Association between Zenker diverticulum and gastroesophageal reflux disease: development of a working hypothesis

Surgical Nonresponders in Zenker Diverticulum and Lower Esophageal Pathology (POUCH Collaborative)

OBJECTIVE

To identify characteristics of patients who have poor improvement in symptoms following surgical management of Zenker Diverticulum (ZD).

METHODS

Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgical repair of ZD between August 2017 and January 2024. Patient demographics, esophagrams, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were obtained from a REDCap database. t-tests, Wilcoxon rank sum tests, Chi-square or Fisher's exact tests were used to compare the characteristics. Patients with <50% improvement in their EAT-10 scores were deemed surgical nonresponders (SNRs). Those with ≥50% improvement in their EAT-10 scores were deemed surgical responders (SRs).

RESULTS

A total of 184 patients were prospectively followed after undergoing either open or endoscopic surgical management. Twenty-two patients (12%) were deemed SNRs. Preoperative presence of a hiatal hernia was statistically significant characteristic between the SNRs (63.6%) and SRs (32.1%) (p = 0.004). Size of the ZD and history of previous ZD surgery was not a significant characteristic. The length of stay and complication rate were not statistically different between the groups.

CONCLUSION

Coexistent esophageal pathology may lead to poor symptomatic improvement following ZD surgery. Preoperative workup of other esophageal disorders is recommended to detect likely SNRs. For SNRs, further esophageal workup may be necessary to evaluate for other esophageal causes related to poor symptomatic improvement following ZD surgery.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:4897-4902, 2024.

Rare Association of Killian-Jamieson Diverticulum and Peptic Stricture of the Esophagus: Is It Causal or Casual?

Killian-Jamieson diverticulum (KJD) is a rare esophageal diverticulum that arises from the anterolateral wall of the proximal cervical esophagus in the Killian-Jamieson space. Although rare presentations include dysphagia, globus sensation, or a suspected thyroid nodule, it is often asymptomatic. Treatment is indicated only in symptomatic cases. We report a 55-year-old female who had long-standing heartburn and presents now with dysphagia, weight loss, and anemia. Imaging and upper endoscopy revealed peptic stricture and an associated KJD. She underwent serial endoscopic dilatation of the peptic stricture and was symptomatically better afterwards. She is currently doing well on follow-up.

How to cite this article

Sirasapalli SK, Senthamizhselvan K, Mohan P. Rare Association of Killian-Jamieson Diverticulum and Peptic Stricture of the Esophagus: Is It Causal or Casual? Euroasian J Hepato-Gastroenterol 2023;13(1):32-35.

Transoral endoscopic repair of Zenker diverticulum by a thoracic surgical service

OBJECTIVE

Zenker diverticulum (ZD), a pulsion diverticulum of the esophagus, has been traditionally managed with an open surgical approach, but endoscopic transoral stapling has been reported with increasing frequency. The objective of this study was to evaluate the results of endoscopic repair of ZD by a thoracic surgery service.

METHODS

We conducted a retrospective review of patients who underwent transoral stapling repair of ZD at our institution by the thoracic surgery service. We evaluated perioperative outcomes including dysphagia (1, no dysphagia to 5, unable to swallow saliva) and failure of repair requiring surgical intervention.

RESULTS

A total of 151 patients (median age, 78 years; 75 men, 76 women) underwent evaluation for endoscopic repair of ZD. Endoscopic stapled repair of the ZD was completed in 135. Sixteen patients underwent conversion to open repair. The perioperative mortality was 0.6% (1 patient). The median hospital stay was 2 days (range, 0-18 days). Complications occurred in 5 patients who underwent endoscopic repair. The mean preoperative dysphagia score was 2.8 and improved to 1.2 during follow-up (median, 16 months; P < .001). During further follow-up (median, 52 months), 8 patients (5.3%) had failure of the endoscopic repair requiring open surgery (n = 5) or redo transoral stapling (n = 3).

CONCLUSIONS

Endoscopic stapling repair of ZD can be performed safely with good results in experienced centers by thoracic surgeons with significant esophageal experience. Long-term follow-up is required to evaluate the durability of endoscopic repair of ZD.

Epidemiology and Management of Zenker Diverticulum in a Low-Threshold Single-payer Health Care System

Importance

The incidence of Zenker diverticulum has been established; previous estimates have been extrapolated from small institutional cohorts.

