (group H) with incision using electrical current (group M) in a pig model. METHODS: Twenty domestic pigs were divided into groups H and M. The incision of the PED septum was performed using the ultrasonic device or using electrical current, respectively. The procedural time, complication rate, length of the border of the incised septum, and thermal tissue damage were compared between groups. RESULTS: Mean time to divide the septum and total procedure time were significantly shorter in group H. Mean length of the border of the incised septum was significantly higher in group H. The lateral thermal spread caused by electrical current (group M) was more intense. Hemorrhage was exclusively observed in group M. CONCLUSION: Experimental endoscopic diverticulotomy using ultrasonic device was faster and caused less tissue damage when compared to electrical current.

Pharyngoesophageal Obstruction on the Killian-Laimer Triangle by Zenker's Diverticulum: Case Report and Clinical Significance.

Zenker's diverticulum is a form of esophageal and pharyngeal obstruction located at the Killian-Laimer triangle. It is relatively common in elderly man (seventh or eighth decade of life), and its pathophysiology is not completely understood, albeit theories regarding dysfunction of the upper esophageal sphincter were reported. The main symptoms are dysphagia and odynophagia, but it can complicate to aspiration and perforation of the pharyngeal pouch; also, it can be asymptomatic. Diagnosis is provided through a barium esophagogram. Treatment can be performed through endoscopic surgery, diverticulopexy and myotomy of the cricopharyngeus muscle, although there is no consensus among surgeons regarding the treatment of choice. We report a case of pharyngeal obstruction due to Zenker's diverticulum which caused massive weight loss in a 76-year-old male.

[Zenker's diverticulum: election of surgical treatment and outcome. Case presentation]. / Divertículo de Zenker, elección del tratamiento quirúrgico y resultado. Presentación de un caso.

BACKGROUND: Zenker's diverticulum is a protrusion of the pharyngeal mucosa through a weak area of the posterior wall. It is a rare disorder with an incidence in Mexico of ~0.04% of the population. Its pathophysiology is not yet completely understood. Treatment is surgical and is performed in case of complications. Clinic case: We present the case of a 67 year-old male patient without comorbidities. Symptoms appeared 15 months prior to admission with occasional dysphagia to solids and liquids, breathing difficulty at night, drooling, halitosis, 3 kg weight loss in 2 months, and adequate appetite. Diagnosis of Zenker's diverticulum was established by imaging method and endoscopy. A diverticulectomy with cricopharyngeal muscle myotomy was successfully performed. Liquid diet was started the third postoperative day and progressed without complications; the patient was discharged on the sixth postoperative day without complications. Follow-up at 1 year was successful without recurrence. CONCLUSION: Minimally invasive procedures are useful in patients with comorbidities and for the short anesthesia time and hospitalization. Referring to our field of work, the open treatment is best to relieve symptoms rather than endoscopic procedures because the training for advanced endoscopic procedures is a problem due to lack of infrastructure and specialized personnel.

Antecedentes: los divertículos de Zenker son protrusiones de la mucosa faríngea a través de una zona débil de su pared posterior. Es un padecimiento raro, con una incidencia en México de aproximadamente 0.04% de la población. El tratamiento indicado es quirúrgico. Caso clínico: paciente masculino de 67 años de edad, que 15 meses antes del diagnóstico experimentó síntomas de: disfagia a sólidos y ocasionalmente a líquidos, ahogo por las noches, sialorrea, halitosis, pérdida de 3 kg en dos meses y aumento del apetito. El diagnóstico se confirmó a través de métodos de imagen y endoscopia. Se realizó exitosamente una diverticulectomía con miotomía de músculo cricofaríngeo. Al tercer día de operado pudo ingerir líquidos sin complicaciones, y fue dado de alta al sexto día. Un año después no había mostrado recurrencias. Conclusión: los procedimientos de invasión mínima son útiles en pacientes con comorbilidades porque requieren corto tiempo de anestesia y de hospitalización. En este medio, el tratamiento abierto es la mejor técnica para su resolución, ya que la capacitación para efectuar procedimientos endoscópicos representa un problema por la falta de infraestructura y personal especializado.

Zenker's Diverticulum: Diagnostic Approach and Surgical Management.

Zenker's diverticulum (ZD), also known as cricopharyngeal, pharyngoesophageal or hypopharyngeal diverticulum, is a rare condition characterized by an acquired outpouching of the mucosal and submucosal layers originating from the pharyngoesophageal junction. This false and pulsion diverticulum occurs dorsally at the pharyngoesophageal wall between the inferior pharyngeal constrictor and the cricopharyngeus muscle. The pathophysiology of ZD involves altered compliance of the cricopharyngeus muscle and raised intrabolus pressure. Decreased compliance of the upper esophageal sphincter and failure to open completely for effective bolus clearance both lead to an increase in the hypopharyngeal pressure gradient. Different open surgical techniques and transoral endoscopic approaches have been described for the management of ZD, although there is no consensus about the best option. We report the case of a 61-year-old patient with a 7-year history of dysphagia and odynophagia for solid food, which after 2 months progressed to dysphagia for liquids and after 4 months to regurgitation 2-6 h after meals. The patient experienced a 12-kg weight loss. Diagnosis was established by esophagogram, which showed a diverticulum through the posterior pharyngeal wall, suggestive of a ZD. Esophagogastroduodenoscopy showed a pouch with erythematous mucosa. Under general anesthesia, diverticulectomy and myotomy were performed. After an uneventful recovery and adequate oral intake, the patient remains free of symptoms at 4 months of follow-up.

