Cricopharyngeal spasm and Zenker's diverticulum

An Atypical Zenker's Diverticulum: A Case Report

A Zenker's diverticulum (ZD) is an acquired hernia of the mucosa and submucosa at the pharyngoesophageal junction dorsally through Killian's triangle, considered a zone of weakness. The authors report their experience in the management of a case of a ZD with oral externalization following coughing. Surgery made by a multidisciplinary team consisted first of resection of the edematous exteriorized portion of the diverticulum. Second, endoscopic assistance helped to reduce the remaining portion of the diverticulum, and a right anterolateral cervicotomy allowed to remove it at the origin. Immediate and medium-term postoperative follow-ups were uneventful. Functional and endoscopic results were satisfactory. A ZD is a rare condition that can take confusing or even enigmatic forms, making it a real challenge in terms of management.

Zebras in Adult Dysphagia Workup: Where to Look When You Think You Have Looked Everywhere

While many patients who present with dysphagia have a clinically identifiable cause of dysphagia, the etiology of swallowing difficulty is oftentimes a diagnostic enigma. The aim of this article is to review possible etiologies of dysphagia when objective evidence of dysphagia is lacking. Included in this discussion are cricopharyngeal spasm, retrograde cricopharyngeal dysfunction, muscle tension dysphagia, dysphagia secondary to medications, and functional dysphagia.

Dysphagia in the Elderly

OPINION STATEMENT

Dysphagia is a common problem in the elderly population with an especially high prevalence in hospitalized and institutionalized patients. If inadequately addressed, dysphagia leads to significant morbidity and contributes to decreased quality of life. Dysphagia can be categorized as emanating from either an oropharyngeal or esophageal process. A disproportionate number of elderly patients suffer from oropharyngeal dysphagia with a multifactorial etiology. Historically, treatment options have been limited and included mostly supportive care with a focus on dietary modification, food avoidance, and swallow rehabilitation. Nascent technologies such as the functional luminal imaging probe (FLIP) and advances in esophageal manometry are improving our understanding of the pathophysiology of oropharyngeal dysphagia. Recent developments in the treatment of specific causes of oropharyngeal dysphagia, including endoscopic balloon dilations for upper esophageal sphincter (UES) dysfunction, show promise and are expected to enhance with further research. Esophageal dysphagia is also common in the elderly and more commonly due to an identifiable cause. The full breadth of treatment options is frequently unavailable to elderly patients due to comorbidities and overall functional status. However, the increasing availability of less invasive solutions to specific esophageal pathologies has augmented the number of treatment options available to this population, where an individualized approach to patient care is paramount. This review focuses on the evaluation and management of dysphagia in the elderly and delineates how standard and novel therapeutics are contributing to more nuanced and personalized management.

[Surgical treatment of esophageal diverticula : Endoscopic or open approach?]

Esophageal diverticula are comparatively rare. The majority are Zenker's diverticula but parabronchial and epiphrenic diverticula can also occur. Parabronchial diverticula are of low clinical relevance, whereas Zenker's and epiphrenic diverticula both belong to the group of pulsion diverticula and can become clinically apparent by dysphagia and regurgitation. Approximately 100 years after the first surgical treatment, peroral approaches (e.g. stapler dissection and flexible endoscopic diverticulotomy) have now achieved a certain level of importance. Both approaches are less invasive than the open approach but are evidently more prone to recurrences. Accordingly, traditional open diverticulectomy with cervical myotomy should be recommended to patients with a reasonable life expectancy and an acceptable operative risk. This holds particularly true for Brombart stages I-III of the disease, as complete myotomy cannot be achieved via the peroral access. The classical surgical treatment of epiphrenic diverticula is open or laparoscopic/thoracoscopic diverticulectomy with distal myotomy, mostly combined with an anterior partial fundoplication; however, the leakage rate is high and several alternative options are currently being evaluated.

Dysphagia in the elderly

Dysphagia, or difficulty swallowing, is a common problem in the elderly. Based on the initial clinical history and physical examination, the dysphagia is assessed as either primarily oropharyngeal or esophageal in origin. Most oropharyngeal dysphagia is of neurologic origin, and management is coordinated with a clinical swallow specialist in conjunction with an ear, nose, and throat (ENT) physician if warning signs imply malignancy. Several structural and functional esophageal disorders can cause dysphagia. If a patient has likely esophageal dysphagia, a video barium esophagram is a good initial test, and referral to a gastroenterologist is generally warranted leading to appropriate treatment.

