Pharyngeal pouch carcinoma: real or imaginary risks?

Squamous Cell Carcinoma Arising in a Zenker's Diverticulum

Squamous cell carcinoma (SCC) developing in a Zenker's diverticulum (ZD) is an uncommon condition. The preferred treatment for SCC in the pharyngeal pouch is complete diverticulum resection. Only histopathological evaluation of the pouch can rule out SCC. Here, we present a case of a 62-year-old male patient, who was evaluated for repeated episodes of aspiration and dysphagia, and diagnosed to have a large ZD, the patient underwent Zenker's diverticulectomy with cricopharyngeal myotomy with wide margins due to clinically suspicious specimen. Histopathological examination revealed well-differentiated SCC arising within ZD, involving the whole thickness of the wall and almost touching the serosa (1 mm). The patient developed metastatic lung nodule on PET-CT, so metastatic lung nodule was excised with video-assisted thoracoscopic surgery (VATS), and chemotherapy and immunotherapy were given. On follow-up imaging patient is tumor-free to date, two years after the surgery. The occurrence of synchronous or metachronous lung cancer makes it one of the rarest cases.

Squamous cell carcinoma arising in a Zenker diverticulum

Squamous cell carcinoma (SCC) arising in a Zenker diverticulum (ZD) is an extremely rare entity. Approximately 50 cases have been reported worldwide. We report a case of a 74-year-old man who presented to our institution with chronic regurgitation, dysphagia and halitosis. The patient was initially seen in 2015 at which point he reported a 10-year history of these symptoms and was diagnosed with ZD. A barium swallow was done revealing a large posterior esophageal diverticulum with significant residual contrast within the diverticulum lumen. Given these findings, he was taken for open surgical excision where a SCC was identified. Although it is extremely rare for a SCC to occur in a ZD, patients with ZD must undergo regular surveillance endoscopy of the esophagus and the diverticulum itself to identify any suspicious mass or lesion arising in within.

A cooperative approach for treatment of Zenker's diverticulum

BACKGROUND

Symptomatic Zenker's diverticulum management has evolved from an open intervention to an endoscopic management. At our center, both an otolaryngologist and a gastroenterologist are present in the operating room when treating these lesions. An intra-procedural consensus is reached to undergo either rigid endoscopy or flexible endoscopic diverticulotomy with ENT guidance. We evaluated the real-world efficacy with a cooperative gastroenterology-otolaryngology approach.

METHODS

Single-center retrospective study of patients who underwent a cooperative endoscopic diverticulotomy by a gastroenterologist and otolaryngologist at Cleveland Clinic Florida between 2012 and 2019. Demographic and clinical data, intra-procedural findings/complications, post-procedural symptoms, recurrence rate, and reintervention variables were extracted. Patients included in the study were > 17 years old, with symptomatic confirmed typical single Zenker's diverticulum.

RESULTS

63 subjects were identified. Patients were predominantly males (63.5%) and white (84.1%), with mean age 73.5 years (53-95). Most subjects presented dysphagia (98.4%), mostly to solids (79.4%). Other demographic and clinical data are described in Table 1. The diverticula had a mean size of 36.3 mm. In 30.1% of the cases food debris was found during the procedure. The mean procedure length was 38.4 minutes. All cases were performed as outpatient. Technical success was achieved in all cases. Patients were followed for a mean of 3.24 months post-procedure. Clinical success was achieved in 92% subjects. One intra-procedural perforation was treated with endoclip. Table 1 Pre-procedural demographic and clinical variables in patients undergoing Zenker's diverticulum cooperative approach Variable Value (n = 63) Sex, n (%)  Male  Female 40 (63.5) 23 (36.5) Ethnicity/Race, n (%)  Non-Hispanic White  Hispanic  Black 53 (84.1) 7 (11.1) 3 (4.8) Smoking status, n (%)  Never  Former  Active 29 (46.0) 26 (41.3) 8 (10.7) Previous intervention for Zenker's diverticulum, n (%) 12 (19.1) Dysphagia, n (%)  Only to solids  Only to liquids  Both solids and liquids 50 (79.4) 0 (0) 12 (19.0) Regurgitation of food, n (%)  Chronic cough, n (%) 13 (20.6)  Halitosis, n (%) 9 (14.3) CONCLUSION: A cooperative endoscopic approach by gastroenterology and otolaryngology for symptomatic Zenker's diverticulum management offered excellent technical and clinical success. This approach proved to be safe and effective.

