Surgical treatment for Zenker’s diverticulum: comparison between diverticulectomy and diverticulopexy

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 matter of debate. The aim of this study is to compare the results of diverticulectomy and diverticulopexy after cricopharyngeal myotomy, in homogeneous groups of patients.

Methods

Thirty-seven patients were treated for Zenker’s diverticulum at the same university medical school, but in two different units, with open cricopharyngeal myotomy, associated with diverticulectomy in 17 patients and with diverticulopexy in the remaining. No clinical criteria influenced the different choice of treatment of the diverticular pouch, but only the surgeon’s preference. Clinical data, diverticulum size, postoperative course, and complications were analyzed. Patients were followed up for median duration of 37 months (range 12–113 months) through contrast swallow study and clinical evaluation, aided by a specifically conceived questionnaire. Records were analyzed by Mann–Whitney–Wilcoxon test and Fisher’s exact test.

Results

Homogeneous comparative values for sex, age, diverticulum size, and symptoms were found in the two groups. Statistical analysis indicated that diverticulopexy, as compared with diverticulectomy, allowed reduced postoperative complications and slightly improved long-term swallowing.

Conclusions

Diverticulopexy is feasible also in large Zenker’s diverticula and can achieve equivalent or even better results than diverticulectomy with a smoother postoperative course.

     

Clinical utility of cricopharyngeal distensibility measurements during endoscopic myotomy for Zenker’s diverticulum

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Techniques and efficacy of flexible endoscopic therapy of Zenker’s diverticulum

Zenker’s diverticulum(ZD) is an abnormal hypopharyngeal pouch often presenting with dysphagia. Treatment is often sought with invasive surgical management of the diverticulum being the only mode of definitive therapy.Primarily done by an open transcervical approach in the past, nowadays treatment is usually provided by otolaryngologists using a less invasive trans-oral technique with a rigid endoscope. When first described, this method grew into acceptance quickly due to its similar efficacy and vastly improved safety profile compared to the open transcervical approach. However, the main limitation with this approach is that it may not be suitable for all patients. Nonetheless, progress in the field of natural orifice endoscopic surgery over the last 10-20 years has led to the increase in utilization of the flexible endoscope in the treatment of ZD. Primarily performed by interventional gastroenterologists, this approach overcomes the prior limitation of its surgical counterpart and allows adequate visualization of the diverticulum independent of the patient’s body habitus. Additionally, it may be performed without the use of general anesthesia and in an outpatient setting, thus further increasing the utility of this modality, especially in elderly patients with other comorbidities. Today, results in more than 600 patients have been described in various published case series using different techniques and devices demonstrating a high percentage of clinical symptom resolution with low rates of adverse events. In this article, we present our experience with flexible endoscopic therapy of Zenker’s diverticulum and highlight the endoscopic technique, outcomes and adverse events related to this minimally invasive modality.     

Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study

Esophagus - Peroral endoscopic myotomy for the treatment of Zenker’s diverticulum (Z-POEM) is a novel technique that has been described in several recent reports. This method utilizes the...     

A case of intussuscepted Meckel’s diverticulum

We report colonoscopic features of an intussuscepted Meckel's diverticulum, presenting with hematochezia.A 35-year-old woman presented to the emergency room with acute onset, transient, sharp, severe epigastric pain that began 6 h earlier. Colonoscopy revealed a reddish, soft, fist-sized polypoid lesion in the terminal ileum. The lesion was misinterpreted as a hematoma by an inexperienced endoscopist. The patient began to complain of intermittent, severe periumbilical pain following the colonoscopic examination.Subsequent computed tomography showed an enteric intussusception. An exploratory laparotomy revealed an intussuscepted Meckel's diverticulum, with transmural infarction. Colonoscopy was of little use in assessing the intussusception. However, colonoscopic examination may be performed initially, especially in an intussuscepted Meckel's diverticulum presenting with hematochezia. Endoscopists should note the endoscopic features of an intussuscepted Meckel's diverticulum.     

Direct observation of Young’s double-slit interferences in vibrationally resolved photoionization of diatomic molecules

Vibrationally resolved valence-shell photoionization spectra of H₂, N₂ and CO have been measured in the photon energy range 20–300 eV using third-generation synchrotron radiation. Young’s double-slit interferences lead to oscillations in the corresponding vibrational ratios, showing that the molecules behave as two-center electron-wave emitters and that the associated interferences leave their trace in the angle-integrated photoionization cross section. In contrast to previous work, the oscillations are directly observable in the experiment, thereby removing any possible ambiguity related to the introduction of external parameters or fitting functions. A straightforward extension of an original idea proposed by Cohen and Fano [Cohen HD, Fano U (1966) Phys Rev 150:30] confirms this interpretation and shows that it is also valid for diatomic heteronuclear molecules. Results of accurate theoretical calculations are in excellent agreement with the experimental findings.     

