[Giant Zenker's diverticulum--case report]

Zenker's diverticulum is one of the most common esophageal diverticuli. The reported prevalence in Czech population is approx. 0.5%, typically presents in the elderly. A small Zenker's diverticulum can be asymptomatic. When a diverticulum increases in size, it can cause regurgitation and dysphagia and the condition is often complicated by aspiration and reccurent pneumonia. The diagnosis can be made on a barium esophagogram and CT scan. Surgical therapy is the treatment most commonly offered and the prognosis is excellent. Here we report a 66-years-old male presenting with bleeding from large Zenker's diverticulum. He was immediately admitted to hospital. A computed tomography scan showed a large Zenker's diverticulum protruding into the right superior hemithorax. Resection was chosen as a therapeutic option. Due to the size of the diverticuli his recovery post operation was complicated by fever, bleeding into mediastinum from the place of resection and temporary functional esophagi disorder. Histological examination confirmed ulceration inside the diverticulum as the source of bleeding. Three weeks after the surgery the patient was discharged home in a stable condition with recovered swallowing and phonation.

[Operative treatment and diagnostics of Zenker diverticulum using modern endoscopic technique]

The authors present results of examination and treatment of 272 patients with Zenker diverticulums of different localization. Features and problems in fibroesophagoscopy in patients with Zenker diverticulum are discussed. Surgical interventions with endoscopic assistance were fulfilled in 37 patients with diverticulum. A new way of endoscopic management of Zenker diverticulum using preparation "Disport" and the method of endoscopic incision of cricofaringeal muscle are proposed. Good clinical results of the treatment were obtained.

[Zenker diverticulum: a case report]

Zenker's diverticulum is a pulsion typed pharyngoeosophageal diverticle caused by the herniation of the pharyngeal mucosa, standing beside the posterior pharyngeal wall, through the Killian opening which is known as the weak area between the inferior constructor muscle's oblique fibres and transverse fibres of cricopharyngeal muscle. In patients with Zenker's diverticulum, symptoms such as disfagia, globus in the cervical area, weigh loss, regurgitation, cough, and aspiration. These patients are primarily admitted to the Gastroenterology and Othorhinolaryngology clinics with the complaint of disfagia and the diagnosis of this disease is mostly established late and the treatment is started late because the results of their physical examinations seem normal. Therefore, especially in the patients who have disfagia complaint, pharyngoeosophageal diverticle prediagnosis should be thought and that should be examined by passage graphies with barium and endoscopic methods, if needed. In this article, we presented the 67-year-old Zenker's diverticulum patient in whom we performed open diverticulectomy and posterior cricopharyngeal myotomy, and we specified the important points in choosing the patient and the type of surgery.

Endoscopic stapling of pharyngeal pouch: a 10-year review of single versus multiple staple rows

OBJECTIVE

To compare the outcomes obtained in patients undergoing endoscopic stapling of pharyngeal pouches with single versus multiple rows of staples.

STUDY DESIGN

A retrospective, 10-year review.

SUBJECTS AND METHODS

Review of medical records in 38 patients who underwent endoscopic pharyngeal pouch repair.

RESULTS

Patients who underwent stapling with multiple rows had a higher postoperative leak rate than patients who were stapled with a single row (36% vs 0%, P < 0.05). Patients with multiple rows also had a more prolonged length of stay and a slower return to both clear fluids and solid diet (P < 0.05). There was no difference in recurrence rate or patient satisfaction between the two groups.

CONCLUSION

The technique of endoscopic pharyngeal pouch stapling has the potential to achieve excellent results. The application of more than one row of staples may be necessary to divide the common wall. However, in our series this is associated with a significantly increased risk of esophageal or pouch perforation. Care should be taken during the placement of multiple rows of staples.

[Special gastrointestinal problems of elderly patients]

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.

