Pharyngoesophageal diverticuli: diagnosis, incidence and management

Diagnosis of bilateral pharyngoesophageal diverticula with using swallow contrast-enhanced ultrasound: a case report

Pharyngoesophageal diverticulum (PED) is a rare disease of the esophagus that is usually asymptomatic and often found incidentally during a thyroid ultrasound examination. Due to its anatomical location close to the thyroid, it is easily misdiagnosed as a thyroid nodule, which leads to unnecessary thyroid biopsies and surgical treatment. The occurrence of a single esophageal diverticula is common, while the existence of multiple diverticula is rare. Left side diverticula are more common than right sided ones, while bilateral occurrences are rarely reported. We report an extremely rare case of bilateral pharyngeal esophageal diverticula. The patient was a 55-year-old asymptomatic man who came to our hospital after thyroid nodules were identified in another hospital. Due to the extensive clinical experience of the ultrasound physician at our facility, the patient was suspected to have bilateral esophageal diverticula, which was confirmed by using swallow contrast-enhanced ultrasound (CEUS). Consequently, unnecessary thyroid treatments were avoided in this patient. This study shows that although bilateral pharyngeal diverticula are unusual, the possibility of their existence should be considered if nodules are located posterior to the bilateral thyroid glands and have suspicious imaging characteristics. Particular attention should be given to nodules located on the right side of the thyroid, which are sometimes overlooked easily due to their very low incidence. If real-time ultrasound cannot be used in making the diagnosis, PED can be further identified using swallowing CEUS to avoid unnecessary thyroid fine needle aspiration (FNA) and surgical treatment.

Comparing Open Versus Rigid Endoscopic and Flexible Endoscopic Techniques for the Treatment of Zenker's Diverticulum

OBJECTIVE

To describe the outcomes of patients undergoing open stapler versus transoral rigid and flexible endoscopic therapies for symptomatic Zenker's diverticulum.

STUDY DESIGN

Single institution retrospective review.

SETTING

Tertiary care academic hospital.

METHODS

We retrospectively evaluated the outcomes of 424 consecutive patients who underwent Zenker's diverticulotomy via an open stapler, rigid endoscopic CO2 laser, rigid endoscopic stapler, rigid endoscopic harmonic scalpel, or flexible endoscopic technique from January 2006 to December 2020.

RESULTS

A total of 424 patients (173 females, mean age 73.1 ± 11.2 years) from a single institution were included. A total of 142 patients (33%) underwent endoscopic laser treatment, 33 (8%) underwent endoscopic harmonic scalpel, 92 (22%) underwent endoscopic stapler, 70 (17%) underwent flexible endoscopic, and 87 (20%) underwent open stapler. All open and rigid endoscopic procedures and most of the flexible endoscopic procedures (65%) were performed under general anesthesia. The flexible endoscopic group had a higher percentage of procedure-related perforation, defined as subcutaneous emphysema or contrast leak on imaging (14.3%). The recurrence rates were higher in the harmonic stapler, flexible endoscopic, and endoscopic stapler groups at 18.2%, 17.1%, and 17.4%, respectively, and lower in the open group (1.1%). Length of hospital stay and return to oral intake were similar among groups.

CONCLUSION

The flexible endoscopic technique was associated with the highest rate of procedure-related perforation, while the endoscopic stapler had the lowest number of procedural complications. Recurrence rates were higher among the harmonic stapler, flexible endoscopic, and endoscopic stapler groups and lower in the endoscopic laser and open groups. Prospective comparative studies with long-term follow-up are needed.

Pharyngoesophageal diverticulum mimicking thyroid nodules: Some interesting ultrasonographic signs

Objective

To analyze the ultrasonographic features of pharyngoesophageal diverticulum (PED) mimicking thyroid nodules and to explore the clinical value of ultrasonography in the diagnosis of PED.

Method

The sonographic findings of 68 patients with PED were retrospectively reviewed. According to the diverticulum echo intensity characteristics, the lesions were divided into solid nodular diverticulum, gas-containing nodular diverticulum, liquid-containing nodular diverticulum, and atypical diverticular changes; and the ultrasonographic manifestations were compared among the four groups.

