Fig 2 - uploaded by Jacopo Vannucci
Content may be subject to copyright.
Zenker's diverticulum (a). Volumetric diverticular pouch enlargement and possible clinical implications (b, c)
Source publication
Background
The ideal surgical technique for symptomatic Zenker’s diverticulum has not been identified yet. Endoscopic treatment, although frequently performed, has not replaced the open cricopharyngeal myotomy, which is still deemed the standard therapy by many dedicated physicians. The management of the diverticular sac after myotomy is still a m...
Similar publications
Background:
Cricopharyngeal dysfunction following head and neck cancer treatment may lead to a significant reduction in oral intake. Carbon dioxide laser is an established procedure for the treatment of non-malignant cricopharyngeal disorders. We report our experience of laser cricopharyngeal myotomy with objective swallowing outcome measures, bef...
Zenker′s diverticulum (ZD) is a posterior hypopharyngeal mucosal and submucosal outpouching through an area of relative muscular weakness, known as Killian′s triangle. It is an uncommon but highly treatable cause of mechanical dysphagia in elderly patients. Diagnosis is established by esophagography and upper endoscopy. The treatment has evolved wi...
Citations
... This technique is replicable and seems to be efficient which ensures long-term symptom alleviation that is the primary goal of the treatment. 11 The eat 10 assessment is utilized to monitor the resolution of symptoms post-treatment, demonstrating an excellent success rate, with inmediate result: 2 points , 2 weeks post operative: 1 point , 1 month: 0 points, which supports impact on the quality of life of our patient. ...
Background: Zenker´s diverticulum is an acquired sac-like outpouching of the mucosa and submucosa layers located at the pharyngoesophageal junction. It has an incidence of 2 in 100,000 adults with predominance in males. The main symptom of Zenker´s diverticulum is dysphagia, and surgical treatment is generally used to resolute the symptomatology. Although, Zenker´s diverticulum symptomatology treatment is challenging.
The main objective of this article was to present a clinical case of a patient with Zenker´s diverticulum who underwent an emergent surgical treatment; diverticulopexy.
Clinical case: A 67-year-old male with Zenker´s diverticulum who presented pyrosis, foreign body sensation, regurgitation, halitosis, and solid foods dysphagia. An esophagogram revealed a saccular image on the proximal third of the esophagus with no lesions in the rest of the tissue. The patient underwent cricopharyngeal myotomy plus diverticulopexy.
Conclusions: The clinical course of Zenker's diverticulum lies in an appropriate diagnosis through symptomatology and imaging study to provide the best surgical option.
... Although there is no reported case of malignant changes, Herbella et al. [24] reported a prevalence of malignant transformation in ZD from 0.3 to 7%. After diverticulectomy of ZD, suture or staple line leakage has been reported in 1.7-12.7% of patients [25] . Our case was very high risk because of old age, mitral valve repair, and permanent pacemaker dependency. ...
Unlabelled:
An 82-year-old male presented with progressive dysphagia and simultaneous hoarseness of voice for the past 6 months. He had mitral valve repair and a permanent pacemaker for a heart block 5 years ago. A computed tomographic scan of the neck demonstrated a cervical esophageal diverticulum. Oral Gastrogrifin contrast study confirmed esophageal diverticulum in Killian-Jamieson space. Open surgical diverticulectomy was performed safely. Patient's dysphagia resolved immediately, and he regained his normal voice after 6 weeks.
Introduction:
Killian-Jamieson's esophageal diverticulum is a rare form of pulsion diverticulum which originate through a muscular gap in the anterolateral wall of the esophagus, inferior to the cricopharyngeus muscle and superior to the circular and longitudinal muscle of the esophagus. Killian-Jamieson defined this area where the recurrent laryngeal nerve enters the pharynx, called Killian-Jamieson triangle. Ekberg and Nylander, in 1983, described an esophageal diverticulum in Killian-Jamieson space. The most common clinical manifestations in such patients are dysphagia, cough, epigastric pain, recurrent respiratory tract infections, and rarely hoarseness of voice. In symptomatic patients, surgical or endoscopic resection of the diverticulum is mandatory. We report this case in line with SCARE (Surgical CAse REport) criteria.
