Surgical experience of the national institution in the treatment of Zenker's diverticula

[Endoscopic treatment of recurrent Zenker diverticulum and postoperative esophageal stricture]

Zenker diverticulum is a rare disease accounting for 1.5-5% of esophageal diverticula. For a long time, surgical treatment of Zenker pharyngoesophageal diverticula implied open diverticulectomy via cervical approach. However, this intervention is characterized by high postoperative morbidity and recurrence rate. Oral endoscopic minimally invasive cricopharyngoesophagomyotomy has become widespread over the past 10 years. We present a 55-year-old female who underwent endoscopic treatment for recurrent Zenker diverticulum and postoperative esophageal stricture. We obtained favorable result in a patient with recurrent Zenker diverticulum after previous open surgeries complicated by esophageal stricture. Endoscopic management eliminated recurrent diverticulum and esophageal stricture, as well as improved the quality of life. Endoscopic approach is preferable for pharynoesophageal diverticula compared to traditional surgical diverticulectomy. Obvious advantages of this technique are stable functional result, low incidence of complications and mortality, short-term postoperative period with fast rehabilitation. Extended myotomy is essential for successful oral endoscopic cricopharyngoesophagomyotomy.

From Scalpel to Scope: How Surgical Techniques Made Way for State-of-The-Art Endoscopic Procedures

The continuous evolution of endoscopic tools over the years has paved the way for minimally invasive alternatives to surgical procedures for multiple gastrointestinal conditions. While few endoscopic techniques have supplanted their surgical counterparts like percutaneous gastrostomy tubes, many have emerged as noninferior, less morbid alternatives for such diverse conditions as achalasia (peroral endoscopic myotomy), obesity (endoscopic sleeve gastroplasty), drainage of pancreatic walled off necrosis (EUS-guided cystogastrostomy), and gastric outlet obstruction (EUS-guided gastrojejunostomy). These techniques were based on surgical concepts and would not have been feasible without collaboration between surgeons and endoscopists. Such collaboration is exemplified by the antireflux fundoplication, which features combined hiatal hernia repair with transoral and incisionless fundoplication. The burgeoning armamentarium of endoscopic alternatives to traditional surgical procedures requires a multidisciplinary discussion and individually tailored treatment plans that consider patient preferences as well as the relative risks and benefits of surgical and endoscopic approaches. As technological advances give rise to ever more innovative endoscopic techniques, studies to evaluate clinical outcomes and define their role in treatment algorithms will be required.

Occult Early Squamous Cell Carcinoma in Zenker's Diverticulum Treated With Diverticulectomy Followed by Additional Esophagectomy With Free Jejunal Reconstruction: A Case Report

A 63-year-old man was evaluated for a 20-year history of dysphagia and vomiting. Barium-swallow esophagography showed a Zenker's diverticulum at the upper end of the esophagus. Esophagogastroduodenoscopy revealed the diverticulum about 20 cm from the incisors. There was no mucosal inflammation or irregularity in the diverticulum. Computed tomography showed that the diverticulum was about 8 cm in size. There was no lymphadenopathy around the esophagus. Because the patient's symptoms were worsening, we performed diverticulectomy using a linear stapling device and cricopharyngeal myotomy. The mucosa of the resected specimen had no macroscopically abnormal lesions. However, an area unstained by iodine that widely involved the surgical margin was recognized at pathologic examination. Pathologic findings revealed squamous cell carcinoma invading the lamina propria mucosa with inflammatory cell infiltration. In addition, the pathologic surgical margin was widely positive. However, a remnant tumor lesion was not detected by postoperative esophagogastroduodenoscopy. Biopsies near the staple line were negative. After obtaining informed consent, we performed resection of the cervical esophagus including the proximal stump of the diverticulum and cervical lymphadenectomy approximately 4 months after the primary operation as an additional surgery. Reconstruction was performed by free jejunal transplantation with microvascular anastomosis. The patient was discharged on postoperative day 45. Pathologic examination revealed no malignant lesion in the resected specimen, and radical cure was confirmed.

Esophageal surgery in minimally invasive era

The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.

