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

[Severe pneumonia and delirium in a 90-year-old male patient with postdeglutition regurgitation]. / Schwere Pneumonie und Delir bei einem 90-jährigen Patienten mit postdeglutitivem Aufstoßen.

Pneumonia and in particular aspiration pneumonia, is a common disease in geriatrics. These aspirations are often due to dysphagia, which is frequently first noticed in the context of a geriatric assessment. The reasons for dysphagia are manifold. In this geriatric department several patients have been detected in recent months in whom a Zenker diverticulum was the cause of recurrent aspiration pneumonia. The swallowing disorder was already apparent during the logopedic examination on admission to hospital. A supplementary fiber optic endoscopic evaluation of swallowing (FEES) revealed a postswallow hypopharyngeal reflux (PSHR), which is typical for a Zenker diverticulum. A supplementary contrast esophagography confirmed the findings. In the present case the treatment of choice was a myotomy with a flexible endoscope performed by gastroenterologists. After successful treatment, swallowing was again possible with no indications of penetration or aspiration in the FEES control. The case highlights the importance of logopedic diagnostics and treatment in geriatric patients with recurrent pneumonia. With the aid of early diagnostics it was possible to quickly recognize the finding of a PSHR that is typical for a Zenker diverticulum. The findings in this case could be clearly demonstrated based on the images of the FEES and contrast esophagography.

[Zenker´s diverticulum in a hemodialysis patient]. / Diverticule de Zenker chez une patiente en hémodialyse.

Zenker's diverticulum is a rare and generally benign condition. Its occurrence in a hemodialysis patient has therapeutic and prognostic implications and is a risk factor for mortality and morbidity due to its complications, such as protein-energy malnutrition and pneumonitis. We here report a case of Zenker's diverticulum diagnosed in a chronic haemodialysis patient. The study involved a 61-year-old female patient admitted with upper gastrointestinal bleeding associated with dysphagia. Physical examination showed alteration of general condition and the patient reported an average weight loss of 5 kg in 3 months. Esophagogastroduodenal transit was characterized by dilatation of the cervical esophagus, appearing as a large heterogeneous niche whose upper pole was at the level of the pharyngoesophageal junction. The diagnosis of Zenker's diverticulum was retained. Diverticulectomy by cervical incision was performed. The patient died due to inhalational lung disease in the early postoperative period. Zenker diverticulum is a rare, generally benign disease, but in patients undergoing chronic haemodialysis, it increases mortality and morbidity.

Swallowing Characteristics in Zenker's-like Diverticulum After Anterior Cervical Spine Surgery.

OBJECTIVES: A Zenker's diverticulum (ZD) is a hypopharyngeal pulsion diverticula caused by dysfunction of the cricopharyngeus muscle with herniation of hypopharyngeal mucosa through Killian's dehiscence. Anterior cervical spine surgery (ACSS) can cause a Zenker's-like traction diverticulum (ZTD) with a similar presentation but different pathophysiology. The purpose of this investigation was to compare the fluoroscopic parameters and surgical outcomes of ZTD after ACSS to those of typical ZD. STUDY DESIGN: Case-control study. METHODS: The charts of patients undergoing a videofluoroscopic swallow study after ACSS between January 1, 2014, and January 1, 2018, were evaluated for evidence of ZTD. Patients with ZTD were age and gender matched to persons with ZD. Fluoroscopic parameters and patient-reported outcomes were compared between groups. RESULTS: Eleven patients with ZTD were identified. The mean pharyngeal constriction ratio (PCR) was significantly higher for persons with ZTD (0.87 [±0.07] vs. 0.17 [±0.08]; P < 0.05). Mean hyolaryngeal elevation was significantly less (2.5 [±0.9] cm vs. 3.5 [±0.7] cm) and mean diverticulum size significantly smaller (1.3 [±1.0] cm vs. 2.3 [±2.0] cm) for persons with ZTD (P < 0.05). Five ZTD patients had exposed hardware necessitating open approach for removal. CONCLUSION: We report the largest cohort of ZTD after ACSS. ZTD are smaller than traditional Zenker's and associated with more pharyngeal weakness, poorer laryngeal elevation, and worse treatment outcomes. Although these diverticula can be managed endoscopically, the high percentage of exposed cervical hardware necessitates a thorough preoperative assessment and frequent need for open management and pharyngeal repair. LEVEL OF EVIDENCE: 3b Laryngoscope, 130:1383-1387, 2020.