Occult Early Squamous Cell Carcinoma in Zenker's Diverticulum Treated With Diverticulectomy Followed by Additional Esophagectomy With Free Jejunal Reconstruction: A Case Report

A 63-year-old man was evaluated for a 20-year history of dysphagia and vomiting. Barium-swallow esophagography showed a Zenker's diverticulum at the upper end of the esophagus. Esophagogastroduodenoscopy revealed the diverticulum about 20 cm from the incisors. There was no mucosal inflammation or irregularity in the diverticulum. Computed tomography showed that the diverticulum was about 8 cm in size. There was no lymphadenopathy around the esophagus. Because the patient's symptoms were worsening, we performed diverticulectomy using a linear stapling device and cricopharyngeal myotomy. The mucosa of the resected specimen had no macroscopically abnormal lesions. However, an area unstained by iodine that widely involved the surgical margin was recognized at pathologic examination. Pathologic findings revealed squamous cell carcinoma invading the lamina propria mucosa with inflammatory cell infiltration. In addition, the pathologic surgical margin was widely positive. However, a remnant tumor lesion was not detected by postoperative esophagogastroduodenoscopy. Biopsies near the staple line were negative. After obtaining informed consent, we performed resection of the cervical esophagus including the proximal stump of the diverticulum and cervical lymphadenectomy approximately 4 months after the primary operation as an additional surgery. Reconstruction was performed by free jejunal transplantation with microvascular anastomosis. The patient was discharged on postoperative day 45. Pathologic examination revealed no malignant lesion in the resected specimen, and radical cure was confirmed.

Endoscopic septotomy of Zenker's diverticulum with Stag-Beetle Knife™: A descriptive observational study and literature review

INTRODUCTION

Zenker's diverticulum (ZD) is a protrusion of the hypopharyngeal mucosa with a prevalence of 2/100,000 inhabitants. The symptoms of the patients determine the need for treatment, which can be surgical or endoscopic. The latter, known as endoscopic septotomy or diverticulotomy (ED), this involves dissecting the diverticular septum, which can be performed with different dissection devices.

AIM

The aim of our study was to evaluate the efficacy and safety of ED with Stag-Beetle-Knife™ device, as well as to conduct a literature review to assess the position of the technique in the current scientific panorama.

MATERIAL AND METHODS

Descriptive retrospective study that includes patients who underwent ED with SB-Knife™ between June 2017 and February 2020. Literature review of the available evidence between January 2013 and April 2020 of ED with SB-Knife™ technique and its variants.

RESULTS

Twelve patients (66% male) with a median age of 70.5 years were collected. The median size of diverticular was 32.5mm and complete remission was observed in 75% of the cases. Fourteen interventions were performed with a technical success of 92.8. There were no serious complications. A literature review was carried out, finding 13 papers, of which 8 were finally included (6 retrospective studies, a series of cases and a clinical case).

CONCLUSION

Based on our experience and the reviewed literature, we consider ED with SB-Knife™ is a safe, effective and reproducible technique, and may be a better alternative to surgery in patients with ZD.

Factors Predicting Endoscopic Exposure of Zenker's Diverticulum

Objectives

The objectives of this study were 1) to understand which anatomic variables are associated with failed endoscopic exposure of Zenker's diverticulum and 2) to enable preoperative selection of patients suitable for endoscopic repair of Zenker's diverticulum on the basis of anatomic variables.

Methods

We performed a prospective, Institutional Review Board-approved study of 30 patients undergoing attempted endoscopic repair of Zenker's diverticulum. Three categorical variables (sex, presence of maxillary dentition, and Mallampati score) and 6 continuous variables (age, neck circumference, hyomental distance, neck length, neck extension, and body mass index [BMI]) were collected before operation and then correlated to successful endoscopic exposure of the Zenker's pouch by use of a Fisher's exact test and Student's t-test, respectively.

