Tratamiento quirúrgico del divertículo de Zenker; un caso clínico; Hospital Militar Central de La Paz (COSSMIL) gestión 2022 / Surgical treatment of Zenker's diverticulum, a Clinical Case Central Military Hospital of La Paz (COSSMIL) gestión 2022

Se presenta un caso clínico de una paciente de 66 años de edad masculino que acude a nuestro hospital (COOSMIL), después de hacer una anamnesis donde el paciente manifiestas molestias como tos, regurgitación y mal alientos (halitosis) y se le hace exámenes complementarios y se llega a un diagnóstico de divertículo faringo-esofágico o Zenker. Esta patología no es muy frecuente, pero se presenta en ancianos por una alteración anatomo-funcional que es un debilitamiento del músculo esofágico Hay tres divertículos esofágicos de los cuales el divertículo de Zenker es el más común aunque es relativamente raro que se presente, en la mayoría de las personas en edad seniles. Después de analizar el tamaño y forma del divertículo de este paciente se toma la decisión de una intervención quirúrgica el más acertado por el tamaño que mide es la diverticulectomia este tratamiento quirúrgico actualmente se continúa realizando en esta patología y con buen pronóstico de vida del paciente. Actualmente, el paciente se encuentra en buen estado salud y su recuperación es favorable desde la operación hasta el momento.

A case of a male patient of 66 years old was referred to our hospital (COSSMIL), after making an anamnesis in which the patient manifested cough, regurgitation and bad breath (halitosis). After further examination a the diagnosis is pharyngo-esophageal diverticulum or Zenker. This condition is rare, but sometimes it happens in elders due to an anatomical and functional alteration caused by is an esophagus muscle weakening. There are three esophageal diverticula in which the Zenker diverticulum is the most common but relatively rarely to occur in elder people. Before analyzing the size and shape of the diverticulum in this patient, the decision is proceed with surgery, the most recommended solution for measuring the size of the diverticulectomy. is The surgical treatment is still being applied in this pathology, with a high probability of success. Currently, the patient is in good health and the recovery from surgery is favorable so far.

Divertículo de Zenker / Zenker's Diverticulum

Introducción: Los divertículos de Zenker son los más frecuentes del esófago. El tratamiento quirúrgico más utilizado es la diverticulectomía con miotomía cricofaríngea abierta. Objetivo: Describir un paciente con diagnóstico de divertículo de Zenker cuya presentación fue la disfagia e infecciones respiratorias recurrentes. Presentación del caso: Describimos el caso de una paciente de 73 años con disfagia alta e infecciones respiratorias recurrentes, con el diagnóstico de divertículo de Zenker, a quien se le realiza diverticulectomía más miotomía. Conclusiones: El divertículo de Zenker o divertículo yuxtaesfinteriano faringoesofágico es una entidad de baja prevalencia que se presenta en pacientes entre los 50 y 70 años, predominantemente en los de sexo masculino. La radiografía contrastada del tracto digestivo superior y endoscopia determinan el diagnóstico en su mayoría y la diverticulectomía más cricomiotomía es la técnica más empleada(AU)

Introduction: Zenker's diverticula are the most frequent diverticula of the esophagus. The most commonly used surgical treatment is diverticulectomy with open cricopharyngeal myotomy. Objective: To describe a patient with a diagnosis of Zenker's diverticulum and whose presentation was dysphagia and recurrent respiratory infections. Case presentation: We describe the case of a 73-year-old female patient with high dysphagia and recurrent respiratory infections, with the diagnosis of Zenker's diverticulum, and who underwent diverticulectomy plus myotomy. Conclusions: Zenker's diverticulum or pharyngoesophageal juxtasphincteric diverticulum is a low-prevalence condition that occurs in patients between 50 and 70 years of age, predominantly in males. Contrast radiography of the upper digestive tract and endoscopy determine the diagnosis in the majority of cases, while diverticulectomy plus cricomyotomy is the most commonly used technique(AU)

Hybrid Sling for the Treatment of Concomitant Female Urethral Complex Diverticula and Stress Urinary Incontinence.

