Transoral endoscopic repair of Zenker diverticulum by a thoracic surgical service.

OBJECTIVE: Zenker diverticulum (ZD), a pulsion diverticulum of the esophagus, has been traditionally managed with an open surgical approach, but endoscopic transoral stapling has been reported with increasing frequency. The objective of this study was to evaluate the results of endoscopic repair of ZD by a thoracic surgery service. METHODS: We conducted a retrospective review of patients who underwent transoral stapling repair of ZD at our institution by the thoracic surgery service. We evaluated perioperative outcomes including dysphagia (1, no dysphagia to 5, unable to swallow saliva) and failure of repair requiring surgical intervention. RESULTS: A total of 151 patients (median age, 78 years; 75 men, 76 women) underwent evaluation for endoscopic repair of ZD. Endoscopic stapled repair of the ZD was completed in 135. Sixteen patients underwent conversion to open repair. The perioperative mortality was 0.6% (1 patient). The median hospital stay was 2 days (range, 0-18 days). Complications occurred in 5 patients who underwent endoscopic repair. The mean preoperative dysphagia score was 2.8 and improved to 1.2 during follow-up (median, 16 months; P < .001). During further follow-up (median, 52 months), 8 patients (5.3%) had failure of the endoscopic repair requiring open surgery (n = 5) or redo transoral stapling (n = 3). CONCLUSIONS: Endoscopic stapling repair of ZD can be performed safely with good results in experienced centers by thoracic surgeons with significant esophageal experience. Long-term follow-up is required to evaluate the durability of endoscopic repair of ZD.

Endoscopic retreatment of Zenker's diverticulum using novel endoscopic scissors - The Clutch Cutter device.

Treatment of Zenker's diverticulum by flexible endoscopy consists of the myotomy of the cricopharyngeal muscle and is considered to be feasible, effective and safe. This report describes the novel use of a Clutch Cutter® device to perform flexible endoscopic retreatment of a symptomatic recurrence after previous treatment using a Needle knife in a 68 year old woman with symptoms of dysphagia for solids.

Flexible endoscopic treatment for Zenker's diverticulum: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Flexible endoscopic septum division (FESD) is a rapidly evolving technique for the treatment of Zenker's diverticulum (ZD). The aim was to perform a systematic review and meta-analysis of the literature focusing on FESD for ZD, including an in-depth evaluation of its efficacy, safety, and limitations. METHODS: A comprehensive literature search was completed to identify papers that examined the efficacy and safety of FESD for ZD. Demographic, clinical, and technical information was retrieved. Main outcomes were extracted, pooled, and analyzed. Heterogeneity among studies was assessed using the I(2) statistic. A random effect model was used as the pooling method in cases of high heterogeneity; otherwise the fixed effect model was applied. Meta-regression was also performed. Main outcomes such as rates of success, adverse events, and recurrences were evaluated. RESULTS: Twenty studies with a total of 813 patients were selected. The pooled success, adverse events, and recurrence rates were 91% (95% confidence interval [CI], 86%-95%; I(2) = 69.5%), 11.3% (95% CI, 8%-16%; I(2) = 64%), and 11% (95% CI, 8%-15%; I(2) = 38.4%), respectively. Substantial heterogeneity across studies was found. However, for success rates, excluding 3 studies reduced heterogeneity to non-significant rates [I(2) = 25.6%; P = .154]. Adverse event rates decreased with larger samples (coefficient, -0.0123; 95% CI, -0.03 to -0.003; P = .017), whereas recurrence rates increased (coefficient, 0.006; 95% CI, -0.0010 to 0.0125; P = .093). Year of publication was negatively associated with success rate, whereas the opposite pattern was found for recurrence rates. CONCLUSIONS: FESD is a feasible, safe, and effective treatment for symptomatic ZD, with low adverse event and recurrence rates.

Esophageal diverticula and cancer.

