Systemic inflammatory response after endoscopic surgery of Zenker's diverticulum

C-reactive protein as an early marker of postoperative leakage in patients after endoscopic laser assisted Zenker's diverticulotomy

BACKGROUND AND AIM

Minimally invasive endoscopic techniques are the treatment of choice for Zenker's diverticulum (ZD). Our objective was to evaluate the results and efficacy of endoscopic and open approaches, to determine whether postoperative C-reactive protein (CRP) serum levels can be used as a marker to exclude the presence of esophageal leakage, and to identify risk factors for development of postoperative leakage and complications.

MATERIALS AND METHODS

Patients who underwent transcervical myotomy and diverticulotomy (TMD) or endoscopic cricopharyngeal myotomy (ECM) with CO₂ laser for ZD in years 2008-2021 at our department were included in this retrospective study.

RESULTS

Of the 101 patients enrolled, 83 patients underwent ECM and 18 TMD. The procedure time of the endoscopic technique was significantly shorter compared to that of transcervical method (p < 0.001). The median time to oral intake was 6 days for ECM and 10.5 days in the TMD group (p < 0.001). There was a 13% (n = 11) and 16.7% (n = 3) symptomatic recurrence rate and 3.6% (n = 3) and 16.7% (n = 3) major complications rate for ECM and TMD groups, respectively. The incidence of contrast leak (CL) evaluated by postoperative swallow study was 8.9% (9 from 83 patients in the ECM group only). In patients with CL, a significant increase in CRP levels on postoperative day (POD) 2 and 3 was detected when compared to patients without CL.

CONCLUSIONS

Endoscopic diverticulotomy with CO₂ laser represents a safe and efficient treatment of ZD. Elevation of postoperative CRP serum levels over 123.8 mg/L on POD2 and 98.8 mg/L on POD3 may indicate presence of an esophageal leakage.

A dilemma of a case of Zenker diverticulum; leak or Acinetobacter baumannii?! A case report

INTRODUCTION

Zenker's diverticulum is an acquired mucosal pulsion of the upper esophagus. The aim of this paper is to report a case of Zenker's diverticulum with a complicated postoperative course including infection by Acinetobacter baumannii causing diagnostic as well as management dilemma.

CASE REPORT

A 43-year-old male complained from dysphagia for three months. Barium swallow revealed Zenker's diverticulum. Under general anesthesia, the small Zenker's diverticulum was ligated and myotomy was done. He developed erythematous swelling at the site of the operation. The patient was taken to the operation theater. The esophagus was tested, no trace of leak was found. The patient developed cardiac arrest. He was admitted to the intensive care unit and remained there for twenty eight days. Bronchial wash culture showed Acinetobacter baumannii. The patient was on antibiotic, supportive treatment and enteral feeding through nasogastric tube. After recovery he was extubated and barium swallow was done which was normal and showed no signs of leak. Three months after the operation, the patient was completely normal.

DISCUSSION

This case had a positive culture for Acinetobacter baumannii. It is commonly accounted for nosocomial infections. It has been documented as a serious threat worldwide because of the emerging prevalence of multidrug resistant. However, an inadequate understanding of A. baumannii pathophysiology and ecosystem confines the progress of alternative therapeutic policies. In the current case, it was not clear either leak or Acinetobacter baumannii was the cause of deterioration.

CONCLUSION

Both esophageal leak and infection with Acinetobacter baumannii are fulminant debilitating conditions that could be managed with conservative strategies.