Endoscopic treatment of Zenker’s diverticulum with the stag beetle knife (sb knife) – feasibility and follow-up

Background and aims: Flexible endoscopic treatment of symptomatic Zenker’s diverticulum (ZD) is an established treatment option. This study reports the first large cohort of ZD patients treated with the stag beetle knife (sb knife, a new scissor-like device) regarding feasibility, safety, and sustainability of mucomyotomy using this technique.

Methods: From August 2013 to January 2016, n?=?52 patients (pts) were treated at Klinikum Augsburg, a tertiary referral center, with the sb knife junior or standard. For stability and safety, the septum is fixed with a soft overtube before intervention. Symptoms were analyzed before and at 1 and 6 months past intervention using an extensive questionnaire of dysphagia, odynophagia, regurgitation, chronic cough, state of health, and complications.

Results: The mean size of ZD was 3?cm (1–5?cm). Forty-seven out of 52 (90.4%) patients received one treatment session. The mean procedure time was 32?min (18–60?min). In 10 procedures (17%), a clip was placed at the bottom of the resection line. No major complications (e.g., perforation, mediastinitis) occurred. Five patients (9.6%) required a second treatment after a mean of 7 months (3–13) due to symptomatic recurrence. One patient was lost to further follow-up after one month with no or rare complaints. One patient had a third treatment (1.9%) without complications. During a mean follow-up of 16 months (2–31), the dysphagia score improved from 2 (1–4) prior of treatment to 1 (0–4), odynophagia, regurgitation, and chronic cough were no longer reported in the asymptomatic patients at all.

Conclusions: Flexible endoscopic treatment of ZD with the sb knife and overtube is effective, safe, and has lasting effects with a relatively low recurrence rate.     

Balloon-assisted enteroscopy for suspected Meckel’s diverticulum and indefinite diagnostic imaging workup

Meckel’s diverticulum (MD) is estimated to affect 1%-2% of the general population, and it represents a clinically silent finding of a congenital anomaly in up to 85% of the cases. In adults, MD may cause symptoms, such as overt occult lower gastrointestinal bleeding. The diagnostic imaging workup includes computed tomography scan, magnetic resonance imaging enterography, technetium 99m scintigraphy (99mTc) using either labeled red blood cells or pertechnetate (known as the Meckel’s scan) and angiography. The preoperative detection rate of MD in adults is low, and many patients ultimately undergo exploratory laparoscopy. More recently, however, endoscopic identification of MD has been possible with the use of balloon-assisted enteroscopy via direct luminal access, which also provides visualization of the diverticular ostium. The aim of this study was to review the diagnosis by double-balloon enteroscopy of 4 adults with symptomatic MD but who had negative diagnostic imaging workups. These cases indicate that balloon-assisted enteroscopy is a valuable diagnostic method and should be considered in adult patients who have suspected MD and indefinite findings on diagnostic imaging workup, including negative Meckel’s scan.     

Posttraumatic pseudo-Zenker’s diverticulum (with videos)

Zenker’s diverticulum (ZD) is the posterior pulsion diverticulum below the esophageal introitus. We describe a case of posttraumatic pseudo-ZD, its etiology and management. A 57-year-old man with schizophrenia complained of sore throat and dysphagia. He believed that he had a foreign body (FB) in his throat and routinely swallowed various objects trying to push it down. As a result of repeated trauma, he was found to have an active laryngeal ulcer, a pseudo-ZD with a large fibrous polyp and a linear ulcer along the posterior upper esophagus. Intervention included endoscopic polypectomy within the diverticulum, removing sharp objects, and behavioral modifications. Two months later, his sore throat and dysphagia resolved. Repeat endoscopy revealed complete ulcer healing. Unfortunately, he still believes that there is an FB inside his throat. The potential complications related to repeated traumatic injury in the larynx and esophagus include perforation, ulceration, formation of pseudo-ZD and reactive fibrous polyps.     

Squamous cell carcinoma after radiofrequency ablation for Barrett’s dysplasia

Barrett’s oesophagus(BO)is a usually indolent condition that occasionally requires endoscopic therapy.Radiofrequency ablation(RFA)is an effective endoscopic treatment for high grade dysplasia(HGD)and intramucosal cancer in BO.It has a good efficacy,durability and safety profile although complications can occur.Here we describe a case of RFA in a patient with high grade dysplasia.Although the response to treatment was initially very good with the development of neosquamous epithelium,the patient very rapidly developed a squamous cell cancer of the oesophagus confirmed on radiology,histology and immunohistochemistry.Sanger sequencing confirmed that the original HGD and the squamous cell cancer(SCC)were derived from separate clonal origins.The report highlights the fact that SCC of the oesophagus has been noted after endoscopic ablation for BO previously and suggest that ablation of BO may encourage the clonal expansion of cells carrying carcinogenic mutations once a dominant clonal population has been eradicated.     

