Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative

OBJECTIVES

The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication.

METHODS

Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi-institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management.

RESULTS

There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases (n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases (p = 0.002); postoperative diet was not different between open and endoscopic (p = 0.26).

CONCLUSIONS

Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction.

LEVEL OF EVIDENCE

Level III Laryngoscope, 134:2678-2683, 2024.

Outcomes after per-oral endoscopic myotomy for Zenker's diverticula (Z-POEM) and correlation with impedance planimetry (FLIP)

INTRODUCTION

Zenker's diverticulum (ZD) is a false pulsion diverticulum of the cervical esophagus. It is typically found in older adults and manifests with dysphagia. The purpose of this study is to describe our experience with Per-oral endoscopic myotomy for Zenker's (Z-POEM) and intraoperative impedance planimetry (FLIP).

METHODS

We performed a single institution retrospective review of patients undergoing Z-POEM in a prospective database between 2014 and 2022. Upper esophageal sphincter (UES) distensibility index (DI, mm2/mmHg) was measured by FLIP before and after myotomy. The primary outcome was clinical success. Secondary outcomes included technical failure, adverse events, and quality of life as assessed by the gastroesophageal health-related quality of life (GERD-HRQL), reflux severity index (RSI), and dysphagia score. A statistical analysis of DI was done with the paired t-test (p < 0.05).

RESULTS

Fifty-four patients underwent Z-POEM, with FLIP measurements available in 30 cases. We achieved technical success and clinical success in 54/54 (100%) patients and 46/54 patients (85%), respectively. Three patients (6%) experienced contained leaks. Three patients were readmitted: one for aforementioned contained leak, one for dysphagia, and one post-operative pneumonia. Three patients with residual dysphagia underwent additional endoscopic procedures, all of whom had diverticula > 4 cm. Following myotomy, mean DI increased by 2.0 ± 1.7 mm2/mmHg (p < 0.001). In those with good clinical success, change in DI averaged + 1.6 ± 1.1 mm2/mmHg. Significant improvement was found in RSI and GERD-HRQL scores, but not dysphagia score.

CONCLUSION

Z-POEM is a safe and feasible for treatment of ZD. We saw zero cases of intraoperative abandonment. We propose that large diverticula (> 4 cm) are a risk factor for poor outcomes and may require additional endoscopic procedures. An improvement in DI is expected after myotomy, however, the ideal range is still not known.

Endoluminal treatment for Zenker's diverticulum - a population-based observational study

BACKGROUND

Zenker's diverticulum is a false diverticulum arising in the oesophago-pharyngeal junction. It may cause symptoms like dysphagia and regurgitation. In Central Norway, treatment is centralized to St. Olavs hospital, either as an endoscopic stapled oesophago-diverticulostomy procedure at the Department of Gastrointestinal Surgery or as laser diverticulostomy at the Department of Ear, Nose and Throat Surgery, depending on diverticulum size.

METHODS

Retrospective, population-based, study from 2001-2020 on patients treated for Zenker's diverticulum, at the time with a rigid endoscopic approach. Patients were identified through the in-hospital register for operations. The two treatment groups were compared on relevant pre-, intra-, and postoperative variables by review of the individual patient records.

RESULTS

78 consecutive patients, 36 at Dept. of Ear, Nose and Throat Surgery and 42 at Dept. of Gastrointestinal Surgery, were treated with a total of 104 interventions. Crude incidence for a surgery-demanding Zenker's diverticulum was 0.57 per 100 000 per year. The Dept. of Ear, Nose and Throat Surgery administered significantly less often prophylactic antibiotics than the Dept. of Gastrointestinal Surgery (p < 0.001), administered more frequently intraoperative dexamethasone (p < 0.001), and had significantly more postoperative infections (19.6% vs 3.4%, p = 0.01). No procedure-related mortality was registered. Although no standardized follow-up took place, at a median of 119 months elapsed, observed clinical recurrence was 35% for the endostapler treatment and 51% for the laser treatment procedure.

CONCLUSION

Both rigid endoscopic stapled oesophago-diverticulostomy and laser diverticulostomy are safe treatments for Zenker's diverticulum, however with a substantial risk of recurrence.

Management of the Zenker diverticulum: multicenter retrospective comparative study of open surgery and rigid endoscopy versus flexible endoscopy

BACKGROUND AND STUDY AIM

Zenker's diverticulum is a rare disease that affects quality of life due to dysphagia and regurgitation. This condition can be treated by various surgical or endoscopic methods.

