Divertículo de Zenker. Visits. Download PDF. Eduardo Marín-López, Sergio Rojas Ortega. a 0. This item has received. Visits. Article information. Vol. Num. r Pages Full text access. Divertículo de Zenker. Visits. Download PDF. Eduardo Marín-López, Sergio Rojas Ortega. BACKGROUND: Zenker’s diverticulum is a protrusion of the pharyngeal mucosa Publisher: Antecedentes: los divertículos de Zenker son protrusiones de la.
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Department of General and Digestive Surgery. 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 to this day in a third-level hospital.
The most common clinical manifestations were dysphagia, regurgitation, syalorrhea, cough, and weight loss. All cases were diagnosed using an esophagogram. Zenker’s diverticulum was first described in by Ludlow 1.
It is a sac-like deformation in the posterior wall of the pharynx that develops in the posterior mid line between the thyropharyngeal and cricopharyngeal muscles, above the level of the upper esophageal sphincter. It is currently accepted that its origin is a primary dysfunction of the cricopharyngeal muscle, which cannot relax adequately and thus gives rise to a high pressure inside the pharynx when swallowing, and the formation of a secondary pulsion diverticulum.
Its exact nature remains unclear to this day, with discrepancies between numerous studies 2. Cricopharyngeal dysfunction and the presence of a sac condition the appearance of clinical manifestations.
Most frequent symptoms are dysphagia, regurgitation and halitosis, although it sometimes manifests as a swallowing noise or the presence of a neck lump 3. The current treatment of symptomatic Zenker’s diverticulum is surgery, approaching the diverticulum and cricopharyngeal muscle. The aim of this study was to describe the acquired experience with the diagnosis and treatment of Zenker’s diverticulum in a third-level hospital during a period of 20 years.
Clinical data were obtained from a review of clinical records. A descriptive statistical study was performed using the program SPSS Quantitative variables following a Gaussian model were defined by mean and range.
[Zenker’s diverticulum: election of surgical treatment and outcome. Case presentation].
For non-Gaussian variables median rather than mean values were used. Qualitative variables were defined by number of cases and percentage. After general anesthesia zenkef the patient is placed in the supine position with the neck rotated to the right. A left cervicotomy is performed over the anterior border of the sternocleidomastoideus muscle, displacing it laterally.
CASO DE DIVERTICULO DE ZENKER | Revista Clínica Española (English Edition)
The anterior portion of the homohyoideus muscle is retracted without cutting it. The superior and medium thyroideal vessels are ligated and cut. One proceeds to the identification of the left laryngeal recurrent nerve, avoiding its damage. After surrounding the cervical esophagus, the diverticulum and its neck are dissected following a cm myotomy of the cricopharyngeal muscle in most cases.
Finally, the resection of diverticulum is performed, and the esophageal wall is mechanically closed using GIA or hand sewed. A drain is placed in the surgical bed and the incision is closed. Dysphagia involved both solids and liquids. Regurgitation consisted of partially digested or non-digested food, increasing in the supine position.
Asymptomatic cases were incidentally diagnosed when undergoing an esophagogram for another reason. Esophageal manometry showed a high-pressure upper esophageal diverticjlo in all 3 patients who underwent this study.
In 2 patients an incomplete relaxation of the upper esophageal sphincter and pharynx-esophageal discoordination was also observed. A chest CT scan was performed in one case of aspirative pneumonia -it showed a dilated cervical esophagus suggesting Zenker’s diverticulum, which was confirmed by an esophagogram.
Most cases began oral feeding hours after surgery. Pathology did not reveal any case of carcinoma in association with Zenker’s diverticulum. Follow-up was performed for all operated patients 6 months after surgery. The only case of recurrence developed zneker one patient where a diverticulectomy without cricopharyngeal myotomy had been performed, who was again symptomatic 23 months after surgery.
A new diverticulectomy, associated in divertiuclo case with myotomy, was performed. Post-surgical complications included 1 case of upper esophageal stenosis 3 weeks after surgery, which was solved with endoscopic dilatations. One case presented with a transient recurrent nerve paralysis, which was treated with steroids. One patient developed a cervical abscess requiring surgical drain and antibiotics.
An esophageal fistula developed in 2 subjects conservatively managed with parenteral feeding. Zenker’s diverticulum is an infrequent pathology in young people, being considered an acquired entity.