Extraösophagealer Reflux und Zenker-Divertikel

INTRODUCTION

Patients with Zenker's diverticulum often present with a hiatal hernia. Theoretically, the gastric acid fluid could rise up to the hypopharynx producing an injury to the mucosa of Killian's triangle and hypertrophy of the cricopharyngeal muscle. We performed dual-channel pH monitoring in healthy people as a control group and in patients with a Zenker's diverticulum to elucidate the relationship between Zenker's diverticulum and gastroesophageal reflux disease (GERD) as well as extraesophageal reflux (EER).

METHODS

Patients with Zenker's diverticulum underwent dual-channel 24-h pH monitoring to exclude the possibility of an EER or a GERD. The measurements were performed in 4 patients preoperatively and postoperatively as well as in 14 patients only postoperatively. The control group consisted of healthy volunteers who did not suffer from a reflux disease (n=20). In each group we determined the number of refluxes, the fraction time, the RAI (reflux area index), and the DeMeester Score Index. In addition we classified the severity of the EER with a grading system which was developed in an earlier study in our department.

RESULTS

Patients with a Zenker's diverticulum suffered significantly from EER (p<0.01). The difference between the patients measured preoperatively and the patients postoperatively was minor. More than 72% of the patients suffered from a severe EER.

CONCLUSIONS

Patients with a Zenker's diverticulum have a high possibility of suffering from EER and GERD. The pathophysiology of this relationship can only be speculated. In addition to a cricopharyngeal myotomy, long-term therapy with a PPI (proton pump inhibitor) seems indicated.

[Respiratory manifestations in esophageal diseases]

Respiratory symptoms might originate sometimes in the diseases of another thoracic organ than the lungs, the esophagus, which is able to determine sufferings mimicking pulmonary diseases. The authors review a series of esophageal diseases capable of generating respiratory symptoms, as well as the criteria for differential diagnosis: Zenker diverticulum, esophageal fistula, achalasia, cancer of the esophagus, esophageal cyst and gastro-esophageal reflux disease.

20 years experience in the management of Zenker's diverticulum in a third-level hospital

Zenker s diverticulum arises in the posterior wall of the pharynx, above the cricopharyngeal muscle, secondary to a functional cricopharyngeal disorder. We describe our experience with the management of Zenker s diverticulum from 1985 to this day in a third-level hospital. We review clinical data from 27 patients (78% males) with a mean age of 60.4 years. The most common clinical manifestations were dysphagia, regurgitation, syalorrhea, cough, and weight loss. All cases were diagnosed using an esophagogram. A diverticulectomy with cricopharingeal myotomy was performed in 74% of patients. Complications developed in 5 cases (21%), and the recurrence rate was 4% (1 of 3 cases, where myotomy was not performed).

Ulcer in the basis of Zenker's diverticulum mimicking esophageal malignancy

Complications of Zenker's diverticulum are rare and include ulcer, bleeding and malignancy. Ulcer in the basis of diverticulum is a very rare complication and to date only four cases have been reported in the literature. Herein, we report a new case of ulcer in Zenker's diverticulum mimicking esophageal malignancy presumed to be due to aspirin and/or alcohol consumption. The exact diagnosis was troublesome and needed to perform diagnostic procedures repeatedly. The patient underwent external pharyngoesophageal diverticulectomy. We emphasize that endoscope should be withdrawn if any resistance is encountered during esophageal intubation-even with forward-viewing endoscope-especially when there is a Zenker's diverticulum suspicion and the patient receives ulcerogenic agents. Endoscopic examination should be performed prior to any definitive surgical procedure in all patients with Zenker's diverticulum.

Carcinoma Arising in a Pharyngeal Pouch Previously Treated by Endoscopic Stapling

OBJECTIVES

A case is described in which squamous cell carcinoma was found during surgery for a recurrent pharyngeal pouch previously treated by endoscopic stapling. A search of the English language literature suggests this is the first reported case of a carcinoma developing in a pharyngeal pouch previously treated by endoscopic stapling.

STUDY DESIGN

Case report and literature review.

MATERIALS AND METHODS

The records of a patient who presented with a recurrent pharyngeal pouch after a previous endoscopic stapling procedure were reviewed. The presentation, imaging, and histopathologic findings are presented and the implications of these discussed.

