Killian-Jamieson diverticulum: a case for open transcervical excision

Recurrent Laryngeal Nerve Intraoperative Neuromonitoring Indications in Non-Thyroid and Non-Parathyroid Surgery

Introperative nerve monitoring (IONM) of the recurrent laryngeal nerve (RLN) is a well-established technique to aid in thyroid/parathyroid surgery. However, there is little evidence to support its use in non-thyroid or non-parathyroid surgery. The aim of this paper was to review the current evidence regarding the use of IONM in non-thyroid/non-parathyroid surgery in the head and neck and thorax. A literature search was performed from their inception up to January 2024, including the term "recurrent laryngeal nerve monitoring". IONM in non-thyroid/non-parathyroid surgery has mainly been previously described in oesophageal surgery and in tracheal resections. However, there is little published evidence on the role of IONM with other resections in the vicinity of the RLN. Current evidence is low-level for the use of RLN IONM in non-thyroid/non-parathyroid surgery. However, clinicians should consider its use in surgery for pathologies where the RLN is exposed and could be injured.

Killian-Jamieson diverticulum: A rare cause of dysphagia

Pharyngoesophageal diverticula are a rare anatomical abnormality and are classified in 3 types based on the area of their protrusion: Zenker diverticulum is the most common, followed by Killian-Jamieson diverticulum and the rarest, Laimer diverticulum. We report a case of a 68-year-old man who presented to our clinic with a 3-year history of moderate anemia uncovered after routine blood tests, progressive dysphagia for solids and food bolus impactions resolved spontaneously. Upper endoscopy revealed a wide-mouthed diverticulum, measuring 2-3 cm, with normal mucosa and food residue inside, just below the upper esophageal sphincter, on the left side of the esophageal wall and also hiatal hernia with diffuse mucosal bleeding. Subsequent barium swallow study showed as well a 25 mm left-sided outpouching arising from the anterolateral wall of the proximal cervical esophagus, consistent with a Killian-Jamieson diverticulum. Killian-Jamieson diverticulum is a rare condition with a highly variable clinical presentation, most often reported symptoms being dysphagia, regurgitation and globus sensation.

Killian Jamieson Diverticulum, the Great Mimicker: A Case Series and Contemporary Review

OBJECTIVE

To assess barium esophagram (BAS) as a diagnostic marker for patients with Killian Jamieson diverticula (KJD).

METHODS

Prospective, multicenter cohort study of individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative. Patient demographics, comorbidities, radiographic imaging reports, laryngoscopy findings, patient-reported outcome measures (PROM), and operative reporting were abstracted from a REDCap database and summarized using means, medians, percentages, frequencies. Paired t-tests and Wilcoxon Signed Rank test were used to test pre- to post-operative differences in RSI, EAT-10, and VHI-10 scores. Diagnostic test evaluation including sensitivity, specificity, positive, and negative predictive value with 95% confidence intervals were calculated comparing BAS findings to operative report.

RESULTS

A total of 287 persons were enrolled; 13 (4%) patients were identified with confirmed KJD on operative reports. 100% underwent open transcervical excision. BAS has a 46.2% (95% confidence interval [CI]: 23.2, 70.9) sensitivity and 97.8% (95% CI: 95.3, 99.0) specificity in detecting a KJD and 50% (95% CI: 25.4, 74.6) positive predictive value but 97.4% (95%CI: 94.8, 98.7) negative predictive value. Preoperatively, patients reported mean (SD) RSI and EAT-10 of 19.4 (9) and 8.3 (7.5) accordingly. Postoperatively, patients reported mean (SD) RSI and EAT-10 as 5.4 (6.2) and 2.3 (3.3). Both changes in RSI and EAT-10 were statistically significant (p = 0.008, p = 0.03).

CONCLUSION

KJD are rare and represent <5% of hypopharyngeal diverticula undergoing surgical intervention. Open transcervical surgery significantly improves symptoms of dysphagia. BAS has high specificity but low sensitivity in detecting KJD.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2110-2115, 2023.

