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

Epidemiology and Management of Zenker Diverticulum in a Low-Threshold Single-payer Health Care System.

IMPORTANCE: The incidence of Zenker diverticulum has been established; previous estimates have been extrapolated from small institutional cohorts. OBJECTIVE: To describe the population-wide incidence of Zenker diverticulum over a 20-year period and characterize management strategies across specialties and treatment settings. DESIGN, SETTING, AND PARTICIPANTS: This retrospective national cohort study was conducted from January 1, 1996, through December 31, 2015, and reviewed patient records from the Care Register for Healthcare in Finland, from which patients with Zenker diverticulum were identified. The data were analyzed in October 2021. EXPOSURES: Zenker diverticulum. MAIN OUTCOME AND MEASURE: The incidence of Zenker diverticulum per 100 000 person-years. RESULTS: A total of 2736 patients (median [IQR] age at diagnosis 72.0 [19-106] years; 1278 women [46.7%]) were identified, making the annual incidence of Zenker diverticulum in Finland 2.9/100 000 person-years. Men had higher incidence (3.7/100 000 person-years) compared with women (2.3/100 000 person-years), with an incidence rate ratio of 1.61 (95% CI, 1.48-1.76; P < .001). Within the study population, 1044 patients (38.2%) underwent surgical treatment and 227 (8.3%) underwent 2 or more surgeries. The choice of initial operative approach depended on the medical specialty (Cramer V = 0.41) and on specific catchment area (Cramer V = 0.41). Overall, endoscopic approaches for initial operations were most popular. CONCLUSIONS AND RELEVANCE: The cohort study results found that the incidence of Zenker diverticulum was 2.9/100 000 person-years. Most patients with Zenker diverticulum did not undergo definitive therapy. Some hospital districts and some medical specialties were more likely to opt for conservative treatment than others. The choice of operative approach depended more on physician-level factors rather than patient profiles.

Zenker Diverticulum: A Potential Pitfall in Thyroid Ultrasound Evaluation: A Case Report and Systematic Review of Literature.

BACKGROUND AND OBJECTIVE: Zenker Diverticulum (ZD) can sometimes be misinterpreted as a thyroid nodule both at clinical evaluation and at Ultrasound (US). CASE PRESENTATION: We reported the case of a 46-years-old woman complaining of a lump in the anterior left aspect of the neck. Following clinical examination and US evaluation, a thyroid nodule was initially diagnosed and the patient was referred to our institution to be submitted to a fine-needle aspiration cytology. Management and Outcome: A ZD was suspected by US and diagnosed by gastrografin esophagram, thus an endoscopic diverticulotomy was requested. CONCLUSION: A correct US evaluation can be crucial for the appropriate management of a neck mass.

Total laryngectomy: Surgical morbidity and outcomes - A case series.

BACKGROUND: Total laryngectomy (TL) is a well-established procedure for laryngeal and hypopharyngeal cancers. There is an increasing number of TLs done after organ preservation strategies. AIM: The aim of this study was to report 30-day morbidity and survival outcomes in patients undergoing TL at a tertiary referral center. SETTING AND DESIGN: This was a retrospective review of a prospective database of TL patients operated during 2012-2013. MATERIALS AND METHODS: Patient demographics and other data were captured from the database. Surgical complications were graded as per Clavien-Dindo grading system and were also divided into major and minor as per predecided criteria. Recurrence and survival data were computed using Kaplan-Meier survival curves. RESULTS: A total of 169 patients underwent TL during the study period. About 34% of the patients had received prior radiation therapy. Around 18% of the patients had major complications with a pharyngocutaneous fistula rate of 22.4%. Ninety percent of these were managed conservatively. Though used in a small subset, microvascular reconstruction had the least complication rates. The 3-year disease-free survival and overall survival were 66% and 72%, respectively. There was no difference in survival between per primum and salvage surgery cohorts. CONCLUSION: TL is a safe and oncologically sound procedure in patients with laryngeal and hypopharyngeal cancers. A large proportion of patients still undergo TL as a de novo procedure. This denotes that patients still present with locally advanced cancers which are not amenable to organ preservation.