Results

30/68 were solid nodular diverticula. The diverticulum cavity was oval or elliptic with a clear border, and the diverticulum wall suggested exhibited a typical hyper-hypo-hyper-echogenic pattern. The diverticulum wall and esophageal wall were seen to be continuous if multiple sections were scanned, and hypoechoic walls showed punctate blood flow. 29/68 diagnosed with air-containing nodular diverticulum, lesions appeared with gas-like hyper-echogenicity internally, with some amount of gas and change in the tail pattern during swallowing. 6/68 patients were diagnosed with liquid-containing nodular diverticulum, and the main ultrasonic manifestations were an anechoic internal diverticulum cavity that was clearly bounded from the thyroid but continuous with the esophageal wall, with a typical hyper-hypo-echoless pattern from the outside to the inside. Another 3/68 were found to have atypical diverticular changes, regional convexities of the esophageal wall with unfashioned nodules. The convex segment was continuous with the hyper-hypo-echogenic esophageal wall and could be seen on slitting scanning.

Conclusion

Overall, PEDs mimicking thyroid nodules have specific ultrasonographic features. Familiarity with them can avoid missed diagnoses and misdiagnoses.

Spontaneous Rupture of Esophageal Diverticulum-A Case Report and Literature Review

The spontaneous rupture of the esophageal diverticulum is a rare condition that occurs without any warning signs. Its incidence is low, but the mortality rate is high. This paper reports a case of spontaneous esophageal diverticulum rupture and analyzes it along with 13 other cases to explore its prevention and treatment measures. When patients suffer from chronic swallowing difficulties and chest pain or vomiting that cannot be explained after meals, they should be suspected to have a possible spontaneous rupture of the esophageal diverticulum, which is critical to the patient's prognosis.

Squamous cell carcinoma arising in a Zenker diverticulum

Squamous cell carcinoma (SCC) arising in a Zenker diverticulum (ZD) is an extremely rare entity. Approximately 50 cases have been reported worldwide. We report a case of a 74-year-old man who presented to our institution with chronic regurgitation, dysphagia and halitosis. The patient was initially seen in 2015 at which point he reported a 10-year history of these symptoms and was diagnosed with ZD. A barium swallow was done revealing a large posterior esophageal diverticulum with significant residual contrast within the diverticulum lumen. Given these findings, he was taken for open surgical excision where a SCC was identified. Although it is extremely rare for a SCC to occur in a ZD, patients with ZD must undergo regular surveillance endoscopy of the esophagus and the diverticulum itself to identify any suspicious mass or lesion arising in within.

Recurrent Dysphagia Associated with Esophageal Intramural Pseudodiverticulosis

Esophageal intramural pseudodiverticulosis (EIPD) is a rare disorder of the esophagus characterized by the presence of outpouching flask-shaped lesions. These lesions represent false lumens that may be scattered throughout the esophageal wall. We present a rare case of EIPD complicated with esophageal strictures. The case is unique because the small lesions of EIPD remained undiagnosed for many years on prior esophagogastroduodenoscopy examinations until complicated with worsening symptoms of dysphagia due to esophageal stricture. The patient was managed with serial dilations of esophageal stricture. Diagnosing these lesions may be missed in early stages as the lesions are small and may require other radiological modalities to confirm the diagnosis. EIPD lesions itself can be managed conservatively with anti-inflammatory therapy and treatment of underlying risk factors. Those with severe disease and coexisting complications are managed with endoscopic or surgical interventions.

Comparison of Surgical Treatments for Zenker Diverticulum: A Systematic Review and Network Meta-analysis

Importance

Zenker diverticulum (ZD) can cause significant dysphagia, and symptoms can return or persist after surgery. This systematic review and network meta-analysis is the first to our knowledge to compare 3 common surgical techniques for ZD.

Objective

To compare the 3 most common surgical techniques-endoscopic laser-assisted diverticulotomy, endoscopic stapler-assisted diverticulotomy, and transcervical diverticulectomy with cricopharyngeal myotomy-in adult patients with ZD.

Data Sources

The published literature was searched using strategies designed by a medical librarian (search performed September 21, 2018). Strategies were established using a combination of controlled vocabulary terms and keywords and were executed in Ovid MEDLINE (1946 to September 21, 2018), Embase (1947 to September 21, 2018), Scopus (1823 to September 21, 2018), Cochrane Library, and ClinicalTrials.gov. Results were limited to English using database-supplied filters, which generated studies from 1997 to 2017.

Study Selection

Inclusion criteria were cohort studies or randomized clinical trials. Studies that included patients needing revision surgery or undergoing an alternative technique were excluded.