Distinguishing Killian-Jamieson diverticulum from Zenker's diverticulum

BACKGROUND

Killian-Jamieson diverticulum, which is a relatively rare pharyngoesophageal diverticulum, is difficult to distinguish from Zenker's diverticulum. Because major points of the relevant surgical procedures for these two entities differ, it is important to make an accurate diagnosis. We herein report a case of Killian-Jamieson diverticulum initially diagnosed as Zenker's diverticulum.

CASE PRESENTATION

A 56-year-old man complaining of discomfort during swallowing was diagnosed with pharyngoesophageal diverticulum. He was initially diagnosed with Zenker's diverticulum before surgery, but the diverticulum actually arose from the left side of the esophageal wall, at the level of the cricoid cartilage and below the cricopharyngeal muscle. We therefore ultimately diagnosed this case as Killian-Jamieson diverticulum during surgery, and were able to preserve the muscle above the diverticulum, which would normally have to be cut when treating a case of Zenker's diverticulum.

CONCLUSION

To make an accurate diagnosis, clinical and surgical findings are important to consider, including the location of the diverticulum and the relationship between the diverticula and cricopharyngeal muscles or between the diverticula, thyroid cartilage and cricoid cartilage.

Distinguishing Killian–Jamieson diverticulum from Zenker’s diverticulum

Background

Killian–Jamieson diverticulum, which is a relatively rare pharyngoesophageal diverticulum, is difficult to distinguish from Zenker’s diverticulum. Because major points of the relevant surgical procedures for these two entities differ, it is important to make an accurate diagnosis. We herein report a case of Killian–Jamieson diverticulum initially diagnosed as Zenker’s diverticulum.

Case presentation

A 56-year-old man complaining of discomfort during swallowing was diagnosed with pharyngoesophageal diverticulum. He was initially diagnosed with Zenker’s diverticulum before surgery, but the diverticulum actually arose from the left side of the esophageal wall, at the level of the cricoid cartilage and below the cricopharyngeal muscle. We therefore ultimately diagnosed this case as Killian–Jamieson diverticulum during surgery, and were able to preserve the muscle above the diverticulum, which would normally have to be cut when treating a case of Zenker’s diverticulum.

Conclusion

To make an accurate diagnosis, clinical and surgical findings are important to consider, including the location of the diverticulum and the relationship between the diverticula and cricopharyngeal muscles or between the diverticula, thyroid cartilage and cricoid cartilage.

Cricopharyngeus Muscle Dysfunction and Hypopharyngeal Diverticula (e.g., Zenker): A Multicenter Study

OBJECTIVE

To describe demographics and imaging and compare findings and symptoms at presentation in a large cohort of persons with cricopharyngeus muscle dysfunction (CPMD) with and without hypopharyngeal diverticula.

METHODOLOGY

Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeal Hypertonicity (POUCH) Collaborative. Patient survey, comorbidities, radiography, laryngoscopy findings, and patient-reported outcome measures (e.g., Eating Assessment Tool [EAT-10]) data were abstracted from a REDCap database and summarized using means, medians, percentages, and frequencies. Diagnostic categories were compared using analysis of variance.

RESULTS

A total of 250 persons were included. The mean age (standard deviation [SD]) of the cohort was 69.0 (11.2). Forty-two percent identified as female. Zenker diverticula (ZD) was diagnosed in 85.2%, 9.2% with CPMD without diverticula, 4.4% with a Killian Jamieson diverticula (KJD), and 1.2% traction-type diverticula. There were no differences between diagnostic categories in regard to age, gender, and duration of symptoms (p = 0.25, 0.19, 0.45). The mean (SD) EAT-10 score for each group was 17.1 (10.1) for ZD, 20.2 (9.3) for CPMD, and 10.3 (9.4) for KJD. Patients with isolated CPMD had significantly greater EAT-10 scores compared to the other diagnostic groups (p = 0.03).

CONCLUSION

ZD is the most common, followed by CPMD without diverticula, KJD, and traction-type. Patients with isolated obstructing CPMD may be more symptomatic than persons with ZD or KJD.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:1349-1355, 2023.