Esophageal diverticula are rare. The association of cancer and diverticula has been described. Some authors adopt a conservative non-surgical approach in selected patients with diverticula whereas others treat the symptoms by diverticulopexy or myotomy only, leaving the diverticulum in situ. However, the risk of malignant degeneration should be may be taken in account if the diverticulum is not resected. The correct evaluation of the possible risk factors for malignancy may help in the decision making process. We performed a literature review of esophageal diverticula and cancer. The incidence of cancer in a diverticulum is 0.3-7, 1.8, and 0.6% for pharyngoesophageal, midesophageal, and epiphrenic diverticula, respectively. Symptoms may mimic those of the diverticulum or underlying motor disorder. Progressive dysphagia, unintentional weight loss, the presence of blood in the regurgitated material, regurgitation of peaces of the tumor, odynophagia, melena, hemathemesis, and hemoptysis are key symptoms. Risk factors for malignancy are old age, male gender, long-standing history, and larger diverticula. A carcinoma may develop in treated diverticula, even after resection. Outcomes are usually quoted as dismal because of a delayed diagnosis but several cases of superficial carcinoma have been described. The treatment follows the same principals as the therapy for esophageal cancer; however, diverticulectomy is enough in cases of superficial carcinomas. Patients must be carefully evaluated before therapy and a long-term follow-up is advisable.

Endoscopic treatment of Zenker's diverticulum by harmonic scalpel.

BACKGROUND: Zenker's diverticulum (ZD) is a rare condition with a reported prevalence of 0.01% to 0.11% in the general population. Endoscopic treatment consists of the division of the septum between the diverticulum and the esophagus, within which the cricopharyngeal muscle is contained. Diathermic monopolar current, argon plasma coagulation, and laser have been used to incise the muscular septum with satisfactory results. The main limitation of endoscopic treatment is the occurrence of complications. Perforation and hemorrhage are reported in as many as 23% and 10% of patients, respectively. OBJECTIVE: The aim of this study was to use the technique of endoscopic diverticulotomy by using a harmonic scalpel in patients with ZD and to demonstrate the feasibility of using flexible and rigid devices in ZD treatment. DESIGN: Case series study. Standard protocol was used for patient management, endoscopic procedure, and data collection. SETTING: Single endoscopist demonstrating preliminary results. PATIENTS: Five patients (4 men; median ± standard deviation [SD] age 69.6 ± 9.06 years, range 59-83 years) with ZD were treated with this technique. All patients reported dysphagia and halitosis. The diagnosis was based on clinical, endoscopic, and radiographic findings. INTERVENTIONS: All patients received general anesthesia and were placed in the left lateral position. A standard videogastroscope (9.8 mm) and a stiff guidewire were used to insert and achieve an adequate exposure of the ZD septum. The septum was divided using a harmonic scalpel under thin endoscope (5.2 mm) visualization through a soft diverticuloscope. MAIN OUTCOME MEASUREMENT: Feasibility of an endoscopic technique by using rigid and flexible devices to treat ZD. RESULTS: Four patients (80%) were successfully treated in 1 session. The median ± SD size of the diverticulum was 3.6 ± 0.89 cm (range 3-5 cm). Median ± SD procedure time was 17.33 ± 2.33 minutes (range 15-20 minutes) in 6 procedures. No hemorrhage or perforation occurred. One patient (20%) required a second session to complete dissection of the ZD septum. All patients demonstrated improvement of dysphagia score after treatment. LIMITATIONS: Small case series design. CONCLUSIONS: Endoscopic treatment of ZD by harmonic scalpel through a soft diverticuloscope was feasible and effective in this small case series. Larger studies are warranted to further evaluate this technique.

Divertículo de Zenker associado ao carcinoma espinocelular: relato de caso / Zenker's diverticulum related squamous cell carcinoma: Case report

O divertículo faringoesofagiano de Zenker é doença rara, sendo a endoscopia digestiva alta exame fundamental para excluir malignização. Relata-se caso de paciente de 73 anos, masculino, com divertículo volumoso. Após um ano, evoluiu com lesão vegetante em mucosa diverticular, do tipo carcinoma espinocelular pouco diferenciado. Apresentou metástase cervical bilateral e crescimento importante do tumor, impossibilitando a ressecção cirúrgica, sendo indicado tratamento radioterápico. Destacamos a importância da valorização de pequenos sintomas, do acompanhamento médico dos divertículos já diagnosticados, bem como tratamento adequado.