Upper esophageal sphincter dysfunction: diverticula-globus pharyngeus

The following discussion of upper esophageal sphincter dysfunction includes commentaries on the role of the cricopharyngeus muscle in reflux disease; the etiology and treatment of Zenker diverticulum; the use of videofluoroscopy in patients with dysphagia, suspicion of aspiration, or globus; the role of pH-impedance monitoring in globus evaluation; and treatment for reflux-associated globus.

Zenker's diverticulum: aetiopathogenesis, symptoms and diagnosis. Comparison of operative methods

Zenker’s diverticulum is an alimentary tract pouch localized in the area of the upper esophageal sphincter. Treatment procedure complications and coexisting diseases constitute a serious diagnostic and therapeutic problem. Characteristic symptoms and signs facilitate differential diagnosis, simultaneously being real patient maladies. There are many treatment procedures leading to pouch septum reduction and decrease of upper esophageal sphincter pressure. After years of experience in operating and endoscopic treatments we found it necessary to compare these different methods.

Flexible endoscopic and surgical management of Zenker's diverticulum

Zenker's diverticulum is an outpouching of the mucosa through the Killian's triangle. The etiology of Zenker's diverticulum is not well understood. It is thought to be due to the incoordination or incomplete relaxation of the cricopharyngeal muscle. Most patients are men who present with symptoms of dysphagia between the seventh and eighth decades of life. The diagnosis is made with a dynamic contrast swallowing study. Treatment options include open surgical diverticulectomy and diverticulopexy with myotomy or myotomy alone using flexible or rigid endoscopes. Rigid endoscopic treatment is currently the preferred initial choice for Zenker's diverticulum of any size. The flexible endoscopic technique is used when there is a high risk of general anesthesia, or neck extension is contraindicated. Some centers use flexible endoscopy as the initial treatment option. Due to a lack of prospective studies, the treatment choice should be tailored to the individual patient and local expertise.

Modern pathophysiology and treatment of esophageal diverticula

INTRODUCTION

Esophageal diverticula are rare. They may occur in the pharyngoesophageal area (Zenker's), midesophagus, or distally (epiphrenic). A motility disorder (either at the level of the esophageal sphincters or body) is frequently associated with esophageal diverticula. The risk of malignant transformation is low.

METHODS

A literature search was performed using Medline/PubMed database.

RESULTS

The treatment of esophageal diverticula must be based on the pathophysiology and natural history of the disease: (a) asymptomatic diverticula do not need a specific treatment, (b) small diverticula may be left in place and not resected, (c) medium-size diverticula may be either treated by diverticulectomy, diverticulopexy, or esophagodiverticulostomy in case of pharyngoesophageal diverticula, (d) resection is probably the ideal therapy for larger diverticula, and (e) a myotomy should always be included to the procedure.

CONCLUSIONS

Due to its rarity, esophageal diverticula must be treated by esophageal surgeons since even in experienced hands the complication rate can be significant.

A 78-year-old man with difficulty swallowing

CP bar is an uncommon but important cause of dysphagia in elderly people. A CP bar is often undetected during upper endoscopy and might be missed with barium radiography if adequate attention is not focused on the hypopharynx. In suspected cases, evaluation for alternative etiologies of dysphagia is important because the CP bar might be an incidental finding. Secondary causes of CP dysfunction resulting from underlying primary myopathic or neuropathic disorders should be considered before therapy. The effectiveness of dilation and surgical myotomy in alleviating dysphagia associated with CP bars has been reported in small series.