Results

Exposure was unsuccessful in 9 of 30 patients (30%). Factors that correlated significantly with exposure failure included a shorter neck length (7.2 ± 1.2 cm; p = 0.047), a shorter hyomental distance (5.0 ± 1.1 cm; p = 0.004), and a higher BMI (27.2 ±4.0 kg/m2; p = 0.05). The presence of maxillary dentition did not reach significance in exposure failure, but did show a trend toward an association.

Conclusions

Surgical exposure in endoscopic repair of Zenker's diverticulum tends to be significantly less successful in patients with short necks, decreased hyomental distance, and/or a high BMI. An open approach should be considered in this patient population.

[Pathophysiology, diagnosis and treatment of Zenker's diverticulum]

Zenker's diverticulum occurs at the dorsal pharyngoesophageal junction through Killian's dehiscence and is caused by increased intrabolus pressure. Symptomatic disease most frequently affects male elderly patients. Primary symptom is oropharyngeal dysphagia, as well as regurgitation of undigested food, halitosis, and chronic aspiration. A barium swallow study is performed to confirm diagnosis. Treatment options for symptomatic patients include open surgery, as well as transoral rigid or flexible endoscopic procedures. Transoral procedures have become the main treatment approach over the past year thanks to reduced intraoperative complication rates compared to open surgery. The septum dividing the diverticulum from the esophagus is most commonly divided by a stapler device, papillotome, or laser. For high-risk patients who are poor candidates for general anesthesia, the procedure can be performed via flexible endoscopy in awake patients, albeit at an increased risk of recurrence.

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.

Zenker's diverticulum: flexible versus rigid repair

Zenker's diverticula (ZDs) are a relatively common cause of cervical dysphagia. Diagnosis is best by a good upper GI exam though upper endoscopy should be performed as well. Treatment is either by open, transcervical approaches or trans-oral. Over the past 20 years, transoral approach has mostly replace transcervical approaches due to less pain, no scarring and a rapid recovery. Transoral approaches are either using rigid access or flexible endoscopy. Today, the most common approach is transoral stapling using a 12 mm laparoscopic linear cutting stapler. This has the drawbacks of requiring extreme neck extension, the massive size of the stapler making visualization mostly impossible and the current staple design that does not cut/staple all the way to the end of the blades-resulting in a residual pouch. Flexible endoscopy allows a more tailored approach under direct vision, the myotomy can even be extended beyond the diverticulum and onto the esophageal wall to minimize the risk of incomplete myotomy. Experienced endoscopists report high technical success and low complication. Success rates are similar but maybe slightly higher than with ridged transoral approaches or open surgery. Today, flexible endoscopic Zenkers is our preferred initial approach-with open or ridged being reserved for special indications.

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.

Assessment of the Results of Surgical Treatment of Zenker'S Diverticulum in Own Material

Zenker diverticulum (ZD) is the most common type of diverticula of the esophagus. Most often refers to men with a peak incidence in the seventh and eighth decade of life. In the majority diverticula remains asymptomatic and in patients with symptomatic course of the disease symptoms are often nonspecific. Aim of the study was to present the authors' own experience in surgical treatment of Zenker diverticulum.

MATERIAL AND METHODS

In this paper we present an analysis of 31 patients with confirmed ZD treated surgically at the Clinic in 2004-2014. Patients were analyzed in terms of age, gender, clinical symptoms, diverticulum size, type of surgery, the time to return to the oral intake, hospital stay and perioperative complications.

RESULTS

22 men and 9 women were enrolled it this study. The mean age of the patients was 64.8 (SD, 10.7; in the range of 28 to 82 years). 29 patients (93.5%) underwent resection of the diverticulum, while diverticulopexy was performed in two patients. In 25 (80.6%) cases stapler device was used, while in 4 (12.9%) resection was performed manually. The average size of resected diverticulum was 4.9 cm (SD, 1.5). Following the surgery in four patients (12.9%) complications were present. The average operating time was 118.7 minutes (SD, 42.2, in the range of 50 to 240 minutes). The mean length of hospital stay was 9.3 (SD, 3.3).