32 years of experience with CO2 -LASER-assisted treatment for Zenker's Diverticulum - an update of 227 patients treated in Kiel.

OBJECTIVES: To underline the value of the microendoscopic CO2 -LASER-assisted treatment (MEDCO2 ) for Zenker's diverticulum by investigating a large patient cohort treated in a single medical centre. DESIGN: Retrospective cohort study of consecutive patients. SETTING: Department of Otorhinolaryngology, Head and Neck Surgery, Christian-Albrechts-University Kiel, Germany. PARTICIPANTS: A total of 227 patients with Zenker's diverticulum were treated by MEDCO2 , and the results were compared with those reported in the literature for the open transcervical approach (OTA) and the endoscopic staple-assisted oesophagodiverticulostomy (ESED). OUTCOME MEASUREMENTS: Data assessment regarding preoperative symptoms, perioperative management, morbidity, mortality and longtime results. Comparison of results with data from the literature regarding MEDCO2 , ESED and OTA. RESULTS: Operation duration: 25 min median; morbidity: 4.7%; mortality: 0%; mediastinitis: 0.9%; hospitalisation: 7 days; feeding tube dependency: 4 days; recurrence rate: 6.1%. Rise of body temperature above 38°C and 39°C in 36.7% and 12.2% of cases on first postoperative day, respectively. CONCLUSIONS: The results identify MEDCO2 as superior in comparison with ESED and OTA concerning the treatment for Zenker's diverticulum especially in terms of excellent long-term functional results and a low morbidity and mortality. The short operation time qualifies MEDCO2 as specifically suitable for the treatment of the characteristic patient cohort with Zenker's diverticulum, namely the elderly, whereas OTA should be reserved for cases with sophisticated or impossible endoscopic exposure of the pouch. The occurrence of perioperative fever can be managed with a systemic antibiotic and antipyretic medication. Although a mediastinitis as major complication is a rare event, the early introduction of its diagnosis with CT scans and consecutive therapy including thoracotomies can be lifesaving.

Crico-faringo-mío-septotomía endoscópica flexible: “gold standard” en el tratamiento del divertículo de Zenker / Flexible endoscopic cricopharyngeal myotomy. The gold standard for the management of Zenker's diverticulum

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Tratamiento endoscópico flexible del divertículo de Zenker: trece años de experiencia en España / Flexible endoscopic treatment of Zenker’s diverticulum: thirteen years’ experience in Spain

Introducción: el tratamiento endoscópico flexible del divertículo de Zenker es una alternativa a otros abordajes terapéuticos. El presente estudio muestra nuestros resultados a corto y largo plazo de la crico-faringo-mío-septotomía endoscópica flexible. Pacientes y método: análisis retrospectivo de nuestra experiencia entre 2002 y 2015 en pacientes con divertículo de Zenker tratados mediante un endoscopio flexible con la asistencia de un diverticuloscopio flexible. La mío-septotomía se realiza con un papilotomo de aguja bajo sedación profunda o anestesia general. Resultados: de los 64 pacientes tratados dos fallecieron antes de 10 días después del procedimiento por causas no directamente relacionadas con la intervención y otro presentó una perforación faringo-esofágica que se resolvió con tratamiento conservador tras 47 días de ingreso. Carecemos de seguimiento a corto plazo de otros cuatro. Cincuenta y dos de los 57 restantes mostraron un alivio completo de la disfagia a las 6 semanas. Once de ellos presentaron recurrencia sintomática a medio o largo plazo. Ocho fueron retratados con el mismo método endoscópico flexible, uno mediante un abordaje endoscópico híbrido, otro mediante cirugía abierta clásica y otro rechazó el retratamiento. Tras un seguimiento medio de 2 años y medio, 33 de 37 pacientes refieren ausencia o mínima disfagia controlable con restricciones dietéticas puntuales. Conclusiones: el tratamiento endoscópico flexible del divertículo de Zenker es eficaz y seguro. Representa una alternativa en igualdad de condiciones al abordaje endoscópico rígido y a la cirugía abierta clásica y puede aplicarse cuando existe imposibilidad técnica o contraindicación para estos (AU)