Per-oral endoscopic myotomy as treatment for Killian-Jamieson diverticulum

Killian-Jamieson diverticulum (KJD) is a rare type of esophageal diverticulum less commonly encountered compared with Zenker's diverticulum (ZD). Endoscopic approach for these diverticula has been rapidly evolving. Currently, a flexible endoscopic septum division is considered the first-line treatment for symptomatic ZD patients, however reported recurrence rates are over 10% according to recent literature. With the advent of submucosal tunneling technique established by per-oral endoscopic myotomy for achalasia, it has been applied to treat ZD named as Zenker's diverticulum per-oral endoscopic myotomy (Z-POEM) as a minimally invasive treatment. Although there are very few reports utilizing submucosal tunneling approach to KJD, we have opted to perform Z-POEM in order to safely perform complete dissection of the muscle septum while maintaining mucosal integration. Due to the difficulty of anatomical location of KJD, we created mucosal incision and subsequent submucosal tunnel directly at the level of the septum as opposed to creating a submucosal tunnel few centimeters proximal to the septum as being previously proposed. We report a case in which this technique was successfully performed with complete resolution of dysphagia without any adverse event. This technique permits to perform complete myotomies without the fear of causing perforation. Although larger cohorts are required to assess its safety and efficacy, Z-POEM to treat KJD seems to be promising.

Endoscopic diverticulotomy for Killian-Jamieson diverticulum: mid-term outcome and description of an ultra-short tunnel technique

Background and study aims  Killian-Jamieson Diverticulum (KJD) is a rarer and more recently described upper pharyngeal diverticulum than Zenker's diverticulum (ZD). KJD is more difficult to manage than ZD because it tends to extend lower into the upper mediastinum and the diverticulum neck is in close proximity to the recurrent laryngeal nerve. There is limited literature on KJD management and transcervical surgical diverticulectomy is the mainstay of therapy. Patients and methods  Here we describe two methods of endoscopic diverticulotomy to treat KJD - direct and tunneling diverticulotomy (with hypopharyngeal tunnel or ultra-short tunnel - the latter being our preferred technique). Results  This was a retrospective study including 13 consecutive patients between March 2015 and April 2018. Three patients received direct and 10 received tunneling diverticulotomy (7 with the hypopharyngeal tunnel and 3 with the ultra-short tunnel). All procedures were completed in 16 to 52 minutes. There was no incidence of bleeding, mediastinitis, or sign of recurrent laryngeal nerve injury. At follow up of 9 to 79 months (median 33), the clinical success rate was 92 % (12/13); 11 patients had complete symptom resolution (post-operative symptom score = 0) and one patient had near-complete symptom resolution (occasional residual dysphagia). One patient receiving direct myotomy had limited symptom relief (frequent residual dysphagia and occasional residual regurgitation), possibly related to incomplete myotomy. Conclusions  Endoscopic tunneling diverticulotomy is a feasible, safe, and effective method to treat KJD.

99mTc-Sestamibi Scintigraphy Reveals Parathyroid Adenoma Masquerading as Esophageal Diverticulum

ABSTRACT

A 74-year-old woman with primary hyperparathyroidism diagnosed from routine laboratory tests described symptoms of fatigue and difficulty with concentration. During surgical consultation, the cervical and thoracic spine MRI scans from the preceding 10-year period, performed for relapsing-remitting multiple sclerosis, were reviewed. In this clinical context, the slowly enlarging left upper paraesophageal lesion, reported as a lateral proximal esophageal (Killian-Jamieson) diverticulum, was reevaluated for a potential parathyroid adenoma. 99mTc-sestamibi SPECT/CT demonstrated focal uptake in the paraesophageal lesion with surgical resection, confirming it to be a large parathyroid adenoma.

Endoscopic observation of the palisade vessels in Killian-Jamieson diverticulum was useful for diagnosis and surgical treatment: a case report

Background

Killian–Jamieson diverticulum is a rare pharyngoesophageal diverticulum that arises below the cricopharyngeus muscle. Unlike the most common Zenker’s diverticulum, which requires cricopharyngeal and esophageal myotomy, diverticulectomy is sufficient for surgical treatment of Killian–Jamieson diverticulum. Thus, accurate preoperative diagnosis is indispensable for avoiding unnecessarily invasive surgery. Here, we report a case of Killian–Jamieson diverticulum in which endoscopic observation of the palisade vessels was useful for diagnosis and intraoperative endoscopy was effective in guiding surgical resection.