Objective

To describe the population-wide incidence of Zenker diverticulum over a 20-year period and characterize management strategies across specialties and treatment settings.

Design, Setting, and Participants

This retrospective national cohort study was conducted from January 1, 1996, through December 31, 2015, and reviewed patient records from the Care Register for Healthcare in Finland, from which patients with Zenker diverticulum were identified. The data were analyzed in October 2021.

Exposures

Zenker diverticulum.

Main Outcome and Measure

The incidence of Zenker diverticulum per 100 000 person-years.

Results

A total of 2736 patients (median [IQR] age at diagnosis 72.0 [19-106] years; 1278 women [46.7%]) were identified, making the annual incidence of Zenker diverticulum in Finland 2.9/100 000 person-years. Men had higher incidence (3.7/100 000 person-years) compared with women (2.3/100 000 person-years), with an incidence rate ratio of 1.61 (95% CI, 1.48-1.76; P < .001). Within the study population, 1044 patients (38.2%) underwent surgical treatment and 227 (8.3%) underwent 2 or more surgeries. The choice of initial operative approach depended on the medical specialty (Cramer V = 0.41) and on specific catchment area (Cramer V = 0.41). Overall, endoscopic approaches for initial operations were most popular.

Conclusions and Relevance

The cohort study results found that the incidence of Zenker diverticulum was 2.9/100 000 person-years. Most patients with Zenker diverticulum did not undergo definitive therapy. Some hospital districts and some medical specialties were more likely to opt for conservative treatment than others. The choice of operative approach depended more on physician-level factors rather than patient profiles.

A Case of Zenker’s Diverticulum in a Patient with Tight Esophageal Peptic Stricture

Zenker’s diverticulum (ZD) is a posterior Sac like outpouching of the hypopharyngeal mucosa and submucosa through Killian’s triangle, which is an area of muscular weakness between the transverse fibers of the cricopharyngeus muscle and the oblique fibers of the lower inferior constrictor muscle. ZD usually presents with swallowing difficulties, regurgitation of undigested food, choking, halitosis, weight loss, and respiratory symptoms due to chronic aspiration. Several esophageal pathologies have been reported in association with ZD. These include cervical esophageal webs, upper esophageal stenosis, and hiatus hernia. Herein, we report a case of ZD in association with severe gastroesophageal reflux disease and tight lower esophageal peptic stricture.

Exteriorized Giant Zenker’s Diverticulum: Case Report

Zenker’s diverticulum (ZD) also known as cricopharyngeal (CP), pharyngoesophageal or hypopharyngeal diverticulum is an outpouching of mucosal and submucosal layers originated from the pharyngoesophageal junction. Radiological evaluation of deglutition, modified barium swallow radiography may reveal the retentive character of the diverticular sac and confirm the diagnosis. Many different types of surgical approaches have been developed over the decades with modifications focusing on the need to reduce intra-operative or post-operative complications and overall morbidity. The authors present the case of a 76-years-old woman with spontaneous apparition of an exteriorised tumor in the oral cavity after an excessive cough effort. Surgical treatment is elective, preventing the occurence of complications that may endanger the patients life and improve the quality of life. Surgical therapy was open neck resection of the Zenker’s diverticulum with esophageal myotomy and pharynx reconstruction.

Hypopharyngeal Diverticulum: Toward a Unified Understanding of Its Etiopathogenesis

The etiopathogenesis of Zenker's diverticulum (ZD) remains uncertain. Increased hypopharyngeal pressure due to a hypertonic upper esophageal sphincter results in herniation proximal to the sphincter producing a pulsion diverticulum. Gastroesophageal reflux, which is known to induce shortening of the injured esophagus, likely plays a prominent role in ZD formation by pulling the cricopharyngeus muscle (CPM) away from the anchored inferior constrictor muscle. This creates a "weak zone" encouraging herniation. A bilobed diverticulum may originate from continuation of the fibrous midline raphe inferiorly to developmentally include part of the CPM. We report using laser endoscopy to divide the inter-diverticular septum followed by transmucosal cricopharyngeus myotomy. Presentation of a rare, bilobed diverticulum emphasizes the importance of the midline prevertebral raphe in anchoring the pharyngeal constrictor muscles with respect to the CPM. This lends support to the hypothesis that the etiopathogenesis of ZD is multifactorial while guiding us to a unified understanding of ZD.