Case report:
An 82-year-old male presented to our outpatient clinic with a history of progressive dysphagia for solid food and hoarseness of voice for the last 6 months. He denied gastroesophageal reflux, cough, and shortness of breath. On examination of the neck, there was swelling on the left side but no tenderness or lymphadenopathy. Basic blood investigations, including complete blood count, liver, and renal panels, were normal. An echocardiogram showed mild impairment of left ventricle function and normally functioning mitral valve. Chest X-ray showed a pacemaker in position. Computed tomography scan of the neck showed esophageal diverticulum. Gastrogrifin contrast study showed esophageal Killian-Jamieson diverticulum (KJD).
Discussion:
The acquired esophageal diverticulum is categorized into three types based on its anatomical location. Zenker's and Killian-Jamieson (pulsion diverticulum) in the proximal part, traction diverticulum in the middle part, due to pulling from fibrous adhesions following the lymph node infection and epiphanic pulsion type in the distal esophagus. Although the KJD and Zenker's diverticulum (ZD) arise close to each other in the pharyngoesophageal area, they are anatomically distinct. Although ZD and KJD have the same demographic features, they are more commonly found in older men (60-80 years) and women, respectively. The incidence of ZD is 0.01-0.11%, and KJD is 0.025% of the population. Rubesin et al. reported radiographic findings in 16 KJD cases. They found the majority of them were on the left side (72%), followed by 20% on the right side and 8% bilateral.
Conclusion:
In conclusion, we report a rare case of dysphagia and simultaneous hoarseness of voice in an octogenarian due to KJD, who was treated with open diverticulectomy, and dysphagia resolved; he regained his voice back after 6 weeks. In our opinion, endoscopic surgery in such a patient with KJD can put recurrent laryngeal at risk of injury since an endoscopic approach operator cannot visualize and dissect away the recurrent laryngeal nerve, particularly when KJD already compresses it.
... Although there is not yet any report of cancer in KJD, the possibility of carcinogenesis in the diverticulum should be considered when deciding on the surgical method, especially in young people. On the other hand, suture line or staple line leakage can occur in diverticulectomy, and the incidence is 1.7 to 12.7% [25,28,29]. The staple line leakage also occurred in one of the present cases (Case 1). ...
... Diverticulopexy is associated with a lower risk of leakage and allows earlier peroral feeding [28][29][30][31][32]. Puma et al. compared the treatment outcome after diverticulectomy with those after diverticulopexy for ZD and reported that diverticulopexy achieved better symptom control and a lower morbidity rate than diverticulectomy [28]. ...
... Diverticulopexy is associated with a lower risk of leakage and allows earlier peroral feeding [28][29][30][31][32]. Puma et al. compared the treatment outcome after diverticulectomy with those after diverticulopexy for ZD and reported that diverticulopexy achieved better symptom control and a lower morbidity rate than diverticulectomy [28]. Therefore, we consider that diverticulopexy is a reasonable treatment for high-risk patients. ...
Background:
Killian-Jamieson diverticulum (KJD) is a rare diverticulum arising from a muscular gap in the anterolateral wall of the proximal cervical esophagus. The first choice of treatment for KJD remains controversial due to its rare incidence. Here, we report two cases of KJD for which we performed different surgery: diverticulectomy in one case and diverticulopexy in the other.
Case presentation:
Case 1 involved a 58-year-old woman presenting progressive pharyngeal discomfort for the past year. She was diagnosed as KJD using endoscopic and radiographic findings. She underwent diverticulectomy with cricopharyngeal and proximal esophageal myotomy. Staple line leakage developed at 1 month after surgery and was successfully treated conservatively. At 5 months after surgery, she was asymptomatic. Case 2 involved a 77-year-old woman presenting dysphagia for the past 2 years. She had a history of bilateral breast cancer and had hypertension, asthma, and osteoporosis. Taking her age and medical history into account, we selected diverticulopexy with cricopharyngeal and proximal esophageal myotomy. The postoperative course was uneventful. At 2 years after surgery, she remained free of dysphagia.
Conclusion:
The first choice of surgery for KJD is diverticulectomy. In a high-risk patient, diverticulopexy is a reasonable treatment. We recommend the addition of myotomy as a part of any surgical treatment.
... The limit to define patient satisfaction was 85% and patients were told to place themselves above 85% if satisfied or below 85% if not. This method is not a validated assessment scheme but already used in past publication [4]. We decided not to use the common dysphagia assessment tools, considering we were not trying to grade, to categorize, or to describe the kind of dysphagia. ...
... Diverticulectomy and diverticulopexy are the most commonly performed accessory managements to myotomy for Zenker's diverticulum and few studies have compared them but no one study has been prospectively randomized [4,21]. Furthermore, guidelines do not exist regarding treatment selection. ...