RESULTS

Imaging confirmed a recurrent pharyngeal diverticulum. An endoscopic assessment revealed the presence of tumor in the recurrent pouch that histopathologic evaluation confirmed to be squamous cell carcinoma. The patient underwent an external excision of this diverticulum followed by a course of external beam radiotherapy.

CONCLUSIONS

This is the first reported case of a carcinoma developing in a recurrent pharyngeal diverticulum previously treated by endoscopic stapling and brings to light a rare risk of endoscopic stapling procedures for the treatment of pharyngeal diverticula.

FATAL VENOUS AIR EMBOLISM IN A CAT WITH A RETROPHARYNGEAL DIVERTICULUM

A cat with a 1-year history of oropharyngeal foreign bodies was diagnosed with a pharyngeal diverticulum. The cat experienced fatal cardiac arrest during endoscopy, and postmortem radiographs and ultrasound revealed venous air embolism. Venous air embolism is uncommonly reported in veterinary medicine, but is a risk during any procedure that introduces air into a body cavity. Precautions should be taken during these procedures to help minimize the risk of adverse events.

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.

Fluoroscopic balloon–guided transesophageal echocardiography in a patient with Zenker's diverticulum

During the past 20 years, transesophageal echocardiography (TEE) became an important diagnostic technique. Indications for TEE include: defining the cause and severity of native valve disease, particularly mitral regurgitation; detecting vegetations and other sequelae of endocarditis; assessing prosthetic valve function; and identifying a potential cardiac source for emboli.(1) TEE is usually well tolerated and is associated with few adverse events. However, structural abnormalities of the esophagus such as diverticula, stenoses, tumors, and advanced varices are relative contraindications to TEE because of the technical difficulties associated with probe advancement and the risk of esophageal perforation.(2) This report describes the successful performance of TEE in a patient with a Zenker's diverticulum. The patient was severely symptomatic of atrial fibrillation and was a poor candidate for long-term anticoagulation. Therefore, it was necessary to rule out a thrombus before cardioversion. Because the Zenker's diverticulum was large, a novel approach was taken using a balloon to occlude the orifice allowing safe passage of the TEE probe.

Scintigraphic evaluation of Zenker's diverticulum

Zenker's diverticulum (ZD) is a rare pathology, with a prevalence of between 0.01% and 0.11%. Definitive diagnosis of ZD can be accomplished by contrast radiographic examination (barium oesophagogram, BE); oesophageal manometry (ME) is recommended mainly for those patients suffering from dysphagia and/or gastro-oesophageal reflux. The aims of the present study were to assess whether oropharyngo-oesophageal scintigraphy (OPES) is able (a) to visualise ZD and (2) to demonstrate the corresponding alteration in the swallowing phases. We studied 16 patients (nine male, seven female, mean age 67.4 years), and 17 healthy volunteers (ten male, seven female, mean age 53 years) as a control group. All the patients underwent ME, BE and OPES. Nine patients underwent surgery and six of them were re-evaluated after 6 months. We administered 10 ml of water with 37 MBq of technetium-99m colloid through a straw, acquiring 480 sequential images (0.125 s/frame for a total of 60 s) with the patient standing in front of the gamma camera in the 80 degrees right anterior oblique position. Two static images were performed at the end of the dynamic phase, before and after ingestion of 100 ml of unlabelled water to evaluate the presence of inflammation (persistence of radioactivity in the diverticulum or oesophagus). Study of the sequential scintigraphic images and time-activity curves permitted both qualitative (diverticulum visualisation, multiple deglutitions, reflux, presence of inflammation) and quantitative analyses [oral, pharyngeal and oesophageal transit times and retention indexes, tracheal aspiration percentage] of swallowing disorders. OPES showed a good correlation with the results of other diagnostic techniques usually performed in patients with this pathology, and especially with ME in the evaluation of oropharyngeal phase disorders. Furthermore, OPES is a sensitive and simple technique that is well tolerated and entails a low irradiation dose for patients.