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-analyses-Network Meta-analyses (PRISMA-NMA) checklist was used to report the study findings. Two authors independently reviewed the studies.

Main Outcome and Measure

The primary outcome measure was the incidence of persistent or recurrent symptoms following surgery. The primary study outcome was planned before data collection began.

Results

The search generated 529 studies. After applying inclusion and exclusion criteria, 9 cohort studies remained, consisting of 903 patients treated with either laser-assisted diverticulotomy (n = 283), transcervical diverticulectomy (n = 150), or stapler-assisted diverticulotomy (n = 470). A network meta-analysis was performed. Between endoscopic laser-assisted diverticulotomy and open diverticulectomy, the open approach showed a statistically lower likelihood of persistent/recurrent symptoms following treatment (odds ratio [OR], 0.20; 95% CI, 0.04-0.91). Comparing laser-assisted diverticulotomy with the stapler-assisted technique, there was not a significant difference between the 2 techniques (OR, 0.83; 95% CI, 0.43-1.60). The consistency model for the network meta-analysis was supported (χ21 = 0.12; P = .73).

Conclusions and Relevance

This systematic review and meta-analysis compared 3 common techniques for treating ZD. The open approach showed a decreased likelihood of persistent or recurrent symptoms following surgery compared with the 2 other techniques.

Surgical management of recurrent Zenker's diverticulum: A multi-institutional cohort study

OBJECTIVE

This study identifies how recurrent Zenker's diverticula are treated.

METHODS

A retrospective chart review was performed from four tertiary referral academic voice and swallowing centers to identify individuals who underwent surgery for recurrent Zenker's diverticulum. Demographic data, surgical modalities for primary and revision surgery, symptoms pre and post revision and complications were recorded.

RESULTS

56 individuals met inclusion criteria. Primary surgery was open in 30.3% (n = 17) and endoscopic in 69.6% (n = 39). Revision surgery was performed via an open approach in 37.5% of cases (N = 21) and via an endoscopic approach in 62.5% of cases (N = 35). Revision surgical technique was based on pouch size, patient age and comorbidities, as well as patient and surgeon preference. There were no major complications and few minor complications.

CONCLUSION

Zenker's diverticulum symptoms can recur regardless of primary treatment modality. Both endoscopic and open approaches can safely treat recurrent Zenker's diverticula.

Acute abdomen caused by a large solitary jejunal diverticulum that induced a midgut volvulus. Report of a case

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Diverticuli are found throughout the gastrointestinal tract from esophagus to rectum.

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In the jejunum diverticuli are most commonly proximal, multiple and asymptomatic.

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A large solitary jejunal diverticulum caused life endangering midgut volvulus.

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In the absence of timely surgical intervention the condition would have been fatal.

Background

Jejunal diverticula are a rare subtype of false diverticula found in the gastrointestinal tract. When present, they are usually multiple, in the proximal jejunum and asymptomatic. Rarely, they can cause acute complications that can develop into an acute abdomen requiring surgical intervention. We present the rare manifestation of a single jejunal diverticulum causing midgut volvulus and bowel ischemia. Early surgical intervention with small bowel derotation allowed complete recovery.

Methods

Data regarding the case, operative intervention, and patient follow-up was prospectively accumulated with permission of the patient at an academic institution. All patient identifiers were removed. All research steps were performed under guidance outlined in the SCARE criteria.

Results

We present the case of a 78-year-old man who presented to our institution with an acute abdomen. CT imaging demonstrated a whirlpool sign without an obvious lead point. The patient was without prior surgical intervention. Urgent exploratory laparotomy revealed a midgut volvulus with associated bowel ischemia and impending infarction secondary to adhesive disease from a large single jejunal diverticulum. Derotation resulted in gradual recovery of bowel vascularity. Resection of the portion of the jejunum containing the diverticulum resulted in full clinical recovery of the patient.

Conclusions

Complications of jejunal diverticula, although rare, should be considered as part of the differential diagnosis of an acute abdomen of unknown etiology. Urgent surgical intervention was required to avoid a potential catastrophic outcome.

Incidental 18F-Fluorocholine Uptake in an Esophageal Diverticulum: 18F-FCH in an Esophageal Diverticulum

F-fluorocholine has recently emerged as a very sensitive agent for seeking parathyroid adenomas. We represent a case with esophageal diverticulum incidentally detected on F-fuorocholine PET/CT, which should be kept in mind as a reason of false positivity in primary hyperparathyroidism.