Case presentation

A 65-year-old woman complained of pharyngeal discomfort and increased coughing and was referred to our hospital with a diagnosis of a pharyngoesophageal diverticulum. Contrast esophagography and cervical computed tomography revealed a diverticulum measuring 3 cm in diameter on the left side of the cervix. The diverticulum was identified by endoscopy just below the palisade vessels, which represents the level of the upper esophageal sphincter, and was diagnosed as Killian–Jamieson diverticulum. She underwent diverticulectomy without cricopharyngeal and esophageal myotomy. After exposing the diverticulum under light from the endoscope and washing out the food residue inside endoscopically, the diverticulum was resected using the endoscope as a bougie so as not to narrow the esophagus. The postoperative course was uneventful, and she remains asymptomatic without recurrence or stenosis at 6 months after surgery.

Conclusions

Endoscopic observation of the palisade vessels in addition to esophagography can help diagnose Killian–Jamieson diverticulum and determine the optimal surgical procedure. Diverticulectomy can be performed intentionally and safely with the aid of intraoperative endoscopy.

Surgery for Killian-Jamieson diverticulum: a report of two cases

BACKGROUND

Killian-Jamieson diverticulum (KJD) is a rare diverticulum arising from a muscular gap in the anterolateral wall of the proximal cervical esophagus. The first choice of treatment for KJD remains controversial due to its rare incidence. Here, we report two cases of KJD for which we performed different surgery: diverticulectomy in one case and diverticulopexy in the other.

CASE PRESENTATION

Case 1 involved a 58-year-old woman presenting progressive pharyngeal discomfort for the past year. She was diagnosed as KJD using endoscopic and radiographic findings. She underwent diverticulectomy with cricopharyngeal and proximal esophageal myotomy. Staple line leakage developed at 1 month after surgery and was successfully treated conservatively. At 5 months after surgery, she was asymptomatic. Case 2 involved a 77-year-old woman presenting dysphagia for the past 2 years. She had a history of bilateral breast cancer and had hypertension, asthma, and osteoporosis. Taking her age and medical history into account, we selected diverticulopexy with cricopharyngeal and proximal esophageal myotomy. The postoperative course was uneventful. At 2 years after surgery, she remained free of dysphagia.

CONCLUSION

The first choice of surgery for KJD is diverticulectomy. In a high-risk patient, diverticulopexy is a reasonable treatment. We recommend the addition of myotomy as a part of any surgical treatment.

Presentation and Management of Killian Jamieson Diverticulum: A Comprehensive Literature Review

Objective:

To examine the clinical presentation, diagnostic evaluation, and management of Killian–Jamieson diverticula (KJD) through literature review.

Methods:

A comprehensive literature review was conducted through December 2018 using keywords Killian–Jamieson diverticula/diverticulum. Data extracted included clinical presentation, imaging characteristics, surgical management, and postoperative care.

Sources:

PubMed and Google Scholar.

Results:

Sixty-eight cases of KJD in 59 reports (29M:39F; median 58 years old) were identified for review. The most common presentation was dysphagia (n = 39), suspected thyroid nodule (n = 24) and globus (n = 14). The majority of KJD (n = 51) occur on the left, with rare reports of right side (n = 11) and bilateral (n = 5) presentation. Thirty-two cases describe surgical management: 22 utilizing a transcervical approach, with (n = 13) or without (n = 9) cricopharyngeal myotomy; and 10 reported endoscopic surgery. Diverticula managed transcervically averaged 3.8 cm in size in comparison to average 2.8 cm in the endoscopic group. Time to diet initiation after transcervical surgery averaged 4 days versus 2 days after endoscopic surgery. Complications were reported in 2/68 cases; both were diverticula recurrence after endoscopic surgery.

Conclusion:

Killian–Jamieson diverticula is a rare diagnosis that should be considered in the evaluation of dysphagia, globus, and also suspected thyroid nodule. When patient symptoms warrant intervention, a transcervical approach, with or without cricopharyngeal myotomy, is most commonly utilized. In recent years, an endoscopic approach has been presented as an alternative for smaller diverticula. Further understanding of the optimal treatment and postoperative management for KJD requires larger cohorts.