Introduction: Flexible endoscopic treatment is one of the alternative approaches for the management of Zenker’s diverticum. The present paper shows our short-term and long-term results with flexible endoscopic cricopharyngeal myotomy/septotomy. Patients and methods: A retrospective analysis of our experience in patients with Zenker’s diverticulum treated using a flexible endoscope, assisted by a flexible diverticuloscope, between 2002 and 2015. Myotomy/septotomy was performed with a needle-knife papillotome under deep sedation or general anesthesia. Results: Among the 64 patients treated, two died within 10 days of surgery from causes not directly related to the procedure, and one presented with pharyngo-esophageal perforation, which recovered with conservative management at 47 days after admission. Four additional patients were lost to short-term follow-up. Among the 57 remaining patients, 52 had complete relief of dysphagia after 6 weeks. Eleven of these had recurrent symptoms on the mid and the long term. Eight were retreated with the same flexible endoscopic technique, one with a hybrid endoscopic approach, one with classical open surgery and one refused retreatment. After a mean follow-up of 2 years and a half, 33 of 37 patients reported absent or minimal dysphagia, controllable with punctual dietary restrictions. Conclusions: Flexible endoscopic treatment for Zenker’s diverticulum is effective and safe. It represents an option on an equal footing to rigid endoscopy and classical open surgery and may also be used when the latter two are technically impracticable or contraindicated (AU)

Zenker's Diverticulum.

Zenker's diverticulum (ZD) is an outpouching of tissue through the Killian triangle that is believed to be caused by dysfunction of the cricopharyngeal muscle. ZD is a relatively uncommon disorder occurring in the elderly. The predominant symptom of ZD is dysphagia, and the most serious consequence is pulmonary aspiration. Videofluoroscopy confirms the diagnosis. Therapy of symptomatic ZD has evolved from an open surgical approach to less invasive transoral endoscopic techniques. Transoral endoscopic therapy using rigid instruments is performed primarily by otorhinolaryngologists, whereas transoral therapy using flexible endoscopes is performed by surgical endoscopists and gastroenterologists. The common goal of all modalities is severing of the septum between the esophageal lumen and the diverticulum containing the cricopharyngeal muscle. Although flexible endoscopic therapy was described nearly 20 years ago, it has experienced a recent resurgence paralleling the advancements of therapeutic endoscopy in other areas, such as endoscopic submucosal dissection. Direct head-to-head comparisons of rigid and flexible endoscopic therapy are lacking, and each approach has variations in techniques as well as advantages and disadvantages. In this article, we review the pathophysiology and management of patients with ZD with an emphasis on flexible endoscopic therapy.

Zenker's diverticulum: exploring treatment options.

Zenker's diverticulum is an acquired sac-like outpouching of the mucosa and submucosa layers located dorsally at the pharyngoesophageal junction through Killian's dehiscence. It is the most common type of oesophageal diverticula with a reported prevalence ranging between 0.01 to 0.11% and typically occurs in middle-aged and elderly patients. Predominant symptoms are dysphagia and regurgitation. Treatment is recommended for symptomatic patients and considering the aetiopathogenesis of the disease demands myotomy of the cricopharyngeal muscle. Myotomy may be pursued through either open surgical or endoscopic techniques. Management of Zenker's diverticulum has dramatically progressed during past decades. Open surgery with cricopharyngeal myotomy has long been the conventional treatment with satisfactory results, but is associated with high complication rates. Since Zenker's diverticulum mainly affects frail elderly patients, less invasive treatments are indicated. In recent years, endoscopic repair of Zenker's diverticulum has been found to be a viable safe and effective alternative to surgery and gained widespread acceptance. Endoscopic stapled diverticulotomy is generally the preferred approach, but flexible endoscopy is a valuable option, particularly for high-risk patients. The literature is mainly based on retrospective case series or comparative case series, and the optimal treatment modality has not yet been established. The choice between the different approaches depends on local expertise and preferences. Based on retrospective literature results, appropriate technique selection dictated by the size of the diverticulum and the patient's conditions is however desirable.