... Likewise, the results above support the hypothesis that the diverticular sac becomes remarkably reduced in volume once it has been emptied and pulled upside-down, so it does not create mass effects or fill space. To this regard, a recent study comparing diverticulectomy versus pexis, reported that an experienced radiologist was unable to recognize any radiographic differences between the two procedures when followed up with the barium swallow test at least 1 year after surgery [4]. ...
The aim of the study was to prospectively evaluate the outcome of myotomy plus diverticulopexy over short and long-terms. A prospectively collected consecutive series (2007–2017) of 37 patients undergoing myotomy plus diverticulopexy was analyzed for clinical condition, operative information, peri-operative events, and follow-up by means of interview and physical examination. Diverticulopexy was scheduled regardless of the diverticulum’s features and patient condition, other than operability. There was no choice or selection between possible treatment options. Patients were evaluated pre-operatively, at post-operative day 30 and after 1 year. Follow-up aimed at assessing the subjective condition following treatment. During the interview, patients were asked to self-assess their ability to swallow before and after surgery. No patient had peri-operative events, complications associated with the procedure, wound infection or impaired swallowing. All patients could start drinking the day after operation, could return to solid diet on post-operative day 2 and be discharged on post-operative days 3–4. Barium swallowing was not necessary before discharge. Full solid diet was resumed according to patient’s compliance from post-operative day 2 (some patients refused solid diet soon after the operation even if asymptomatic). Follow-up ranged between 1 and 8 years. No patient was lost at follow-up. No disease recurrence was observed. Finally, no patient needed or sought for a clinical examination between the follow-up calls. Patients reported at least 50% improvement of symptomatology after 1 year. Diverticulopexy appears to be clinically safe, methodologically reproducible, and an effective procedure; it avoids suturing and offers good outcome results along with high patient satisfaction.
An esophageal diverticulum is rare and is usually asymptomatic, although this condition may cause dysphagia, regurgitation, chest pain, globus, halitosis, and aspiration pneumonia. Based on its location and the characteristic pathophysiology associated with this anomaly, esophageal diverticula are classified into the following types: Zenker’s, epiphrenic, and mid-esophageal diverticula (Rokitansky diverticulum). Esophagography is useful to diagnose esophageal diverticula. Evaluation of accompanying esophageal motility disorders, including achalasia and distal esophageal spasm is essential in patients with epiphrenic diverticula. Appropriate treatment is important for management of symptomatic esophageal diverticula. Previously, diverticulectomy or diverticulopexy was the usual treatment for this condition. However, surgical resection of diverticula is challenging owing to the complex esophageal anatomy, particularly in patients with diverticula located in close proximity to the oral cavity. Technological advances have led to the introduction of minimally invasive endoscopic approaches focused on symptom improvement. Rigid diverticuloscope-assisted septotomy, flexible endoscopic septum division, Zenker peroral endoscopic myotomy (Z-POEM), and peroral endoscopic septotomy (POES) are useful for treatment of a Zenker’s diverticulum. Recent studies recommend diverticulum peroral endoscopic myotomy (D-POEM) for endoscopic management of epiphrenic diverticula. Further studies are warranted to conclusively establish the technical success rates, clinical symptom improvement, and long-term prognosis of Z-POEM, POES, and D-POEM.
Die Behandlung der pharyngoösophagealen Divertikel ist mit der Zunahme der therapeutischen Optionen erheblich komplexer geworden. Da es trotz der Vielzahl der offenen und endoskopischen Verfahren keine "ideale“ Behandlungsoption gibt, sollte sich ein moderner therapeutischer Ansatz an der individuellen Situation des betroffenen Patienten orientieren. Für die endoskopischen Verfahren sprechen die relativ einfache Vorgehensweise und die geringe eingriffsspezifische Morbidität. Auch hat die Vermeidung der zervikalen Inzision neben kosmetischen Aspekten Vorteile bei im Halsbereich voroperierten Patienten. Andererseits ist die Rate an Therapieversagern höher als bei offenen Operationen und häufig sind mehrere endoskopische Sitzungen bis zur Erreichung eines akzeptablen Ergebnisses erforderlich.Aus diesen Gründen besteht in unseren Augen bei relativ jungen oder junggebliebenen Patienten mit niedriger Komorbidität weiterhin eine gute Indikation für das transzervikale Vorgehen beim pharyngoösophagealen Divertikel.