Presentation and Management of Killian Jamieson Diverticulum: A Comprehensive Literature Review.

OBJECTIVE: To examine the clinical presentation, diagnostic evaluation, and management of Killian-Jamieson diverticula (KJD) through literature review. METHODS: A comprehensive literature review was conducted through December 2018 using keywords Killian-Jamieson diverticula/diverticulum. Data extracted included clinical presentation, imaging characteristics, surgical management, and postoperative care. SOURCES: PubMed and Google Scholar. RESULTS: Sixty-eight cases of KJD in 59 reports (29M:39F; median 58 years old) were identified for review. The most common presentation was dysphagia (n = 39), suspected thyroid nodule (n = 24) and globus (n = 14). The majority of KJD (n = 51) occur on the left, with rare reports of right side (n = 11) and bilateral (n = 5) presentation. Thirty-two cases describe surgical management: 22 utilizing a transcervical approach, with (n = 13) or without (n = 9) cricopharyngeal myotomy; and 10 reported endoscopic surgery. Diverticula managed transcervically averaged 3.8 cm in size in comparison to average 2.8 cm in the endoscopic group. Time to diet initiation after transcervical surgery averaged 4 days versus 2 days after endoscopic surgery. Complications were reported in 2/68 cases; both were diverticula recurrence after endoscopic surgery. CONCLUSION: Killian-Jamieson diverticula is a rare diagnosis that should be considered in the evaluation of dysphagia, globus, and also suspected thyroid nodule. When patient symptoms warrant intervention, a transcervical approach, with or without cricopharyngeal myotomy, is most commonly utilized. In recent years, an endoscopic approach has been presented as an alternative for smaller diverticula. Further understanding of the optimal treatment and postoperative management for KJD requires larger cohorts. LEVEL OF EVIDENCE: 4.

Operative technical tricks and 12-month outcomes of diverticular peroral endoscopic myotomy (D-POEM) in patients with symptomatic esophageal diverticula.

BACKGROUND: Submucosal tunneling diverticular septotomy by diverticular peroral endoscopic myotomy (D-POEM) has emerged as an alternative to surgery for symptomatic esophageal diverticula, but its medium to long-term outcomes are currently unexplored. METHODS: D-POEM for patients with symptomatic esophageal diverticula was prospectively studied to assess its safety and the 12-month outcomes. RESULTS: 25 patients (72 % male; median age 61 years [range 48 - 88]) with a Zenker's diverticulum (n = 20) or epiphrenic diverticulum (n = 5) were included. Major indications were dysphagia, recurrent bronchoaspiration, and foreign body sensation in 20 patients (80 %), with a mean symptom duration of 2.5 years (range 1 - : 4). Complete submucosal tunneling septotomy was achieved in a mean of 36 minutes (range 25 - : 45), with 100 % technical success. The median hospitalization was 5 days (range 4 - : 10). The mean (standard deviation) Eckardt Score improved significantly from 13.2 (1.0) at baseline to 3.2 (1.4) at 12 months (P < 0.001) with clinical success in 19/22 patients (86 %) and no long-term adverse events. CONCLUSIONS: D-POEM appears safe and durable in patients with esophageal diverticula. Further multicenter studies with a larger patient cohort are warranted.

Safety and efficacy of submucosal tunneling endoscopic septum division for epiphrenic diverticula.

BACKGROUND: Symptomatic epiphrenic diverticula are mostly treated with laparoscopic diverticulectomy. Our study aimed to demonstrate the safety and efficacy of submucosal tunneling endoscopic septum division (STESD) for treatment of symptomatic epiphrenic diverticula. METHODS: Data from patients with epiphrenic diverticula who had undergone STESD were retrospectively reviewed. The parameters analyzed were the modified Eckardt score, total procedure time, length of hospital stay (LOS), number of clips used, adverse events, and patient satisfaction. RESULTS: A total of eight patients (5 men; mean [standard deviation (SD)] age 66.25 [7.17] years) were enrolled in our study. The mean (SD) size of epiphrenic diverticula was 3.68 (1.59) cm. The mean (SD) procedure time was 52.87 (22.47) minutes, with a median number of six clips being applied. The modified Eckardt score significantly decreased post-procedure (P < 0.001). The mean (SD) LOS was 5.87 (0.83) days. No adverse events or symptom recurrences were reported. CONCLUSION: STESD is a safe and effective technique to be performed in the submucosal tunnel for the management of patients with epiphrenic diverticula.