Why do Zenker's diverticulae occur more often on the left than the right side?

BACKGROUND

Zenker's diverticulum is a pharyngoesophageal outpouching of mucosa and submucosa through Killian's dehiscence.

OBJECTIVE

To investigate the propensity for Zenker's diverticulum to occur on the left side by examining muscle thickness in Killian's dehiscence, and to explore correlations between muscle thickness, sex, height and age.

METHODS

The study included 109 Caucasian cadavers, 52 male and 57 female. The mean thickest and thinnest measurements of left medial, left lateral, right medial and right lateral aspects of Killian's dehiscence were calculated. The paired student's t-test was used to determine significance.

RESULTS

The average left muscle layer was significantly thinner than the right muscle layer, in both medial and lateral aspects. Furthermore, medial muscle thickness was significantly thinner than its respective lateral aspect for both the left and right sides. No correlations were found between muscle thickness and cadavers' sex, length or stature, or age.

CONCLUSION

There was a significant difference in muscle thickness between the left and right sides of Killian's dehiscence. The findings suggest there is a reason why Zenker's diverticulum occurs predominantly on the left side. The study also showed a significant difference in muscle thickness between the medial and lateral aspects of Killian's triangle.

Gastroesophageal Reflux Disease Might Induce Certain-Supposedly Adaptive-Changes in the Esophagus: A Hypothesis

BACKGROUND

The increasing prevalence of GERD has become a major concern due to its major health and economic impacts. Beyond the typical unpleasant symptoms, reflux can also be the source of severe, potentially life-threatening complications, such as aspiration.

AIM

Our aim was to support our hypothesis that the human body may in some cases develop various protective mechanisms to prevent these conditions.

METHODS

Based on our experiences and review of the literature, we investigated the potential adaptive nature of seven reflux complications (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter, Zenker's diverticulum, Schatzki's ring, esophageal web, and Barrett's esophagus).

RESULTS

Patients with progressive GERD may develop diverse structural and functional esophageal changes that narrow the lumen of the esophagus and therefore reduce the risk of regurgitation and protect the upper aerodigestive tract from aspiration. The functional changes (hypertensive lower esophageal sphincter, achalasia, hypertensive upper esophageal sphincter) seem to be adaptive reactions aimed at easing the unpleasant symptoms and reducing acid regurgitation. The structural changes (Schatzki's ring, esophageal web) result in very similar outcomes, but we consider these are rather secondary consequences and not real adaptive mechanisms. Barrett's esophagus is a special form of adaptive protection. In these cases, patients report significant relief of their previous heartburn as Barrett's esophagus develops because of the replacement of the normal squamous epithelium of the esophagus by acid-resistant metaplastic epithelium.

CONCLUSION

We believe that GERD may induce different self-protective reactions in the esophagus that result in reduced acid regurgitation or decreased reflux symptoms.

Pharyngeal pouch management: an historical review

BACKGROUND

Management of the pharyngeal pouch has evolved enormously since the first description by Ludlow in 1764 and the first case series by Zenker and Von Ziemssen in 1877. With the introduction of antibiotics, and the advancement of surgical technique with the advent of endoscopic surgery and lasers, current management is vastly different to that in the nineteenth century.

OBJECTIVES

This paper traces the history of pharyngeal pouch management, and discusses the various treatment options and opinions recorded during the nineteenth and twentieth centuries, comparing these with techniques popular today.

RESULTS AND CONCLUSION

Pharyngeal pouch surgery has been associated with significant morbidity, both because of the elderly age of patients typically affected by the condition and because of the surgery itself and potential post-operative complications encountered. The historical development of pharyngeal pouch management and the understanding of pharyngeal pouch pathophysiology are discussed.

Endoscopic staple diverticulostomy for Zenker's diverticulum: review of experience in 337 cases

OBJECTIVE

Surgical treatment of Zenker's diverticulum (ZD) has evolved over the previous 2 decades to a predominantly endoscopic approach. In this study, we review our experience with endoscopic staple-assisted diverticulostomy (ESD) for treatment of ZD from 2002 to 2011.