Surgical management of esophageal diverticulum: a review of the Nationwide Inpatient Sample database.

BACKGROUND: Esophageal diverticulum is rare in the United States. The mainstay treatment of symptomatic esophageal diverticulum is surgical correction. Much of the available information regarding esophageal diverticulum and its surgical management has been derived from small studies and institutional reviews. Our study objective was to investigate the demographics, perioperative conditions, and predictors of outcomes after surgical treatment of acquired esophageal diverticulum using a nationally representative database. METHODS: A retrospective review using the Nationwide Inpatient Sample database from 2000-2009 was performed for patients with acquired esophageal diverticulum. The patients were stratified into Zenker's diverticulum (ZD) or non-Zenker's diverticulum (NZD) subgroups. The covariates retrieved included age, gender, ethnicity, insurance type, and Charlson comorbidity index. A multivariate analysis was performed to determine the predictors of postoperative morbidity. Discharge-level weights were applied. RESULTS: Overall, a total of 4253 patients met our inclusion criteria, 3197 (75%) with ZD and 1056 (25%) with NZD. In the ZD group, the mean age was 73 ± 12.3 y, and most were men (55%) and white (67%). The mean length of stay was 5.82 ± 8.08 d, and the mortality rate was 1.2%. The most common complication was septicemia or sepsis (2.0%). The black patients had higher odds of postoperative morbidity than the white patients (odds ratio [OR] 2.29, 95% confidence interval [CI] 1.02-5.17). The risk of overall postoperative morbidity was 52% greater for women (OR 1.52, 95% CI 1.01-2.29). An increasing Charlson comorbidity index was an independent predictor of morbidity. In the NZD group, the mean age was 69 ± 13.9 y, and most were also men (51%) and white (63%). The mean length of stay was 8.13 ± 10.56 d, and the mortality rate was 1.6%. The most common complication was air leak (3.1%). The black and Hispanic patients had higher odds of postoperative morbidity than the white patients (OR 1.97, 95% CI 1.05-3.72 and OR 2.37, 95% CI 1.06-5.30, respectively). An increasing Charlson comorbidity index was an independent predictor of morbidity. Compared with laparoscopy, the risk of developing postoperative morbidity was higher with the thoracotomy procedure (OR 7.45, 95% CI 1.11-50.18). CONCLUSIONS: Using a nationally representative database, our study found that female gender, black race, and the presence of comorbidities were associated with increased postoperative morbidity among patients with ZD. Among the patients with NZD, black and Hispanic patients had worse postoperative morbidity than the white patients, and the presence of comorbidities was associated with increased postoperative morbidity. Thoracotomy for the correction of NZD was associated with increased postoperative morbidity compared with the laparoscopic approach.

Familial Zenker's diverticulum.

CONCLUSION: The aetiology of Zenker's diverticulum is likely to be multifactorial. The geographical and racial variation in the prevalence and the rare familial cases suggest that genetic predisposition might have a role in the pathogenesis. The mode of inheritance in the rare possible familial cases seems to be autosomal dominant; recessive inheritance is non-existent or extremely rare. OBJECTIVES: To study the inheritance of Zenker's diverticulum. SUBJECTS AND METHODS: A detailed questionnaire concerning physical health and family history was sent to 122 patients with Zenker's diverticulum. RESULTS: The prevalence of familial disease in Finland was found to be < 2%. We found no evidence for genetic founder effect.

[Special gastrointestinal problems of elderly patients]. / Symptomarmer Verlauf--ernste Folgen.

Only a few gastrointestinal diseases develop specifically at advanced ages (e.g. Zenker diverticulum, atrophic gastritis, mesenterial ischaemia). However, the frequency of certain diseases increases and various illnesses are found to take other, mostly silent, courses in elderly people. As a rule, more complications in gastrointestinal diseases are to be expected and the presence of comorbidities can make diagnosis and therapy more difficult. The possibility of tumours should always be considered in the differential diagnosis of elderly patients. The diagnosis and treatment of elderly patients for gastrointestinal diseases are no different from that of other age groups.