PATIENTS AND METHOD

Patients treated for Zenker's diverticulum in three centers in the south of France between 2014 and 2019 were included. The primary objective was clinical efficacy. Secondary objectives were technical success, morbidities, recurrences, and need for a new procedure.

RESULTS

One hundred forty-four patients with a total of one hundred sixty-five procedures performed were included. A significant difference was found between the different groups in terms of clinical success (97% for open surgery versus 79% for rigid endoscopy versus 90% for flexible endoscopy, p = 0.009). Technical failure occurred more frequently in the rigid endoscopy group than in the flexible endoscopy and surgical groups (p = 0.014). Median procedure duration, median time to resumption of feeding, and hospital discharge were statistically shorter for endoscopies than for open surgery. On the other hand, more recurrences occurred in patients treated by endoscopy than those treated by surgery, and more reinterventions were required.

CONCLUSION

Flexible endoscopy appears to be as effective and safe as open surgery in the treatment of Zenker's diverticulum. Endoscopy allows a shorter hospital stay at the expense of a higher risk of recurrence of symptoms. It could be used as an alternative to open surgery for the treatment of Zenker's diverticulum, especially in frail patients.

Novel technique of flexible endoscopic therapy of Zenker’s diverticulum using a pulsed Holmium laser—a retrospective single-center analysis

Background

In recent years, flexible endoscopic therapy of Zenker’s diverticulum seems to become the standard approach. The aim of this study was to assess the safety, efficacy and short-term outcome of flexible endoscopic diverticulotomy of Zenker’s diverticulum with a pulsed Holmium laser (PHL).

Patients and methods

All patients treated with endoscopic laser-diverticulotomy using a PHL between February 2013 and November 2021 at the University Hospital Salzburg were extracted from our prospectively maintained endoscopic database. Demographic data, size of Zenker’s diverticulum, procedure duration, complications, short-term outcome and rate of recurrence were evaluated.

Results

In the study period, 45 procedures in 36 patients were performed. Mean depth of the Zenker diverticulum was 21 mm (10–60 mm), mean procedure time was 31 min (15–60 min), intraprocedural adverse events occurred in 2 out of 45 patients (5%) which were both managed endoscopically, post-procedural stenosis occurred in 1 patient (2%). In the follow-up examinations (mean follow-up after 6.4 months), 27 out of 36 patients (75%) were symptom-free, 6 patients (17%) reported an improvement of dysphagia. 3 patients (9%) suffered from persistent dysphagia. After initial symptom relief, a recurrent diverticulum occurred in 5 patients. Endoscopic re-intervention with PHL was done in these cases.

Conclusions

Flexible endoscopic treatment of primary and recurrent Zenker’s diverticulum using a PHL is a promising, safe and effective treatment with, in our opinion, technical advantages in comparison to the CO2 laser. Further controlled prospective trials are needed.

Open Diverticulectomy and Cricopharyngotomy for Symptomatic Zenker's Diverticulum after Endoscopic Diverticuloesophagostomy

Two of the accepted treatments for symptomatic Zenker's diverticula are open resection of the diverticulum with cricopharyngotomy and transoral, endoscopic diverticuloesophagostomy with cricopharyngotomy. We report our experience with open surgical resection of the diverticulum with repeat cricopharyngotomy in patients with persistent symptoms after endoscopic diverticuloesophagostomy. This is a retrospective review of patients who underwent open surgical resection of the diverticulum, with repeat cricopharyngotomy in patients with persistent symptoms after endoscopic diverticuloesophagostomy. Medical records were reviewed for demographics, surgical detail, short-term complications, and symptomatic outcomes. Four patients underwent open resection of a Zenker's diverticulum with repeat cricopharyngotomy. There were two men and two women, with a mean age of 77.5 years. The mean operative time was 56 minutes and median length of stay was two days. All patients had improvement in dysphagia. Surgical diverticulectomy with cricopharyngotomy after failed endoscopic diverticuloesophagostomy is a technically challenging operation. However, symptomatic improvement can be achieved.

Delayed diagnosis of a case of Zenker's diverticulum. What may happen when a family physician does not visit his family physician

INTRODUCTION

Zenker's diverticulum is a diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle. It occurs commonly in elderly patients (over 70 years) and the typical symptoms include dysphagia, regurgitation, chronic cough, aspiration and weight loss.