METHODS

Retrospective chart review of 359 primary and revision ESD procedures performed on 337 unique patients between September 2002 and December 2011. Data were tabulated for age, sex, size of diverticulum, time to symptom recurrence, complications, and relief of symptoms.

RESULTS

Of 337 attempted primary ESD procedures, 3.9% (N = 13) were aborted due to inadequate exposure. Of 324 patients who underwent primary ESD, 93.8% (N = 304) reported postoperative improvement of dysphagia symptoms. There was a 4.0% (N = 13) major complication rate. Patient-reported recurrence of symptoms occurred in 7.1% (N = 23) of primary ESD patients but was not significantly associated with diverticulum size (P = .9765). Twenty-one patients underwent revision ESD, with 95% (N = 20) of patients reporting improvement and 4.8% (N = 1) developing recurrent symptoms.

CONCLUSION

Primary and revision ESD were shown to have similar success at relieving the symptoms of ZD, with low procedure abandonment and perioperative complication rates. Further patient follow-up is needed to determine the durability of symptom improvement and ZD recurrence rate following ESD.

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.

Management of Zenker's diverticulum in the endoscopic age: current practice patterns

OBJECTIVES

Zenker's diverticulum (ZD) is a common source of dysphagia with a well-established surgical treatment history. Variations may exist between practitioners in the preoperative, intraoperative, and postoperative management of patients with ZD because of recent evolutions in surgical approach toward an endoscopic technique.

METHODS

An online survey instrument was prepared and forwarded to the membership of the American Broncho-Esophagological Association (ABEA) to ascertain the current practice patterns of its members regarding numerous care parameters for patients with ZD.

RESULTS

Data on preoperative evaluation, operative care, postoperative management, and recalled incidence of complications, including mediastinitis, were evaluated. Subgroup analysis demonstrated significant differences in multiple care parameters for those surgeons who predominantly perform endoscopic operations (more than 80% willingness to perform endoscopic operations) compared to those who occasionally perform endoscopic operations (less than 80%), including average case number, advancement of oral intake, hospital discharge, use of antibiotics, and views on the efficacy of endoscopic surgical techniques. These changes were noted despite similar times since graduation from training for the two groups.

CONCLUSIONS

These data present a contemporary snapshot of clinical care patterns of the ABEA membership for patients with ZD and suggest differences in care patterns for surgeons with a higher enthusiasm for endoscopic techniques and larger case volumes.

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.

Pharyngeal dilation in cricopharyngeus muscle dysfunction and Zenker diverticulum

OBJECTIVES/HYPOTHESIS

Prolonged obstruction at the level of the lower esophageal sphincter is associated with a dilated, poorly contractile esophagus. The association between prolonged obstruction at the level of the upper esophageal sphincter (UES) and dilation and diminished contractility of the pharynx is uncertain. The purpose of this investigation was to evaluate the association between prolonged obstruction at the level of the UES and dilation and diminished contractility of the pharynx.

STUDY DESIGN

Case-control study.

METHODS

The fluoroscopic swallow studies of all persons with cricopharyngeus muscle dysfunction (CPD) diagnosed between January 1, 2006 and December 31, 2008 were retrospectively reviewed from a clinical database. Three categories of CPD were defined: nonobstructing cricopharyngeal bars (CPBs), obstructing CPBs, and Zenker diverticulum (ZD). The primary outcome measure was the pharyngeal constriction ratio (PCR), a surrogate measure of pharyngeal strength on fluoroscopy. Secondary outcome measures included pharyngeal area in the lateral fluoroscopic view and UES opening. The outcome measures were compared between groups and to a cohort of nondysphagic age- and gender-matched controls with the analysis of variance.

RESULTS

A total of 100 fluoroscopic swallow studies were evaluated. The mean age (+ or -standard deviation) of the cohort was 70 years (+ or -10 years). Thirty-six percent were female. The mean PCR progressively increased, indicating diminishing pharyngeal strength, from the normal (0.08), to the nonobstructing CPB (0.13), to the obstructing CPB (0.22), to the ZD group (0.28) (P < .001 with trend for linearity). There was a linear increase in pharyngeal area from the normal (8.75 cm(2)) to the nonobstructing CPB (10.00 cm(2)), to the obstructing CPB (10.46 cm(2)), to the ZD group (11.82 cm(2)) (P < .01 with trend for linearity).