Transoral treatment of Zenker diverticulum: flexible endoscopy versus endoscopic stapling. A retrospective comparison of outcomes

Transoral stapled diverticulo-esophagostomy (TSDE) has gained increased popularity in surgical treatment of Zenker diverticulum (ZD). One of the advantages of this approach is early rehabilitation with significant decrease in patient morbidity and time to resumption of oral intake as compared with open treatment. The section of the septum between the diverticulum and the esophagus with a flexible endoscopic (ES) approach has also been proposed since mid-90s as an alternative for treatment of ZD. Both these approaches are a minimally invasive approach to treat ZD. We compared the TSDE management of ZD versus the ES treatment in a retrospective consecutive series of patients who were referred to either the ES or surgical unit of our Institute. Fifty-eight consecutive patients underwent treatment for ZD either by TSDE or ES. The two techniques were evaluated for length of hospital stay, diverticulum size, resumption of oral intake, resolution of dysphagia, and complications. Clinical outcome was evaluated throughout a symptom score from 0 to 3, calculated before and after the procedure. The two groups were compared on the various parameters using a Mann--Whitney test. Twenty-eight patients underwent ES and 30 TSDE for ZD. In both groups, a significant decrease in postoperative versus preoperative dysphagia was reported. The average length of hospital stay wasn't significantly different in the two groups (3.38 days for TSDE vs. 2.42 days for ES). The overall complication rate was similar in the two groups. There were two cases in the ES group and three cases in the TDSE group that required an ES revision to take down a residual diverticular wall that produced a mild but persistent dysphagia. Minimally invasive treatment of ZD both with ES and with TSDE is a valuable option for this disease: both techniques are safe and effective, with similar outcome in terms of hospital stay, symptom reduction, and complication rate. Long-term results have to be evaluated.

Transoral resection of short segment Zenker's diverticulum and cricopharyngeal myotomy: an alternative minimally invasive approach

OBJECTIVES/HYPOTHESIS

Transoral treatment of cricopharyngeal bar and small Zenker's diverticulum remains a challenge. We propose a new transoral approach for transoral cricopharyngeal myotomy (TOCPM) for patients with cricopharyngeal spasm and pharyngeal bar, and for transoral resection of diverticula (TORD) with cricopharyngeal myotomy in the patient with small (<3 cm) Zenker's diverticulum.

METHODS

A retrospective review was conducted of 45 patients with cricopharyngeal spasm (21) and Zenker's diverticulum (24), where 14 patients were considered suitable for TORD and TOCPM. TOCPM used the Weerda laryngoscope (Karl Storz, Tuttlingen, Germany) to expose the cricopharyngeal bar using a microscope; the mucosa is cut and then the muscle is transected using monopolar cautery. A 0 degrees endoscope is inserted through the incision to ensure complete myotomy. Incision closure is by interrupted 4-0 Vicryl sutures (Ethicon Inc., Somerville, NJ) and fibrin glue. For the TORD procedure, the diverticular sac is everted and then resected using scissors. Through the sac opening, the TOCPM is completed. The sac opening is then closed as described in TOCPM. The patients are kept without food for 24 hours, followed by feeding and discharge. Modified barium swallow (MBS) evaluated functional results.

RESULTS

Fourteen patients underwent TOCPM (eight), and TOCPM+TORD (six). There was one case of TOCPM that was aborted due to excessive bleeding, which prevented full myotomy. The rest did well. All were discharged the next day. Two poor results from the TOCPM and TOCPM+TORD group were due to poor esophageal motility. The remainder of patients had resolution of dysphagia and normalized MBS. No patient developed stricture or complications.

CONCLUSIONS

Short segment Zenker's diverticulum and cricopharyngeal bar can now be addressed completely with a transoral approach. Because there is complete closure of the mucosal incision, prolonged hospitalization can be avoided.

Pharyngeal adaptation in Zenker's diverticulum: the "faux pharyngoesophageal segment"

BACKGROUND

We have noticed a protrusion on the pharyngeal wall in patients with Zenker's diverticulum (ZD). The protrusion gives the appearance of a neo-pharyngoesophageal segment (faux-PES) and may represent an adaptation to protect the airway.

STUDY DESIGN

A case-control study.

METHODOLOGY

The fluoroscopic swallow studies of patients with ZD were compared with matched controls. Information regarding the presence and location of a faux-PES, true PES opening, pharyngeal constriction, and laryngohyoid elevation was compared.

RESULTS

The fluoroscopic swallow studies of 31 patients with ZD were compared with 31 controls. A faux-PES was found in 100 percent of ZD patients and in 0 percent of controls. The mean maximum opening of the faux-PES was 1.5 (+/-0.27) cm. The faux-PES was located 1 cm above the true PES below the entrance to the supraglottic airway. This is the optimal location for airway defense.