This study aims to present an alternative technique with the use of a transobturator hybrid sling (autologous fascia lata with a synthetic sling) in two patients with complex urethral diverticulum (CUD), urinary stress incontinence (SUI) and a large incisional infraumbilical hernia. Staged procedures could be performed, but considering the risk of persistence or worsening SUI, and no standard management strategy of SUI associated with CUD; simultaneous treatment was proposed. It is preferable to use autologous materials in such cases. However, the presence of incisional hernia protruded with its content covering the suprapubic area prohibits the retropubic sling technique due to visceral lesion risk. The diverticulum and SUI were repairs in the same surgery using a hybrid transobturator. The technique used for obtaining the fascia lata followed the literature, and a 6 cm segment was acquired. The patients were re-prepared in a lithotomy fashion, and diverticulectomy was performed. The segment of fascia lata was fixed to the mesh and sling was manipulated so that its middle part (fascia) rested directly below the urethra. After 6 months post-operatively, patients referred significant improvement in urinary symptoms. Patients have not had any storage symptoms, International Consultation on Incontinence Questionnaire - Short Form = zero, no SUI, and have not had any mesh-related complications. In conclusion, the present study evaluated a new technique for the treatment of CUD with SUI in a particular clinical scenario. Other studies with extended follow-up periods and larger sample sizes should be performed in this subset of patients.

Divertículo uretral en la mujer: diagnóstico y resección quirúrgica temprana / Female urethral diverticulum: early diagnosis and surgical resection

Resumen ANTECEDENTES El divertículo uretral es la formación de un saco entre la uretra y la vagina. El tratamiento, dependiente de los síntomas, puede ser conservador o quirúrgico. El primero consiste en la descompresión por aspiración, antibióticos profilácticos y dilatadores uretrales. Para el tratamiento quirúrgico existen diversas técnicas, su elección dependerá de la ubicación del divertículo. OBJETIVO Reportar el caso clínico de un padecimiento infrecuente y describir cómo se trató. CASO CLÍNICO Paciente de 59 años que acudió a consulta debido a una disuria severa de varios meses de evolución, asociada con aumento del volumen de la uretra distal, goteo postmiccional y dolor severo en la región vaginal. Se estableció el diagnóstico de divertículo uretral, se efectuó la escisión de la lesión y la evolución fue favorable. CONCLUSIONES El divertículo uretral es un diagnóstico poco frecuente y sospechado, por lo que debe haber un alto grado de sospecha en los cirujanos que intervienen esta área para evitar diagnósticos erróneos, reoperaciones innecesarias y complicaciones. Los tratamientos son variados según el tipo, lugar anatómico y síntomas de la lesión.

Abstract BACKGROUND The urethral diverticulum is the formation of a sac between the urethra and the vagina. The treatment, dependent on the symptoms, can be conservative or surgical. The first consists of aspiration decompression, prophylactic antibiotics and urethral dilators. For surgical treatment there are several techniques, their choice will depend on the location of the diverticulum. OBJECTIVE To report the clinical case of an infrequent condition that generates ignorance of the health professional to detect, treat and refer this type of patients. DESCRIBE The management of an uncommon case, reporting a favorable mediate and long-term postoperative evolution. CLINICAL CASE A 59-year-old patient attended the clinic due to a severe dysuria lasting several months, associated with an increase in the volume of the distal urethra, post-voiding drip, and severe pain in the vaginal region. Diagnosis of urethral diverticulum was made, and excision of the lesion was performed with favorable evolution. CONCLUSIONS The urethral diverticulum is a rare and suspected diagnosis, so there should be a high degree of suspicion in surgeons who address this area to avoid poor diagnosis, unnecessary reoperations and complications. The treatments are varied according to the type, anatomical location and symptomatology of the lesion.