ASSESSMENT OF MECHANICAL AND MANUAL SUTURE IN THE SURGICAL TREATMENT OF THE PHARYNGOESOPHAGEAL DIVERTICULUM

BACKGROUND

The occurrence of the pharyngoesophageal, or Zenker diverticulum is not frequent in the national scenario, and the technique of the diverticulectomy with cricomyotomy in medium and great dimension diverticula is still the most indicated. Because the resection of the diverticulum requires the suture of the pharynx, dehiscence can occur, thereafter delaying swallowing. Hence, the idea is to accomplish this surgical procedure, comparing the manual and mechanical suture, in order to evaluate the real benefit of the mechanical technique.

AIM

To evaluate the results of the pharyngoesophageal diverticulectomy with cricomyotomy using manual and mechanical suture with regard to local and systemic complications.

METHOD

Fifty-seven patients with pharyngoesophageal diverticula diagnosed through high digestive endoscopy and pharyngeal esophagogram were studied. The applied surgical technique was diverticulectomy with myotomy of the cricopharyngeal muscle, done in 24 patients (42.2%) the mechanical suture (group A) with the mechanical linear suture device and in 33 (57.8%) a manual closure of the pharynx (group B).

RESULTS

In the postoperative period, one patient of group A (4.1%) presented fistula caused by dehiscence of the pharyngeal suture, and three of group B (15.1%) presented the same complication, with a good outcome using a conservative treatment. In the same group, three patients (9.0%) presented stenosis of the suture of the pharynx, with good outcome and with endoscopic dilatations, and no patient from group A presented such complication. Lung infection was present in five patients, being two (8.3%) of group A and three (9.0%) on B, having good outcomes after specific treatment. In the late review, done with 43 patients (94.4%) of group A and 22 (88.0%) on B, the patients declared to be pleased with the surgical procedure, because they were able to regain normal swallowing.

CONCLUSION

The diverticulectomy with myotomy and pharyngeal closure using mechanical suture was proven appropriate, for having restored regular swallowing in most of the patients, and the mechanical closure of the pharynx proved to be more effective in comparison to the manual one, because it provided a lower index of local post-surgical complications.

Pharyngeal pouch management: an historical review

BACKGROUND

Management of the pharyngeal pouch has evolved enormously since the first description by Ludlow in 1764 and the first case series by Zenker and Von Ziemssen in 1877. With the introduction of antibiotics, and the advancement of surgical technique with the advent of endoscopic surgery and lasers, current management is vastly different to that in the nineteenth century.

OBJECTIVES

This paper traces the history of pharyngeal pouch management, and discusses the various treatment options and opinions recorded during the nineteenth and twentieth centuries, comparing these with techniques popular today.

RESULTS AND CONCLUSION

Pharyngeal pouch surgery has been associated with significant morbidity, both because of the elderly age of patients typically affected by the condition and because of the surgery itself and potential post-operative complications encountered. The historical development of pharyngeal pouch management and the understanding of pharyngeal pouch pathophysiology are discussed.

Pharyngoesophageal diverticulum surgical therapy using linear stapling device

BACKGROUND

Pharyngoesophageal diverticulum presents itself as an uncommon disorder. Thus, choosing the most effective treatment method may be challenging. Surgical treatment remains as the main option. However, establishing the best surgical technique is still controversial.

AIM

To evaluate the results of diverticulecomy with chricopharyngeal miotomy and linear stapler closure of the pharynx in a patient sample with Zenker`s diverticulum regarding local and systemic complications.

METHODS

Nineteen patients with pharyngoesophageal diverticulum were admitted. All of them presented the clinical conditions required to indicate the surgical procedure. Patients were evaluated with regard to any post-operative complications. This study was conducted retrospectively with patients' data analysis.

RESULTS

Patients showed satisfactory results, with no evidence of fistula at the level of the pharyngeal suture. Two out of 19 lost post-operative follow-up and one of them had pharyngeal stenosis reverted with endoscopic dilation. The entire sample reported being satisfied with the procedure emphasizing improvement of the quality of life mainly due to the return of physiological deglutition.

CONCLUSION

The diverticulectomy with myotomy and posterior pharyngeal closure with linear surgical stapler proved to be an effective technique, offering a lower risk of post-operative complications and improving the overall quality of life.

A Unusual Case of Complicated Zenker's Diverticulum

We report the surgical management of a case of Zenker's diverticulum in a 64 year old man, complicated by metallic nail penetration and surgical scarring due to previous surgery for cervical vertebral trauma.