CASE

We are reporting dysphagia in a 49-years old man who was treated as having Helicobacter Pylori gastritis for three years. Being a family physician himself, the patient applied to specialists in gastroenterology, bypassing primary care. During a casual interview on his symptoms, a family physician referred him to undergo a repeated endoscopy with suspected Zenker's diverticulum. After being diagnosed with Zenker's diverticulum, the patient underwent surgical intervention at the department of thoracic surgery and made a full recovery. He regained five kilograms at the end of five weeks after the operation.

CONCLUSION

This case demonstrates once more the importance of history taking and follow-up in medical care. Attentive listening by a family physician could have probably prevented the delay of service in this case.

[Not Available]

Zusammenfassung. Das Vorliegen eines Zenker-Divertikels ist eine seltene Ursache für Schluckstörungen mit potenziell lebensbedrohlichen Komplikationen. Die endoskopische bzw. chirurgische Sanierung erzielen hohe Raten kompletter Remission. Aus verschiedenen Therapieansätzen werden heute primär minimal-invasive Therapieverfahren favorisiert.

Long-Term Results of Endoscopic Stapling Diverticulotomy for Pharyngeal Pouches

OBJECTIVE: The aim of the present study was to evaluate the long-term success of endoscopic stapling as a primary procedure for the treatment of pharyngeal pouches.

METHODS: This study is a retrospective case review of 25 patients with pharyngeal pouches treated by endoscopic stapling (23 stapled, 2 abandoned) over a 4-year period (1994 to 1998) at a University teaching hospital in the United Kingdom. Outcomemeasures used were relief of symptoms over a long-term follow-up of 2 to 5 years.

RESULTS: Of the 25 patients analyzed, 12 patients (48%) have remained asymptomatic after their initial stapling. Eight patients (32%) were relieved of their symptoms after revision stapling. The overall long-term success rate for endoscopic stapling was 80% (20 of 25 patients)

CONCLUSION: Reduced morbidity and few complications in the elderly make endoscopic stapling a favored primary technique of treating pharyngeal pouches. Open surgery is recommended only in healthy patients with very large pouches.

Unexpected esophageal diseases appeared in thyroid resections

OBJECTIVE

In order to avoid the misdiagnosis of thyroid diseases, we need to discuss the clinical features and diagnostic methods of cervical esophageal cancer and Zenker's diverticulum.

METHODS

The clinical and laboratory data of seven cases were reviewed retrospectively, and in all cases, esophageal-related diseases were misdiagnosed as thyroid diseases preoperatively. Among them, two cases were cervical esophageal cancer metastasized to thyroids but initially, they were misdiagnosed as thyroid cancer. The other five cases were Zenker's diverticulum, but were originally diagnosed as nodular goiter, and two out of the five cases were found with calcification. They were all detected by ultrasound examination without any clinical feature of esophageal diseases. Previous literatures only reported five cases of thyroid metastasis and three cases of Zenker's diverticulum.

RESULTS

In both cases where cervical esophageal cancer metastasized to thyroid, anterior cervical neoplasm biopsy and surgical removal were performed followed by postoperative radiotherapy and chemotherapy. Both patients died from esophageal cancers in 7 and 15 months postoperatively. All five cases of Zenker's diverticulum received excision and repair without any postoperative complication or recurrence in the following 2 to 7 years.

CONCLUSIONS

Cervical esophageal cancer and Zenker's diverticulum may be misdiagnosed as thyroid disease. Careful and comprehensive diagnostic tests would be required to avoid misdiagnosis.

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.

[THE COMBINATION OF RECURRENT INTUSSUSCEPTION DUODENAL, ZENKER DIVERTICULUM, HIATAL HERNIA AND HASTROPTOSIS AS A MANIFESTATION OF NON-DIFFERENT DYSPLASIA OF CONNECTIVE TISSUE]

Presented rare clinical case: a combination of recurrent intussusception duodenal, diverticulum Zenker, hiatal hernia and hastroptosis as a manifestation of non-different dysplasia of connective tissue. Special interest is recurrent intussusception upper horizontal portion duodenal in the bulb, is not detected when esophagogastroduodenoscopy.