ASSESSMENT OF MECHANICAL AND MANUAL SUTURE IN THE SURGICAL TREATMENT OF THE PHARYNGOESOPHAGEAL DIVERTICULUM / AVALIAÇÃO DA SUTURA MECÂNICA E MANUAL NO TRATAMENTO CIRÚRGICO DO DIVERTÍCULO FARINGOESOFÁGICO

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.

Racional: A ocorrência do divertículo faringoesofágico, ou de Zenker, é pouco frequente no cenário nacional, sendo que a técnica da diverticulectomia com cricomiotomia em divertículos de média e grandes dimensões ainda é a mais indicada. Devido à ressecção do divertículo necessitar de sutura da faringe ocorre possibilidade de deiscência, o que retarda o retorno da deglutição. Daí a ideia de realizar este procedimento cirúrgico, comparando a sutura manual com a mecânica, para avaliar o real benefício da técnica mecânica. Objetivo: Avaliar os resultados da diverticulectomia faringoesofágica com cricomiotomia utilizando à sutura manual e mecânica em relação às complicações locais e sistêmicas. Métodos: Foram estudados 57 pacientes com divertículos faringoesofágicos diagnosticados através da endoscopia digestiva alta e faringoesofagograma. A técnica cirúrgica empreendida foi a diverticulectomia com miotomia do músculo cricofaríngeo, sendo a sutura mecânica realizada em 24 pacientes (42,2%, grupo A) com o aparelho linear e em 33 (57,8%, grupo B) a manual para o fechamento da faringe. Resultados: Na avaliação do pós-operatório precoce, um paciente do grupo A (4,1%) apresentou fístula consequente à deiscência da sutura da faringe e três do grupo B (15,1%) ambos com boa evolução com tratamento conservador. Neste mesmo grupo, três pacientes (9,0%) apresentaram estenose da sutura da faringe, com boa evolução com dilatações endoscópicas sendo que nenhum do grupo A apresentou esta complicação. A infecção pulmonar esteve presente em cinco pacientes, dois (8,3%) do grupo A e três (9,0%) do grupo B, com boa evolução com tratamento específico. Na avaliação tardia, realizada em 43 pacientes, 17(94,4%) do grupo A e 22 (88,0%) do grupo B, os pacientes referiram estarem satisfeitos com o procedimento cirúrgico, pois conseguiram resgatar a deglutição normal. Conclusões: A diverticulectomia com a miotomia do cricofaríngeo demonstrou ser procedimento cirúrgico ...

Prolapso retal associado a divertículo vésico-uracal em gato / Rectal prolapse secondary to vesicourachal diverticula in a cat

A etiologia do prolapso retal está comumente relacionada às causas digestivas, sendo observado comumente em animais com diarréia e tenesmo graves. Diante da escassa literatura relatando causas não digestivas dessa patologia, o objetivo do presente trabalho é relatar um caso de prolapso retal recidivante em um felino apresentando divertículo vésico-uracal. Um gato, macho, 3 anos de idade veio para atendimento apresentando prolapso de reto recorrente, além de disúria e hematúria. No momento da colopexia, observou-se a presença de divertículo vesíco-uracal, que foi corrigido. Após o tratamento o felino voltou a urinar normalmente e não houve recidiva do prolapso retal. Os veterinários devem considerar as uropatias como possível causa de prolapso retal, principalmente em casos recorrentes ou que não haja história de diarréia ou outras causas de tenesmo.(AU)

The etiology of rectal prolapse is commonly associated to digestive causes, since it is usually observed in animals with severe diarrhea and tenesmus. There is limited literature reporting nondigestive causes of rectal prolapse, moreover the purpose of this case report is to describe a rectal prolapse in a cat, secondary to vesicourachal diverticula. A cat, male, 3 years old came to be attended at the veterinary hospital presenting recurrent rectal prolapse, dysuria and hematuria. During colopexy it was observed the presence of vesicourachal diverticulum which was immediately corrected. After treatment the cat returned to urinate normally and there was no recurrence of rectal prolapse. Clinicians should consider the possibility of uropathy as an underlying cause when presented with an cat with rectal prolapse, especially in cases of recurrence or when no history of diarrhea or other causes of faecal tenesmus is observed.(AU)