Tratamento clínco de perfuração esofágica após tratamento endoscópico de divertículo de Zenker: relatro de caso / Clinical treatment of esophageal perforation after endoscopic treatment for Zenker

O divertículo de Zenker é uma alteração da anatomia esofágica que acomete adultos de idade avançada, caracterizadao pela presença de um divertículo posterior, proximal ao músculo cricofaríngeo. De forma precoce, apresenta-se como disfagia transitória e, como o evoluir da doença, como sensação de massa no pescoço e regurgitação. seu tratamento pode ser realizado por endoscopia flexível ou por correção cirúrgica através de miotomia cricofaríngea com diverticulectomia. O objetivo deste trabalhoo é relatar uma possível complicação do tratamento do divertículo de Zenker por endoscopia flexível. Descreve-se o caso de uma paciente feminina, 83 anos, portadora de divertículo de Zenker com início da sintomatologia havia seis meses, submetida a diverticulotomia endoscópica e que algumas horas após o procedimento evoluiu dor e efisema subcutâneo bilateral em região cervical. Esofagografia com contrate iodado evidenciou extravasamento em região cervical. Foi então, instituido manejo conservador, com alta hospitalar assintomática no sexto dia pós-procedimento. Portanto, apesar de considera modalidade de tratamento segura, a diverticulotomia endoscópica não é isenta de riscos

Carcinoma epidermoide en divertículo de Zencker / Squamous cell carcinoma in Zencker's diverticulum

La irritación crónica de la mucosa de los divertículos faringoesfágicos puede conducir a la displasia y a la degeneración neoplásica pero es un hecho raro de ver. Se presenta el caso de un paciente de 62 años con un divertículo de Zencker con cuatro años de sintomalogía al que en el estudio se le detecta un carcinoma epidermoide del fondo. Fue operado mediante una simple diverticulectomía, encontrándose una lesión intramural pequeña y sin adenopatías (estadio IIA) de bajo grado (G2)

Divertículo de Zenker / Zenkerïs diveticulum

En el presente trabajo se detalla brevemente la fisiopatología, diagnóstico y tratamiento del divertículo de Zenker. Se muestra la experiencia de los autores en relación al tratamiento quirúrgico de esta patología, de manejo no habitual por los otorrinolaringólogos

Divertículos faringoesofágicos: tratamiento quirúrgico / Pharyngo-esophageal diverticulum: surgical treatment

Se presenta una serie de 61 pacientes portadores de divertículos faringoesofágicos a los que se le realizaron 63 operaciones entre enero de 1964 a junio de 1993. En cuatro oportunidades fueron por recidivas, de las que dos fueron propias. Se discute la táctica quirúrgica de utilidad de la sección del músculo cricofaríngeo. En la serie la diverticulectomía más miotomía fue la operación más frecuente con 43 casos (68,2 por ciento). En la actualidad preferimos la sutura mecánica como cierre en la diverticulectomía. No hubo mortalidad operatoria. La morbilidad fue del 12,6 por ciento. Se pudo controlar al 64,8 por ciento con más de tres años de operados, donde se detectaron dos recidivas el 5,7 por ciento (AU)

Divertículos faringoesofágicos: tratamiento quirúrgico / Pharyngo-esophageal diverticulum: surgical treatment

Se presenta una serie de 61 pacientes portadores de divertículos faringoesofágicos a los que se le realizaron 63 operaciones entre enero de 1964 a junio de 1993. En cuatro oportunidades fueron por recidivas, de las que dos fueron propias. Se discute la táctica quirúrgica de utilidad de la sección del músculo cricofaríngeo. En la serie la diverticulectomía más miotomía fue la operación más frecuente con 43 casos (68,2 por ciento). En la actualidad preferimos la sutura mecánica como cierre en la diverticulectomía. No hubo mortalidad operatoria. La morbilidad fue del 12,6 por ciento. Se pudo controlar al 64,8 por ciento con más de tres años de operados, donde se detectaron dos recidivas el 5,7 por ciento