Management of a postradiation esophageal web in the setting of a coexisting Zenker's diverticulum

We present a case of postradiation obstructive esophageal web, seen in the setting of a coexisting Zenker's diverticulum, that was treated with combined anterograde and retrograde esophagoscopy puncture and dilation. We also review the relevant literature. Obstructing esophageal webs and stenoses are well-documented complications seen in patients with head and neck cancer treated with radiation therapy. For thin webs, combined anterograde and retrograde esophagoscopy along with puncture and dilation can be a relatively safe treatment option for selected patients. The presence of a coexisting Zenker's diverticulum may predispose the patient to the development of postradiation esophageal complications and make subsequent assessment more difficult to perform.

Laser diverticulotomy for Zenker's diverticulum--does it improve quality of life?

To determine quality of life (QoL) in individuals with dysphagia related to identified Zenker's diverticulum before (T1) and one year after undergoing endoscopic laser diverticulotomy surgery (T2). A total of 43 individuals (18 women and 25 men) were included at T1 and 37 of these responded at T2 (13 women and 24 men). Health-related QoL (HRQoL) was determined with the short form 36 (SF-36) and disease-specific QoL (DSQoL) was assessed with the MD Anderson Dysphagia Inventory (MDADI). In addition, two questions about specific symptoms related to Zenker's diverticulum were added and ordered as a fifth subscale of MDADI. Comparisons were made between patients and an age- and gender-adjusted normative sample from the Norwegian population. Significant differences were found in all subscales on MDADI, but none between T1 and T2 on SF-36. Compared to the normative sample, the component score MCS of SF-36 was significantly lower in the dysphagia patients at both T1 and T2. The attrition sample had significantly lower PCS than the completers. The results substantiate that disease severity is associated with poorer disease-related QoL, and that the disease-specific QoL is significantly improved one year after laser diverticulotomy.

Zenker's diverticulum, a rare cause of upper gastrointestinal bleeding

The most common complication of Zenker's diverticulum is aspiration pneumonia, compression of the trachea and esophageal obstruction with large diverticulum, and increased risk of development of carcinoma. Thus bleeding occurs rarely, can be massive and life threatening, with ulceration being the most common cause.

MATERIAL AND METHODS

We describe a patient with sever upper gastrointestinal bleeding as a result of a Zenker's diverticulum. A 75 year-old woman was referred to the emergency room and hospitalized for hematemesis, melena, asthenia and total dysphagia. In this particular case we preferred open technique because of the diverticulum dimensions and bleeding episode. Left cervicotomy was practiced on the anterior edge of the sternocleidomastoid muscle, being known that Zenker diverticulum extend into the left neck 90% of the time, fact also confirmed by radiology in this case.

RESULTS

Postoperatively, the patient showed a complication free recovery. Five days after treatment the patient resumed nourishment. Several days later our patient was able to return home. Follow-up at 12 months after the operation showed complete recovery. Ulcer of the basis of Zenker's diverticulum is a rare entity and, only a few cases were reported in the literature to date. Omitting thecricomyotomy predisposes to fistula or diverticulum recurrence due to the persistence of a high pharyngeal intraluminal pressure that acts on the posterior wall just proximal to the upper esophageal sphincter.

CONCLUSIONS

Zenker's diverticulum is an unusual site of origin for clinically significant upper gastrointestinal hemorrhage and differential diagnosis must include other more frequent causes of upper gastrointestinal bleeding. In our opinion, classicalsurgical therapy is indicated when distal esophageal imaging cannot be obtained during endoscopic examination, there is a large diverticulum or in an emergency setting when fast control over the bleeding source is required.

Zenker's diverticulum. A rare cause of dysphagia

Zenker's diverticulum or pharyngeal pouch is a herniation of pharyngeal mucosa through a defect located on the posterior pharyngeal wall, in an area of natural weakness between the 2 parts of the inferior constrictor muscles. The incidence of presentation of pharyngeal pouch to an ear, nose, throat (ENT) specialist was estimated as 0.47 cases per 100,000 per year. It could be a rare cause of dysphagia in elderly patients, associated with regurgitation, chronic cough, aspiration, and weight loss. The etiology still unknown, but theories focus upon structural or physiological disorders of the cricopharyngeus muscle. Zenker's diverticulum should be considered as one of the rare causes of dysphagia in elderly patients, and the treatment modalities depend on individual experience and availability of the facilities.

[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.