CONCLUSIONS

The data suggest that there is an association between cricopharyngeus muscle dysfunction and progressive dilation and weakness of the pharynx. Laryngoscope, 2010.

Endoscopic transoral stapling of Zenker's diverticula

The pharyngoesophageal pouch was first described by Ludlow in 1764 and later by Zenker. It is a pulsion diverticulum of the posterior pharynx, arising in Killian's triangle. Zenker's diverticula are related to a non-compliant upper esophageal sphincter and have been associated with gastroesophageal reflux. Surgical therapy has been recommended for dysphagia and regurgitation. Many surgical options exist. More recently, minimally invasive, transoral stapling has been used. Transoral stapling may be a less morbid operation and may allow patients a quicker return to oral diet and usual activities.

Surgical experience of the national institution in the treatment of Zenker's diverticula

AIM

To review the 8-year experience of the Department of Esophagogastric Surgery, First Surgical University Hospital in Belgrade in the surgical management of Zenker's diverticula (ZD).

METHODS

Between January 2000 and January 2009, 52 patients underwent surgical procedure for the treatment of ZD. Complete preoperative workup including the symptom evaluation and large variety of structural and functional diagnostic procedures were conducted before the surgery. After the operative treatment patients underwent detailed follow-up in regular intervals up to 3 years.

RESULTS

Preoperative evaluation marked higher incidence of hiatal hernia and pathologic gastroesophageal reflux (GER) among the patients with ZD then in normal population. According to the preoperative evaluation and size of diverticula, as well as due to the intraopertive findings, a variety of surgical procedures were performed, including myotomy alone (n = 2), diverticulopexy and myotomy (n = 36) and diverticulectomy and myotomy (n = 14). Regardless of the operative treatment no salivary cervical fistulas were observed. Late and early postoperative results revealed low incidence in postoperative transitory dysphagia or regurgitation.

CONCLUSION

The results of this study show that the open surgical procedures are safe and effective in the treatment of ZD. Cricopharyngeal myotomy remains the essential focus of treatment, while the choice of resecting or suspending the diverticulum is brought upon its size. Complete preoperative investigation must be conducted in ZD patients, and the role of pathologic GER must be taken into account when we discuss the origin of this disorder.

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.

Familial Zenker's diverticulum

CONCLUSION

The aetiology of Zenker's diverticulum is likely to be multifactorial. The geographical and racial variation in the prevalence and the rare familial cases suggest that genetic predisposition might have a role in the pathogenesis. The mode of inheritance in the rare possible familial cases seems to be autosomal dominant; recessive inheritance is non-existent or extremely rare.

OBJECTIVES

To study the inheritance of Zenker's diverticulum.

SUBJECTS AND METHODS

A detailed questionnaire concerning physical health and family history was sent to 122 patients with Zenker's diverticulum.

RESULTS

The prevalence of familial disease in Finland was found to be < 2%. We found no evidence for genetic founder effect.

Effect of laparoscopic fundoplication on hypertensive lower esophageal sphincter associated with gastroesophageal reflux

For hypertensive lower esophageal sphincter with dysphagia and chest pain, a laparoscopic cardiomyotomy is recommended. Recently, the role of gastroesophageal reflux in this abnormality has been recognized. A prospective study on six patients with manometrically proven hypertensive lower esophageal sphincter was performed. Laparoscopic floppy Nissen fundoplication was performed in all cases. The first follow up was performed 6 weeks after the operation. The mean follow up time was 56 months (range 50-61). Before the operation, all patients had abnormal esophageal acid exposure. Mean DeMeester score was 41.7 (range 16.7-86). Average LES pressure before the operation was 50.5 mmHg (range 35.6-81.3). Six weeks after operation, all patients were symptom free. DeMeester score returned to a normal level of 2.9. Furthermore, a marked decrease in the lower esophageal sphincter pressure (24.7 mmHg) was detected. At late follow up, all patients were symptom-free, and only two patients agreed to undergo functional testing. The mean DeMeester score of this two patients was 1.2. The pressure remained at normal value (15.7 mmHg). In our study, an antireflux operation normalized lower esophageal sphincter pressure suggesting that abnormal esophageal acid exposure may be an etiologic factor in the development of hypertensive lower esophageal sphincter.