Level of Evidence:

4

Surgical treatment of Killian-Jamieson diverticulum: A case report and literature review

This study describes a patient with symptomatic Killian-Jamieson, a rare entity, successfully treated by cervical approach with diverticulum resection and esophagomyotomy.

Pharyngoesophageal diverticuli: diagnosis, incidence and management

PURPOSE OF REVIEW

Pharyngoesophageal diverticuli such as Zenker's diverticulum are relatively rare diseases that may have a significant impact on a patient's quality of life. Open surgical techniques have historically been the mainstay of treatment for Zenker's diverticuli and remain the preferred approach for many surgeons operating on Killian-Jamieson diverticuli (KJD) and pharyngoceles. However, advances in technology in recent decades have allowed for the development of successful endoscopic surgical techniques for the management of these conditions.

RECENT FINDINGS

Endoscopic management of Zenker's diverticulum with carbon dioxide laser-assisted diverticulotomy or endoscopic stapler-assisted diverticulostomy has gained wide acceptance in recent years. This is based on studies showing high rates of successful outcomes, low rates of complications and shorter operative time with an associated impact on overall cost and patient recovery. Endoscopic management of KJD and pharyngoceles has recently been described, but remains controversial with many surgeons preferring open surgical approaches for the ability to identify and protect the recurrent laryngeal nerve.

SUMMARY

Open and endoscopic techniques are accepted for the treatment of Zenker's diverticulum with open approaches remaining the traditional technique for management of non-Zenker's diverticulum. Further investigation of endoscopic approaches for management of KJD is necessary to assess safety and efficacy.

Endoscopic diverticulotomy with a stapler can be an effective and safe treatment for Killian-Jamieson diverticulum

Killian-Jamieson diverticulum (KJD) is a rarely encountered esophageal diverticulum which attributes to several symptoms. Clinically, KJD should be differentiated from the most common type of esophageal herniation, i.e., Zenker's diverticulum (ZD). The two diverticula may present in a similar fashion, and treatments have evolved from transcervical to a minimally invasive endoscopic approach in recent years. We present a case of an 88-year-old male with symptomatic esophageal diverticulum. Barium swallow esophagogram and flexible esophagoscopy demonstrated a large KJD with food debris retention. Endoscopic diverticulotomy using a stapler was performed successfully without injury to the recurrent laryngeal nerve (RLN). A literature review and discussion concerning etiology, clinical presentations, and radiographic characteristics of KJD was conducted, and comparison between open and endoscopic method for esophageal diverticulum was also carried out.

Simultaneously occurring Zenker's diverticulum and Killian-Jamieson diverticulum: case report and literature review

BACKGROUND

Pharyngoesophageal diverticula have many subtypes, with Zenker's diverticulum being the most common. First described in 1983, a Killian-Jamieson diverticulum is an outpouching in the anterolateral wall at the pharyngoesophageal junction. This is located inferiorly to the cricopharyngeus muscle, unlike Zenker's diverticula which occur superiorly. Killian-Jamieson diverticula are rare and are commonly misdiagnosed as Zenker's diverticula. Less than 30 reports of Killian-Jamieson diverticula have been described in the literature.

CASE REPORT

A 69-year-old man presented with a 2-year symptomatic history, and was found to have simultaneous Zenker's diverticulum and Killian-Jamieson diverticulum. He was treated successfully with open surgical excision of both pouches.

CONCLUSION

Zenker's diverticulum and Killian-Jamieson diverticulum are diagnosed using radiological studies and endoscopy. Their differentiation is important, as surgical management differs. This paper reviews the literature on Killian-Jamieson diverticula and the management options available.

Atypical Pharyngeal Pouch Arising Bilaterally between the Hyoid Bone and Thyroid Cartilage

Introduction. Pharyngoesophageal diverticuli are a common cause of dysphagia; they are associated with various morbidities and a decreased quality of life. There are several different types of the diverticuli, and they are divided based on the anatomical location of origin relative to the cricopharyngeal muscle; these include Zenker's, Killian-Jamieson's, and Laimer's diverticula. The authors present a unique case of pharyngoesophageal diverticulum that has not been previously described. Case Presentation. A 65-year-old male presented with a 12-month history of dysphagia and odynophagia for solids. Barium swallow revealed bilateral moderately sized diverticuli that altered in size during the different phases of swallow. CT scan of the neck with oral contrast further identified the anatomy of the diverticuli, arising between the hyoid bone and thyroid cartilage. Discussion. An external transcervical approach was utilised to successfully repair the diverticuli. Subsequent cricopharyngeal spasm was treated with botulinum toxin, and the patient recovered with no ongoing symptoms. The barium swallow study is a commonly utilised initial investigation as it is easy to perform and safe and has good diagnostic value. Definitive management usually involves either endoscopic or open surgery. This case depicts a unique case of a pharyngeal diverticulum arising between the hyoid bone and thyroid cartilage.