Divertículo Esofágico de Zenker como diagnóstico diferencial de lesión quística paratraqueal / Zenker´s esophageal diverticulum as differential diagnosis of paratracheal cystic lesion

Presentamos el caso de un paciente de 52 años con clínica de regurgitación de alimentos y cierta disfagia sin otra sintomatología añadida visto en nuestras consultas externas de ORL. Se le practicó una TC cérvicotorácico que informaba de una lesión quística paratraqueal compatible con divertículo esofágico o traqueal. La posibilidad de este último se descartó mediante broncoscopia que resultó ser normal

We report the case of 52 years old patient with clinica of food regurgitation and some dysphagia without other added symptoms who was sent to our ENT consulting romos. It was performed a cervicothoracic CT which informed as a paratracheal cystic lesion with differential diagnosis between esophageal or tracheal diverticulum. The possibility of that las one was discarded bya a normal bronchoscopy

[Surgical tactics in the treatment of duodenal ulcer disease coexistent with diseases of other organs of abdominal cavity].

Surgical treatment was performed in 102 patients suffering duodenal ulcer and chronical calculous cholecystitis, gastroesophageal leyomyoma, esophageal, duodenal, small intestinal diverticulum, cardiospasm and other diseases. In all the patients the simultant operative intervention was performed for duodenal ulcer and other diseases of the abdominal cavity organs. All the patients had survived after the operation. Good and fair results were noted in terms of 6 mo -20 yrs follow-up in 79 patients.

Stapled diverticulectomy and myotomy for symptomatic Zenker's diverticulum.

BACKGROUND: Few surgeons have extensive experience with the operative management of Zenker's diverticulum (ZD). METHODS: Retrospective review of stapled diverticulectomy and cricopharyngeal myotomy (SDM) for ZD. All procedures were performed by midlevel surgery residents supervised by single board-certified surgeon. A drain was not used, and patients were liberally advanced to a regular diet postoperatively. RESULTS: Three patients with ZD underwent this procedure during a 6-year period. The mean age of the patients was 81 years, and all had multiple comorbidities. Time to discharge was less than 48 hours in 2 patients and 5 days in 1 patient who developed new atrial fibrillation. There were no deaths or clinical leaks. At a mean follow-up of 33 (range 6-62) months, 1 patient died of an unrelated cause, and the other 2 are free of esophageal-related symptoms. CONCLUSIONS: SDM for ZD is a safe and effective operation that is easily taught to surgical residents.

Frequency and etiology of midesophageal diverticula at barium esophagography.

Midesophageal diverticula were identified at 8 of 218 (3.6%) esophagrams performed over a 3-year period in adult patients with no prior history of gastroesophageal surgery. All eight patients received a final diagnosis of esophageal dysmotility with secondary pulsion diverticula, and seven of eight (88%) patients had abnormal peristalsis noted during the esophagram. We conclude that most, if not all, midesophageal diverticula are pulsion in etiology, and the detection of a midesophageal diverticulum should prompt a careful search for underlying dysmotility.

Pharyngeal pouch: associations and complications.

The aetiopathogenesis of pharyngeal pouch remains obscure. This review highlights the associations and complications of pharyngeal pouch to better understand the pathogenesis and management of the pouch. A search of the MEDLINE was conducted to identify studies that looked at associations and/or complications of the pharyngeal pouch. The Medical Subject Headings (MeSH) included Zenker's diverticulum and hypopharyngeal diverticulum. A total of 64 papers were included for the analysis. They consisted mainly of single case reports, case series and review articles and one case control study. A summary of evidence from the literature is discussed. This review shows the various associations and complications that can occur with pharyngeal pouches. It is important to be aware that pharyngeal pouch can co-exist with other pathologies and treatment needs to be altered to incorporate the treatment of the associated pathology too. Surgeons should also be aware of the complications that can occur within and outside the pouch.