Reiter’s syndrome during intravesical BCG therapy for bladder carcinoma

A 50-year-old male with superficial bladder carcinoma developed fever, conjunctivitis, cystitis, and arthritis of the ankles and metatarsophalangeal and sacroiliac joints after the fourth course of intravesical Bacillus Calmette-Guerin (BCG) therapy. Reiter’s syndrome in the context of BCG therapy was diagnosed, and intravesical immunotherapy was discontinued. Treatment with indomethacin was started with partial response, while a significant clinical improvement was noted when prednisolone 30 mg daily was started. One month later, the patient was on full clinical and laboratory remission, and steroid treatment was gradually tapered. Clinicians should be aware of this rare complication of BCG therapy because early diagnosis may lead to early management.     

Cricopharyngeal myotomy with flexible endoscope for Zenker’s diverticulum using hook knife and endoclips (with video describing an objective measurement of the cutting length)

Cricopharyngeal myotomy with flexible endoscope is a well-known and safe treatment for Zenker’s diverticulum. We describe hereafter how we perform this flexible endotherapy. From January 2011 to January 2017, we treated 28 patients with this endotherapy. Our technique is described step-by-step in the paper: the main principle is to perform an endoscopic cut of the diverticular septum and cricopharyngeal muscle’s fibers (see the video). We describe an objective measurement of the cutting length and depth of the myotomy. Technical success was achieved in all the patients. As to clinical success, 76.2% of patients showed a significant improvement and relevant disappearance of preoperative dysphagia. The present follow-up ranges from 6 months to 5 years. This flexible endoscopic technique can overcome some limitations of rigid endoscopic technique (i.e., upper teeth protrusion, inadequate jaw opening, or limited neck mobility). The main indication was based on clinical presentation and referred to the diverticular dimensions between 2 and 5 cm. Tips for the technique are described in the paper. This variant of cricopharyngeal myotomy with flexible endoscopy is feasible and effective for the treatment of Zenker’s diverticulum in selected patients.     

Fistula-associated anal carcinoma in Crohn’s disease

Introduction: Fistula-associated anal carcinoma in patients with Crohn’s disease (CD) is a rare condition. More recently, this entity has been increasingly reported likely due to increased recognition, and the incidence may be greater than once appreciated. There remains a paucity of data regarding the incidence, diagnosis, treatment, and outcome of fistula-associated anal carcinoma.

Area covered: This review evaluates the clinical features, pathology, treatment, and prognosis of fistula-associated anal carcinoma in patients with CD. A strategy for surveillance of this carcinoma is proposed by the authors based on the evidence obtained from this review.

Expert commentary: Clinicians caring for patients with CD and perianal involvement need to be aware of the rare yet extremely important association of long-standing perianal disease and fistula-associated carcinoma. Only through awareness, a high level of suspicion will be diagnosed in a timely manner. This involves a thorough history, a proper, and complete anorectal examination, along with early imaging and examination under anesthesia. Through this approach, it is hoped that early diagnose can be achieved in at-risk patients and change the significant morbidity and mortality associated with this diagnosis.     

Surface Electromyography in Preoperative Evaluation and Postoperative Monitoring of Zenker’s Diverticulum

Patients with Zenker’s diverticulum (ZD) underwent surface electromyography (sEMG) evaluation to determine sEMG patterns specific for ZD. Group 1 comprised patients with proven long-standing ZD that refused surgical treatment (n = 11, age mean = 55.7 years). Group 2 comprised surgically operated on patients with ZD (n = 6, age mean = 61 years). The timing, amplitude, and graphic patterns of activity of the masseter, submental, and laryngeal strap muscles were examined during voluntary single water swallows (“normal”), single swallows of excessive amounts of water (20 ml, “stress test”), and continuous drinking of 100 cc of water. The muscle activity in pharyngeal and initial esophageal stages of swallowing was measured, and graphic records were evaluated in relation to timing and voltage. The data were compared with the previously established normative database. The main sEMG patterns of ZD are (1) duration of swallowing and drinking is longer than normal (p < 0.05), (2) electric amplitude of laryngeal strap muscles during swallowing activity is higher than normal (p < 0.05), and (3) regurgitation peaks immediately after swallow followed by secondary swallow of the regurgitated portion of a bolus as seen at the sEMG records are specific graphic patterns for the ZD. Zenker’s diverticulum has its own specific sEMG patterns. Surface EMG, being an important screening method for patients with dysphagia, is a valuable additional diagnostic tool for ZD. Because it is noninvasive and nonradiographic, it can be used for monitoring of long-standing cases of the disease as well as monitoring of postsurgical recovery.     

Extramammary paget’s disease-epidermotrophic carcinoma of the anal region

Summary and Conclusions This is the fifteenth case of perianal extramammary Paget’s disease reported in medical literature (Table 1). Diagnosis by early biopsy, or repeated biopsies, and histochemical study of the tissues removed is necessary for accurate diagnosis. Treatment consists of wide local excision with follow-up biopsy examinations. Metastasis may be local or widespread.