Efficacy and Safety of Flexible Endoscopic Management of Zenker's Diverticulum.

Zenker's diverticulum (ZD), a pulsion diverticulum of hypopharynx is a rare but treatable cause of morbidity in geriatric population. Traditionally a surgical disease but due to its associated high morbidity, flexible endoscopy has become a lucrative option. We reviewed 997 patients from 23 original studies who underwent flexible endoscopic diverticulotomy (FED) of ZD. Composite technical and clinical success rate for the study cohort was 99.4% and 87.9%, respectively. Composite failure rate was 10.0% but close to half of them (45.3%) had success with repeat endoscopic intervention. Composite rate for symptom recurrence after long-term follow-up was 13.6% but more than half (61.8%) had success with repeat endoscopic intervention. Bleeding (6.6%) and perforation (5.3%) were 2 most common complications of FED. All bleeding events were successfully managed with observation or endoscopic therapy. Majority of perforation events (4.4%) were successfully managed with conservative care and only 0.9% required invasive management. No mortality was reported. Efficacy and safety of FED of ZD remained same irrespective of diverticulum size or prior surgical/endoscopic treatment. FED with diverticuloscope (FEDD) and FED with cap (FEDC) had comparable technical success rate (99.6% vs. 100.0%) but FEDD had higher clinical success rate compared with FEDC (86.8% vs. 75.4%). FEDD had twice the risk of symptom recurrence than FEDC (16.5% vs. 9.5%). FEDD had a comparable bleeding risk to FEDC (3.3% vs. 4.0%) but a much lower perforation rate (2.3% vs. 10.3%). Upper esophageal sphincterotomy and adequate length of septotomy are the cornerstones of FED. FED can be considered a safe and efficacious treatment modality for patients with ZD.

[Pharyngoesophageal diverticulum]. / Pharyngoösophageale Divertikel.

Over the last 20-30 years, treatment of pharyngoesophageal diverticula was subject to a number of fundamental changes. Considering the classical open transcervical approaches, the necessity for myotomy of the upper esophageal sphincter with the goal of interrupting the pathogenesis of the disease has become a standard component of the operation. On the other hand, with the growing popularity of rigid and flexible endoscopic techniques, pharyngoesophageal diverticula are increasingly being treated by gastroenterologists and otorhinolaryngologists, often with the argument of a technically easier and less invasive procedure; however, it remains unclear whether this shift towards endoscopic techniques truly translates into better outcome quality. This aim of this CME article is to summarize the available scientific evidence on the complex pathophysiology, diagnostics and treatment of pharyngoesophageal diverticula and to provide the reader with an updated guide to best clinical practice for diagnostics and treatment.

Improvement in the Reflux Symptom Index Following Surgery for Cricopharyngeal Dysfunction.

OBJECTIVES: Gastroesophageal reflux may contribute to the development of cricopharyngeal dysfunction and Zenker's diverticulum. Common dictum suggests that if upper esophageal sphincter tone is reduced through cricopharyngeal myotomy, symptoms of laryngopharyngeal reflux may worsen. We hypothesized that patients who undergo myotomy should show decreased dysphagia symptoms with concurrent worsening of reflux symptomatology and that these changes would be greater in those patients undergoing complete versus partial myotomy. METHODS: A retrospective chart review was performed for patients who underwent endoscopic or open cricopharyngeal myotomy, with or without Zenker's diverticulectomy. Preoperative and postoperative reflux symptomatology was subjectively measured with the Reflux Symptom Index (RSI), and dysphagia symptomatology was measured with the Eating Assessment Tool 10 (EAT-10). Patients who underwent partial myotomy via endoscopic stapling of Zenker's diverticulum were compared with patients who underwent complete myotomy (either endoscopic laser-assisted or via an open transcervical approach). The patients were further subdivided into three groups for data analysis: endoscopic staple diverticulotomy, laser cricopharyngeal myotomy, and open approach. RESULTS: A total of 41 patient charts were reviewed. Of these 41 patients, 17 underwent endoscopic stapler-assisted diverticulotomy, 4 underwent endosopic laser-assisted cricopharyngeal myotomy, and 20 underwent open transcervical cricopharyngeal myotomy, with diverticulectomy as indicated. Mean pre- and postoperative RSIs were 21.8 and 8.9, respectively (P < 0.001). Mean pre- and postoperative EAT-10 scores were 19.1 and 5.0, respectively (P < 0.001). CONCLUSIONS: Patients' reflux symptoms significantly improved after cricopharyngeal myotomy, with significant improvement in dysphagia symptoms. Concern for worsening of reflux symptoms following surgery does not appear to be clinically common.