Laryngopharyngeal reflux: Current concepts in pathophysiology, diagnosis, and treatment

Laryngopharyngeal reflux (LPR) is the backflow of gastric contents into the pharynx and larynx. The diagnosis of LPR is primarily based on symptoms, including dysphonia, dysphagia, globus, throat-clearing, and post-nasal drip. The gold standard for diagnosis is dual-probe 24-hour pH testing with the upper probe positioned above the upper oesophageal sphincter. Treatment may require 3 months or more of twice-daily proton pump inhibitors along with lifestyle modifications. This review details the pathophysiology, symptoms, findings, treatment, and current controversies in LPR.

Extraösophagealer Reflux und Zenker-Divertikel

INTRODUCTION

Patients with Zenker's diverticulum often present with a hiatal hernia. Theoretically, the gastric acid fluid could rise up to the hypopharynx producing an injury to the mucosa of Killian's triangle and hypertrophy of the cricopharyngeal muscle. We performed dual-channel pH monitoring in healthy people as a control group and in patients with a Zenker's diverticulum to elucidate the relationship between Zenker's diverticulum and gastroesophageal reflux disease (GERD) as well as extraesophageal reflux (EER).

METHODS

Patients with Zenker's diverticulum underwent dual-channel 24-h pH monitoring to exclude the possibility of an EER or a GERD. The measurements were performed in 4 patients preoperatively and postoperatively as well as in 14 patients only postoperatively. The control group consisted of healthy volunteers who did not suffer from a reflux disease (n=20). In each group we determined the number of refluxes, the fraction time, the RAI (reflux area index), and the DeMeester Score Index. In addition we classified the severity of the EER with a grading system which was developed in an earlier study in our department.

RESULTS

Patients with a Zenker's diverticulum suffered significantly from EER (p<0.01). The difference between the patients measured preoperatively and the patients postoperatively was minor. More than 72% of the patients suffered from a severe EER.

CONCLUSIONS

Patients with a Zenker's diverticulum have a high possibility of suffering from EER and GERD. The pathophysiology of this relationship can only be speculated. In addition to a cricopharyngeal myotomy, long-term therapy with a PPI (proton pump inhibitor) seems indicated.

Pharyngeal pouch: associations and complications

The aetiopathogenesis of pharyngeal pouch remains obscure. This review highlights the associations and complications of pharyngeal pouch to better understand the pathogenesis and management of the pouch. A search of the MEDLINE was conducted to identify studies that looked at associations and/or complications of the pharyngeal pouch. The Medical Subject Headings (MeSH) included Zenker's diverticulum and hypopharyngeal diverticulum. A total of 64 papers were included for the analysis. They consisted mainly of single case reports, case series and review articles and one case control study. A summary of evidence from the literature is discussed. This review shows the various associations and complications that can occur with pharyngeal pouches. It is important to be aware that pharyngeal pouch can co-exist with other pathologies and treatment needs to be altered to incorporate the treatment of the associated pathology too. Surgeons should also be aware of the complications that can occur within and outside the pouch.

[Esophageal diverticula]

Esophageal diverticula are classified by location-phrenoesophageal (Zenker's diverticulum-70%), thoracic and mediastinal (10%), and epiphrenic (20%). Almost all esophageal diverticula are acquired pulsion diverticula. The most common symptoms are dysphagia, regurgitation, thoracic pain, and pulmonary manifestations related to aspiration. Barium swallow and upper endoscopy will help to establish the diagnosis while esophageal manometry may reveal underlying dysmotility. Diverticula should not be treated unless they are symptomatic. The treatment of Zenker's diverticulum is surgical and consists of either diverticulectomy or diverticular suspension with a myotomy of the cricopharyngeus muscle via cervical approach. Transoral endoscopic stapled diverticulostomy is a new and simple approach which may become the treatment of choice, particularly in elderly and high-risk patients. Treatment of diverticula of the mid and low esophagus must take into account any motor anomalies or associated lesions. Diverticulectomy with esophageal myotomy and an anti-reflux procedure through a left thoracotomy is the standard approach, but endoscopic approaches seem feasible, particularly for epiphrenic diverticula, and may become the norm in years to come.