Rigid endoscopic LASER diverticulotomy for lateral pharyngoesophageal diverticuli: cases presentation and discussion

Killian-Jamieson diverticulum (KJD) is a rare cervical esophageal abnormality. Transcervical approach has been the main treatment modality to prevent recurrent laryngeal nerve (RLN) injury. We presented two cases of patients confirmed with KJD and were managed successfully under rigid endoscope. The new technique and idea were described in detail. Under rigid laryngoscope, the septum between the true esophagus lumen and diverticulum can be exposed clearly. A microscope equipped with CO₂ LASER system offered precise and focused point cutting energy to the septum. Several efforts were applied to prevent RLN injury in the cases descriptions. We use transnasal esophagoscope and eating assessment tool (EAT-10) for anatomic and functional result evaluation. Much improved symptoms of dysphagia and intact RLN function were observed. Under the assist of rigid laryngoscope and point-cutting CO₂ LASER, KJD diverticulotomy could be performed safely with little complication for patients refusing transcervical route.

Killian-Jamieson diverticulum: real-time sonographic findings

Killian-Jamieson diverticulum (KJD) is a pharyngoesophageal diverticulum that can be observed during a neck ultrasound examination. Because of its position, it is frequently misinterpreted as a thyroid nodule. We present a case of an incidental finding of KJD, where changes in shape during dynamic scanning led to the correct diagnosis, preventing from invasive procedures such as fine needle aspiration.

The Utility of Recurrent Laryngeal Nerve Monitoring During Open Pharyngeal Diverticula Procedures

OBJECTIVES

The recurrent laryngeal nerve is at risk of injury during open pharyngeal diverticula operations. The utility of recurrent laryngeal nerve (RLN) monitoring during these procedures was investigated.

METHODS

A retrospective chart review was performed of 8 open pharyngeal diverticulectomies completed between 2009 and 2014. Intraoperative RLN monitoring took place during all operations.

RESULTS

Open pharyngectomy and myotomy was successfully performed in all cases. In two cases the RLN was encountered outside of its normal course. The identity of the nerve was confirmed with electrical stimulation and normal EMG response. Vocal fold motion was preserved in all cases.

CONCLUSIONS

Use of intraoperative nerve monitoring in pharyngeal diverticula procedures may be beneficial, especially during open operations for Killian-Jamieson diverticulum (KJD) and large Zenker diverticulum (ZD), where the RLN is typically encountered outside of its normal course.

Clinical Conundrum: Killian-Jamieson Diverticulum with Paraesophageal Hernia

Killian-Jamieson diverticulum is a outpouching of the lateral cervical esophageal wall adjacent to the insertion of the recurrent laryngeal to the larynx and is much less common in clinical practice than Zenkers Diverticulum. Surgical management of Killian-Jamieson diverticulum requires open transcervical diverticulectomy due to the proximity of the recurrent laryngeal nerve to the base of the pouch. We present a case of a Killian-Jamieson diverticulum associated with a concurrent large type III paraesophageal hernia causing significant solid-food dysphagia, post-prandial regurgitation of solid foods, and chronic cough managed with open transcervical diverticulectomy and laparoscopic paraesophageal hernia repair with Nissen fundoplication.

Transcervical diverticulectomy for Killian-Jamieson diverticulum

Surgery for Killian-Jamieson diverticulum of the esophagus is scarcely reported in the literature owing to the rarity of this entity. This is a case report of such a diverticulum and a description of the transcervical diverticulectomy that we performed on a 49-year-old lady. The patient was investigated for symptoms of gastroesophageal reflux disease and was diagnosed with a left-sided Killian-Jamieson diverticulum.