Its usual development in advanced-age patients as described in the literature is consistent with our results 3. In spite of this, some authors have described a familiar aggregation 4. It is remarkable the predominance of this pathology among males in our series, which has already been described by other authors 5,6. Dysphagia, regurgitation and halitosis appeared as typical symptoms of Zenker’s diverticulum.
Weight loss could zsnker attributed to dysphagia, avoiding the patient oral feeding in many cases 5. The content of the diverticulum, when aspirated, causes aspirative pneumonia. The concurrence of both morbid conditions can be more probably attributed to coexistence in the same age range than to an association between them with a common pathogenetic base.
Barium esophagogram is the most used technique for the diagnosis of esophageal zejker, being the first one to perform in Zenker’s diverticulum. Esophagoscopy is the most direct method to establish the cause of mechanic dysphagia.
Moreover, there is a risk of penetration and perforation of Zenker’s diverticulum. This is the reason why it is considered as a second-choice technique, the previous performance of an esophagogram is advisable to help the endoscopist.
Anyway, endoscopy is used as the first-choice technique in experienced centers. Manometry registers the pressure in different places of the esophagus and determines changes in the upper esophageal sphincter 8.
No carcinoma associated with a diverticulum appeared in any of our cases. In all 23 operated patients in our study one patient underwent palliative gastrostomyopen diverticulectomy associated with cricopharyngeal myotomy was performed in most patients.
Some authors have reported a lower recurrence rate when myotomy is associated with diverticulectomy 10but there are very few comparative studies to confirm this hypothesis. Our experience reveals that the only patient who presented recurrence was one of the three cases undergoing diverticulectomy without myotomy. In our series all complications appeared in cases where myotomy was associated, except for the patient who suffered from a transient recurrent nerve paralysis, who had undergone diverticulectomy alone.
Konowitz and Biller 11 reported that diverticulopexy associated with cricopharyngeal myotomy is an alternative resulting in lower morbidity and shorter hospital stays when compared to diverticulectomy, with similar efficiency.
The diverticulum is sewn to the retropharyngeal fascia or spinal anterior ligament in this approach. Recently, endoscopic techniques are gaining lots of adepts. In this approach the surgeon cuts with electrocoagulation or an endostapler the mucosa and muscle tissues of the wall, thus separating the diverticulum’s lumen from the esophageal one.
The benefits of this technique include: Most dangerous complications were bleeding, pneumomediastinum, and mediastinitis, although they diverticul infrequent.
Other minor complications were sore throat, lacerations of the oral mucosa, transient paralysis of vocal cords, and a foreign-body sensation in cases where the endostapler was used. In such cases where recurrence takes place, endoscopic reoperation is feasible with no increase in morbidity In conclusion, Zenker’s diverticulum is a condition often resulting in mild symptoms, but interfering with quality of life; some times, however, it causes important manifestations weight loss, nutritional deficiency secondary to dysphagia or aspirative pneumonia that warrant treatment for all symptomatic diverticula.
An esophagogram is the technique of choice for diagnosis, although endoscopy by experienced hands is a useful alternative. The most widely used treatment in our medium is diverticulectomy associated with myotomy, with recurrence being associated with lack of myotomy.
A case of obstructed deglution from a preternatural dilatation of, and bag formed in, the pharynx. Med Observ Inq ; 3: Pharyngeal Zenker’s diverticulum is a disorder of upper esophageal sphincter opening. Evolution of surgical treatment for pharyngeal pouch. Br J Surg ; Pathogenesis of hypopharyngeal diverticulum with special reference to heredity. Acta Otolaryngol ; Flexible endoscopic treatment of Zenker’s diverticulum: Minimally invasive surgery for Zenker’s diverticulum: Arch Surg ; The pathogenesis of gastroesophageal reflux disease.
Oral and pharyngeal dysphagia. Gastroenterol Clin North Am ; Ann Otol Rhinol Laryngol ; How long should it be? Diverticulopexy and cricopharyngeal myotomy: Otolaryngol Head Neck Surg ; Endoscopic stapling vs conventional methods of surgery for pharyngeal pouches: IR Med J ; Endoscopic staple-assisted esophagodiverticulostomy for Zenker’s diverticulum. Endoscopic management of Zenker diverticulum: Am J Medicine ; Endoscopic Zenker’s diverticulum Dohlman procedure: Comparison of the endoscopic stapling technique with more established procedures for pharyngeal pouches: J Laryngol Otol ; Introduction Zenker’s diverticulum was first described in by Ludlow 1.
Surgical technique After general anesthesia induction the patient is placed in the supine position with the neck rotated to the right. Results Clinical data are described in table I.