Does residual wall size or technique matter in the treatment of Zenker's diverticulum?

OBJECTIVES/HYPOTHESIS: We aimed to compare three surgical techniques (open approach for diverticulectomy with cricopharyngeal myotomy [OA], endoscopic laser-assisted diverticulotomy [ELD], and endoscopic stapler-assisted diverticulotomy [ESD]) for treatment of Zenker's diverticulum with regard to validated swallowing outcomes, radiographic outcomes, complications, and revision rates. We statistically analyzed whether the size of residual postoperative party wall or the specific surgical technique correlates with swallowing outcomes. STUDY DESIGN: Retrospective chart review and radiographic study analysis. METHODS: A retrospective chart review and radiographic analysis of preoperative and postoperative contrast swallow studies were conducted on patients undergoing surgery for Zenker's diverticulum between 2002 and 2014 at our institution. A follow-up validated swallowing outcome questionnaire, the Eating Assessment Tool-10, was administered to measure and compare patients' symptomatic outcomes. RESULTS: Seventy-three patients were reviewed and grouped according to technique. Median follow-up was 1.6 years. ESD resulted in a significantly larger residual party wall than ELD and OA but yielded comparative swallowing outcomes. OA had the highest complication rate and ESD had the highest revision rate. There were no revisions after ELD nor OA. CONCLUSIONS: Despite the predictably larger residual postoperative party wall following ESD, this technique produced statistically comparable swallowing outcomes. Given its low complication rate and comparable results, ESD should be considered first line therapy for medically high-risk patients with Zenker's diverticulum, while acknowledging a higher risk of symptom recurrence. ELD, with its slightly greater risk profile but low recurrence rate, is well suited for most in revision cases. OA may best be reserved for those patients in whom endoscopic approach is not feasible. LEVEL OF EVIDENCE: 4 Laryngoscope, 126:2475-2479, 2016.

Short-term Quality-of-Life Outcomes following Transoral Diverticulotomy for Zenker's Diverticulum: A Prospective Single-Group Study.

OBJECTIVE: To prospectively analyze quality-of-life outcomes following transoral diverticulotomy with cricopharyngeal myotomy (DCPM) for Zenker's diverticulum (ZD). STUDY DESIGN: Prospective single-group study. SETTINGS: Tertiary academic institution. SUBJECTS AND METHODS: A prospective multicenter study performed from January 1, 2012, to July 1, 2014, included 18 patients presenting with ZD undergoing DCPM. Standardized questionnaires-including the 10-item Eating Assessment Tool (EAT-10), Functional Outcome of Swallowing Scale (FOSS), and the Reflux Symptom Index (RSI)-were completed preoperatively and at 3 and 6 months postoperatively. Videofluoroscopic studies were obtained and analyzed by our senior speech-language pathologist, who was blinded to the clinical outcomes. RESULTS: Eighteen patients were included (11 women; mean age, 72.6 years; range, 53-86 years). All patients had ZD on preoperative videofluoroscopic swallowing studies. The most common comorbidities included hypertension (10 of 18, 55.6%), dyslipidemia (8 of 18, 44.4%), hiatal hernia (6 of 18, 33.3%), and gastroesophageal reflux disease (5 of 18, 27.8%). Median preoperative RSI was 27 (interquartile range [IQR], 22.5-31.5); FOSS, 2 (IQR, 2-3); and EAT-10, 21.5 (IQR, 13.5-27.5). The 3-month questionnaire (88.9% completion) demonstrated an improved median RSI of 5 (IQR, 1-7.5; P < .001), FOSS of 0 (IQR, 0; P < .001), and EAT-10 of 0 (IQR, 0-3; P < .001). Fourteen patients (77.8%) completed the 6-month questionnaire, demonstrating a median RSI of 4 (IQR, 0-8), FOSS of 0 (IQR, 0-0.5), and EAT-10 of 1 (IQR, 0-3). While regurgitation decreased following surgery (P = .007), nighttime cough did not (P = .25). CONCLUSION: This study supports an improvement in functional outcome and quality of life in patients with ZD undergoing DCPM.