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 faringoesofagiano: avaliação dos resultados do tratamento / Pharyngoesophageal diverticulum: evaluation of treatment results

OBJETIVO: Avaliar a evolução pós-operatória de pacientes com divertículo faringoesofagiano submetidos aos tratamentos cirúrgico e endoscópico. MÉTODOS: Foram analisados de maneira retrospectiva 36 pacientes com divertículo faringo-esofagiano atendidos no Hospital das Clínicas da Faculdade de Medicina de Botucatu - UNESP. Os pacientes foram distribuídos em dois grupos, na dependência do tratamento: grupo 1 (n=24) - diverticulectomia associada á miotomia do cricofaríngeo, através de cervicotomia esquerda; grupo 2 (n=12) - diverticulostomia endoscópica usando grampeador linear. RESULTADOS: A mortalidade operatória foi nula em ambos os grupos. Complicações precoces: grupo 1 - dois pacientes desenvolveram fistula cervical e outros dois, rouquidão; grupo 2 - sem complicações. Complicações tardias: grupo 1 - sem complicações: grupo 2: recidiva da disfagia em quatro pacientes (p=0,01). O seguimento médio foi 33 meses para o grupo 1 e 28 meses para o grupo 2. CONCLUSÃO: Os dois procedimentos foram eficazes na remissão da disfagia. O tratamento cirúrgico apresentou superioridade em relação ao endoscópico, com resolução da disfagia com um único procedimento. O tratamento endoscópico deve ser reservado para os mais idosos e portadores de comorbidades.

OBJECTIVE: To evaluate the postoperative outcome of patients with pharyngoesophageal diverticulum submitted to surgical and endoscopic treatments. METHODS: We retrospectively analyzed 36 patients with pharyngo-esophageal diverticulum treated at the Hospital of the Medical School of Botucatu - UNESP. Patients were divided into two groups, depending on the treatment: group 1 (n = 24): diverticulectomy associated myotomy through a left cervicotomy; group 2 (n = 12): endoscopic diverticulostomy with linear stapler. RESULTS: Operative mortality was zero in both groups. Early complications: group 1- two patients developed cervical fistula and two, hoarseness; group 2 - none. Late complications: group 1 - none; group 2: recurrence of dysphagia in four patients (p = .01). Mean follow-up was 33 months for group 1 and 28 months for group 2. CONCLUSION: Both procedures were effective in remission of dysphagia. Surgical treatment showed superiority to endoscopy, with resolution of dysphagia with a single procedure. Endoscopic treatment should be reserved for the elderly and those with comorbidities.

Diverticulopexia no tratamento do divertículo de Zenker / Diverticulopexy for the treatment of Zenker's diverticulum

O divertículo de Zenker é um pseudodivertículo que se origina de um defeito muscular na parede posterior da faringe, na área de transição entre o músculo constritor inferior da faringe e o músculo cricofaringeo. Apesar do avanço das técnicas endoscópicas, o tratamento cirúrgico persiste como o tratamento padrão. Duas técnicas são possíveis: diverticulectomia (ressecção do divertículo) e a diverticulopexia. As vantagens da diverticulopexia estão ligadas à ausência de anastomose esofágica e suas possíveis complicações: fistulas cervicais, mediastinite, estenose esofágica e infecção de ferida. Em ambas as técnicas a secção das fibras musculares do músculo cricofaringeo (ou, esfíncter superior do esôfago) é fundamental. O objetivo do presente artigo é descrever em detalhes a técnica de diverticulopexia junto ao ligamento pré-vertebral associada à miotomia do músculo cricofaríngeo.

Zenker´s diverticulum is a pseudodiverticulum through a muscular defect in the posterior pharyngeal wall at the area between the inferior pharyngeal constrictor muscles of the pharynx and the cricopharyngeus muscle. Although endoscopic techniques have made significant progress, the surgical treatment remains the gold standard. There are two main techniques: diverticulectomy (resection of the diverticulum) and diverticulopexy. The main advantages of diverticulopexy are mostly linked to the absence of an esophageal anatomosis and its possible complications: cervical fistulae, mediastinitis, esophageal stenosis and wound infection, which allows a rapid recover with satisfactory oral intake. The purpose of this article is to describe in details the technique for diverticulopexy to the prevertebral ligament in association with a miotomy of the cricopharyngeus muscle.