Abordaje endoscópico de cuello: experiencia inicial / Videoendoscopic cervical approach: our initial experience

Antecedentes: El avance de la cirugía video endoscópica ha extendido sus aplicaciones a la cirugía de cabeza y cuello para tratar patologías de tiroides y paratiroides obteniendo así los beneficios de los abordajes miniinvasivos. Objetivo: Analizar nuestra experiencia inicial con el abordaje cervical videoendoscópico en patología paratiroidea, tiroidea y divertículo de Zenker. Diseño: Estudio observacional retrospectivo. Población: Servicios de Cirugía del Instituto Médico de la Comunidad (Junín) y en el Hospital Gral. San Martín (La Plata). Material y métodos: Se incluyen 24 pacientes con: hiperparatiroidismo primario (4) y secundario (7), nódulos tiroideos (9) con baja sospecha de malignidad, y divertículo de Zenker (4). Fueron 8 hombres y 16 mujeres, con una edad promedio de 50,5 años (máximo 71, mínimo 26). Se utilizó un ingreso central de 10 mm distendiéndose la cavidad con un balón para mantenerla con CO a 10 mm Hg. Para realizar la cirugía se agregan 2 trócares de 3 o 5 mm. Se disecan las estructuras de cuello y se realiza el tratamiento de acuerdo a los criterios convencionales para cada una de las patologías. Resultados: Se debieron convertir a cirugía convencional 3 pacientes (12,5 por ciento), todos con patología paratiroidea. El tiempo quirúrgico general fue de 119 minutos (máximo 165, mínimo 42). Para la patología de tiroides fue de 123 minutos (máximo 165, mínimo 85), paratiroides 112 minutos (máximo 150, mínimo 75) y Zenker 65 (máximo 95, mínimo 42). Las complicaciones postoperatorias fueron una hipocalcemia transitoria en una tiroidectomía total y una disfonía de una semana de duración en una lobectomía izquierda. El resultado cosmético fue excelente en todos los casos. Conclusiones: Es posible abordar la patología cervical por vía endoscópica. Creemos que es ideal para la patología de las paratiroides y el divertículo de Zenker. Para las resecciones tiroideas hay que avanzar en las casuísticas para poder llegar a conclusiones válidas (AU)

Abordaje endoscópico de cuello: experiencia inicial / Videoendoscopic cervical approach: our initial experience

Antecedentes: El avance de la cirugía video endoscópica ha extendido sus aplicaciones a la cirugía de cabeza y cuello para tratar patologías de tiroides y paratiroides obteniendo así los beneficios de los abordajes miniinvasivos. Objetivo: Analizar nuestra experiencia inicial con el abordaje cervical videoendoscópico en patología paratiroidea, tiroidea y divertículo de Zenker. Diseño: Estudio observacional retrospectivo. Población: Servicios de Cirugía del Instituto Médico de la Comunidad (Junín) y en el Hospital Gral. San Martín (La Plata). Material y métodos: Se incluyen 24 pacientes con: hiperparatiroidismo primario (4) y secundario (7), nódulos tiroideos (9) con baja sospecha de malignidad, y divertículo de Zenker (4). Fueron 8 hombres y 16 mujeres, con una edad promedio de 50,5 años (máximo 71, mínimo 26). Se utilizó un ingreso central de 10 mm distendiéndose la cavidad con un balón para mantenerla con CO a 10 mm Hg. Para realizar la cirugía se agregan 2 trócares de 3 o 5 mm. Se disecan las estructuras de cuello y se realiza el tratamiento de acuerdo a los criterios convencionales para cada una de las patologías. Resultados: Se debieron convertir a cirugía convencional 3 pacientes (12,5 por ciento), todos con patología paratiroidea. El tiempo quirúrgico general fue de 119 minutos (máximo 165, mínimo 42). Para la patología de tiroides fue de 123 minutos (máximo 165, mínimo 85), paratiroides 112 minutos (máximo 150, mínimo 75) y Zenker 65 (máximo 95, mínimo 42). Las complicaciones postoperatorias fueron una hipocalcemia transitoria en una tiroidectomía total y una disfonía de una semana de duración en una lobectomía izquierda. El resultado cosmético fue excelente en todos los casos. Conclusiones: Es posible abordar la patología cervical por vía endoscópica. Creemos que es ideal para la patología de las paratiroides y el divertículo de Zenker. Para las resecciones tiroideas hay que avanzar en las casuísticas para poder llegar a conclusiones válidas