CONCLUSIONS

The faux-PES was identified in 100 percent of patients with ZD. The faux-PES may represent a physiologic adaptation to protect the airway from regurgitation out of a ZD.

Zenker's diverticula: pathophysiology, clinical presentation, and flexible endoscopic management

Zenker's diverticulum (ZD) is the most common type of diverticulum in the upper gastrointestinal tract. Most patients are elderly and present with symptoms of dysphagia. Serious complications include aspiration and malnutrition. The most common treatments are open surgical diverticulectomy with or without cricopharyngeal myotomy and rigid endoscopic myotomy. Recently, cricopharyngeal myotomy using flexible endoscopes has been described as a treatment option for symptomatic ZD. In this article we describe the pathophysiology, clinical presentation and review the techniques and outcome following flexible endoscopic management of Zenker's diverticulum.

An animal training model for endoscopic treatment of Zenker's diverticulum

BACKGROUND

Zenker's diverticulum (ZD) is an uncommon disease, which is typically treated surgically. The alternative to surgery is a diverticulotomy, performed endoscopically. Given the rarity of this condition, it is not possible to obtain training. There has been no animal model identified that resembles the disease in human beings.

OBJECTIVE

To present an animal model of ZD that resembles the disease in human beings.

DESIGN

We prospectively characterized the endoscopy, the radiography, and the histologic anatomy of the pharyngeal diverticulum in the pig.

SETTINGS

Domestic pigs scheduled for euthanasia underwent radiography and endoscopy and, after euthanasia, neck dissection of the pharyngeal diverticulum.

INTERVENTIONS AND METHODS

Thirteen consecutive animals were studied. Pictures were taken for the endoscopic view, as well as radiographies during barium swallow in 1 pig. The neck region was dissected, and the pharynx and the upper esophagus were extracted. The size of the diverticulum was measured, and the block was fixed in formalin. Fixed specimens were cut in the transverse and coronal axis, and pictures were taken. The septum between the diverticulum and the esophagus was reviewed microscopically.

RESULTS

The pharyngeal diverticulum measured an average of 2.7 cm (1.3-5 cm), depending on the size of the pig. From an endoscopic and radiologic perspective, the pig pharyngeal diverticulum is identical to a ZD. The septum contains muscle as well as fibrous tissue and fat. These anatomical characteristics closely resemble the anatomy in human beings.

CONCLUSIONS

We believe that we established an animal training model for the endoscopic treatment of ZD.

Dysphagia After Endoscopic Repair of Zenker's Diverticulum

OBJECTIVES/HYPOTHESIS

To determine whether patient outcomes after endoscopic staple-assisted diverticulectomy(ESD) were correlated with demographic or disease-specific patient characteristics.

STUDY DESIGN

Retrospective chart review with followup.

METHODS

A survey was sent to all eligible subjects who had undergone ESD from February 1995 to June 2004 to gather information about their postoperative weight, diet, dysphagia symptoms, distress, and overall satisfaction.

RESULTS

Thirty-five individuals responded(49% response rate) at a mean of 29 (range,3-83) months postoperative. There was a significant reduction in the following symptoms: food avoidance,regurgitation, dysphagia for pills, choking, coughing,difficulty finishing a meal, heartburn/reflux, and halitosis. There was no significant difference for dysphonia.Swallow-related distress had decreased from a preoperative level of 7.86 to 2.23 at follow-up (P <.001). Overall satisfaction with the surgery was high. There were no significant differences in outcome by any demographic characteristic, duration of preoperative symptoms, presence of gastroesophageal reflux disease, Zenker's diverticulum size, time since surgery,or number of surgeries. Ninety-one percent of subjects reported improvement in their swallowing after surgery, but 22% reported some decline since that time. Symptomatic subjects reported significantly higher swallow-related distress and lower satisfaction(P < .01). Preoperative variables were not correlated with a return of symptoms. Individuals who underwent multiple procedures had similar levels of benefit and satisfaction as those who underwent a single ESD procedure.

CONCLUSION

ESD results in high levels of patient satisfaction, significant reduction in postoperative symptoms, low levels of complications,and the opportunity to safely and successfully repeat the procedure if necessary.