Laser surgery for Zenker's diverticulum: European combined study.

Surgical intervention is the gold standard of treatment for Zenker's diverticulum. The aim of this study was to examine the role of laser surgery in a large number of patients with this pathological entity. The data of 91 consecutive patients treated due to Zenker's diverticulum with the aid of CO2 laser in three institutions (Homburg/Saar and Marburg, Germany/Athens, Greece) during the last 10 years were retrospectively analyzed. Parameters examined were sex, age, preoperative symptoms, length of operation and complications, revision surgery necessity and degree of patient satisfaction. All patients had a minimum follow-up of one year. Dysphagia was the most common preoperative symptom (78 %). The most common minor complication was dental injury (6.6 %), but a serious complication in form of emphysema was observed in only two patients (2.2 %). A surgical revision was necessary in 8 (8.8 %) of the treated patients. The majority of treated patients was free of symptoms (86.8 %), or presented mild symptoms (9.9 %) one year after intervention, and only three patients (3.3 %) were dissatisfied. Our study shows that laser treatment of Zenker's diverticulum is an efficient operative technique associated with low complications rates and significant improvement of patients' symptoms in most of the examined cases.

Long-term outcome and quality of life after transoral stapling for Zenker diverticulum.

AIM: To investigate long-term results and quality of life after transoral stapling of Zenker diverticulum. METHODS: The data of all patients admitted to our institution for the surgical treatment of Zenker diverticulum were entered into a prospective database. Demographics, symptoms, intraoperative and postoperative data, morbidity, time to oral feeding, and length of hospital stay were recorded. All patients underwent upper gastrointestinal endoscopy and a barium swallow study to measure the length of the diverticulum from the apex of the septum to the bottom of the pouch. Transoral stapling was performed using a Weerda diverticuloscope under general anesthesia. Over time, the technique was modified by applying traction sutures to ease engagement of the common septum inside the stapler jaws. Perioperative variables, symptoms, long-term outcome, and quality of life were analyzed. The operation was considered successful if the patient reported complete remission (grade 1) or marked improvement (grade 2) of dysphagia, regurgitation, and respiratory symptoms. Statistical analysis was performed using Statistical Package for Social Science (SPSS, Version 15, SPSS, Inc., Chicago, IL). RESULTS: Between 2001 and 2013, the transoral approach was successfully completed in 100 patients with a median age of 75 years. Patients with a larger (≥3 cm) diverticulum were older than those with a smaller pouch (P<0.038). Complications occurred in 4% of the patients but there was no mortality. A statistically significant improvement of dysphagia and regurgitation scores (P<0.001) was recorded over a median follow-up of 63 mo. Similarly, a significant decrease in the median number of pneumonia episodes per year (P<0.001) was recorded after surgery. The overall long-term success rate of the procedure was 76%. The success rate of the operation was greater in patients of 70 years of age or older compared to younger individuals (P=0.038). Use of traction sutures on the septum was associated with an improved success rate compared with the standard procedure (P=0.04). All items of the health related quality of life questionnaire were significantly higher compared to baseline (P<0.05). CONCLUSION: Transoral stapling is safe and effective. The operation significantly improves patients' quality of life. It appears that elderly patients with large diverticula significantly benefit from the procedure and that the modified surgical technique including traction sutures can further improve the success rate.

Zenker's diverticulum: a case report and literature review.

The pharyngeal pouch (Zenker's diverticulum) is a diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle (i.e. above the upper sphincter of the oesophagus). It occurs commonly in elderly patients (over 70 year) and the typical symptoms include dysphagia, regurgitation, chronic cough, aspiration and weight loss. We are reporting a case of an oropharyngeal dysphagia due to a Zenker's diverticulum in 75 years old Sudanese man with a chronic history of dysphagia for solids. The pathophysiology of Zenker's diverticulum, clinical presentation, and management are reviewed.