Prolapso retal associado a divertículo vésico-uracal em gato / Rectal prolapse secondary to vesicourachal diverticula in a cat

A etiologia do prolapso retal está comumente relacionada às causas digestivas, sendo observado comumente em animais com diarréia e tenesmo graves. Diante da escassa literatura relatando causas não digestivas dessa patologia, o objetivo do presente trabalho é relatar um caso de prolapso retal recidivante em um felino apresentando divertículo vésico-uracal. Um gato, macho, 3 anos de idade veio para atendimento apresentando prolapso de reto recorrente, além de disúria e hematúria. No momento da colopexia, observou-se a presença de divertículo vesíco-uracal, que foi corrigido. Após o tratamento o felino voltou a urinar normalmente e não houve recidiva do prolapso retal. Os veterinários devem considerar as uropatias como possível causa de prolapso retal, principalmente em casos recorrentes ou que não haja história de diarréia ou outras causas de tenesmo.

The etiology of rectal prolapse is commonly associated to digestive causes, since it is usually observed in animals with severe diarrhea and tenesmus. There is limited literature reporting nondigestive causes of rectal prolapse, moreover the purpose of this case report is to describe a rectal prolapse in a cat, secondary to vesicourachal diverticula. A cat, male, 3 years old came to be attended at the veterinary hospital presenting recurrent rectal prolapse, dysuria and hematuria. During colopexy it was observed the presence of vesicourachal diverticulum which was immediately corrected. After treatment the cat returned to urinate normally and there was no recurrence of rectal prolapse. Clinicians should consider the possibility of uropathy as an underlying cause when presented with an cat with rectal prolapse, especially in cases of recurrence or when no history of diarrhea or other causes of faecal tenesmus is observed.

Presentación de dos casos interesantes de divertículos epifrénicos operados por toracoscopia / Presentation of two interesting cases of epiphrenic diverticula operated on by thoracoscopy

El divertículo epifrénico es una enfermedad poco frecuente, pero constituye el 20 por ciento de los divertículos del esófago, y se consideran falsos porque están constituidos, fundamentalmente, por mucosa y submucosa, y se deben a trastornos de la motilidad esofágica e incoordinación del esfínter esofágico inferior. Su localización más frecuente es en los últimos 10 a 12 cm del esófago distal, por lo que muchos lo llaman supra diafragmáticos. Su síntoma fundamental es la disfagia, aunque en ocasiones cursan asintomáticos, sobre todo, los pequeños, y tienen indicaciones quirúrgicas precisas. Se presentan 2 pacientes operados en el Centro Nacional de Cirugía Endoscópica en los meses comprendidos entre noviembre de 2009 y marzo de 2010, con diagnóstico de divertículos esofágicos epifrénicos. Se muestran los complementarios para el diagnóstico, el proceder quirúrgico con la vía utilizada y las complicaciones(AU)

The epiphrenic diverticulum is an uncommon disease, but account for the 20 percent of esophageal diverticula and are considered as falses due to its constitution mainly by mucosa and submucosa and are provoked by esophageal motility disorders and no coordination of lower esophageal sphincter therefore called supradiaphragmatic. Its fundamental symptom is the dysphagia, although occasionally becomes asymptomatic mainly the small ones and have precise surgical prescriptions. Author present two cases operated on the National Center of Endoscopic Surgery during November, 2009 and March, 2010 diagnosed with epiphrenic esophageal diverticula. Complementary analysis for diagnosis, the surgical procedure and the route used as well as the complications are showed(AU)