CONCLUSIONS

Surgical treatment of ZD is associated with high effectiveness and low recurrence rate. Despite the advantages of endoscopic techniques, surgical treatment is characterized by one- stage procedure. The use of mechanical suture (stapler) significantly improves the operation, although on the basis of our own analysis there was no superiority revealed over hand sewn. Unquestionable adventage of classical technique is the opportunity to histopathological evaluation of resected diverticulum what is impossible to achieve in endoscopic techniques.

Zenker's Diverticulum

Zenker's diverticulum (ZD) is an outpouching of tissue through the Killian triangle that is believed to be caused by dysfunction of the cricopharyngeal muscle. ZD is a relatively uncommon disorder occurring in the elderly. The predominant symptom of ZD is dysphagia, and the most serious consequence is pulmonary aspiration. Videofluoroscopy confirms the diagnosis. Therapy of symptomatic ZD has evolved from an open surgical approach to less invasive transoral endoscopic techniques. Transoral endoscopic therapy using rigid instruments is performed primarily by otorhinolaryngologists, whereas transoral therapy using flexible endoscopes is performed by surgical endoscopists and gastroenterologists. The common goal of all modalities is severing of the septum between the esophageal lumen and the diverticulum containing the cricopharyngeal muscle. Although flexible endoscopic therapy was described nearly 20 years ago, it has experienced a recent resurgence paralleling the advancements of therapeutic endoscopy in other areas, such as endoscopic submucosal dissection. Direct head-to-head comparisons of rigid and flexible endoscopic therapy are lacking, and each approach has variations in techniques as well as advantages and disadvantages. In this article, we review the pathophysiology and management of patients with ZD with an emphasis on flexible endoscopic therapy.

Systematic review of carcinoma arising in pharyngeal diverticula: a 112-year analysis

BACKGROUND

Carcinoma is a rare complication of pharyngeal diverticula. There is a paucity of information about its incidence, presentation, management, and treatment outcomes. A systematic review and analysis of all reported cases has been carried out.

METHODS

A comprehensive literature search for pharyngeal diverticula carcinoma was performed from 1896 to 2008. Descriptive analyses were carried out by analyzing the absolute and relative frequencies. Comparison of groups was illustrated with Kaplan-Meier curves and tested statistically using the log-rank test. A cohort of 56 patients with benign pharyngeal diverticula was selected for comparison with the accumulated cohort of pharyngeal diverticula carcinoma, and a Fisher's exact test was carried out on the extracted clinical characteristics of this cohort to evaluate for differences between benign and malignant pharyngeal diverticula.

RESULTS

Forty-three articles reporting 60 cases satisfied the inclusion criteria. The mean age at presentation was 68.8 years (SD = 9.8 years). Five-year cancer-specific survival (CSS) rates for patients who underwent excision alone, excision + postoperative radiotherapy (PORT), and radiotherapy alone were 0.74 versus 0.63 versus 0.0, respectively (p = .39). Five-year CSS rates of patients <65 versus ≥65 years were 0.43 versus 0.78, respectively (p = .046).

CONCLUSION

Irregular symptoms in benign diverticula should raise suspicion of malignancy. Management consists of surgical excision ± PORT. © 2014 Wiley Periodicals, Inc. Head Neck 36: 1368-1375, 2014.

Zenker's diverticulum complicating achalasia: a 'cup-and-spill' oesophagus

A 72-year-old woman presented with long-standing gastro-oesophageal reflux, regurgitation of swallowed food and worsening cervical dysphagia. Fluoroscopic barium oesophagography revealed a posterolateral pharyngeal pouch (Zenker's diverticulum (ZD)) complicating a 'cup and spill' oesophageal deformity with a smoothly tapered segment at the gastro-oesophageal junction. CT and high-resolution manometry confirmed that the underlying abnormality was a massively dilated oesophagus with aperistalsis and pan-oesophageal pressurisation, consistent with a diagnosis of oesophageal achalasia (type II). She underwent endoscopic stapled diverticulotomy, with good symptomatic relief. We discuss the aetiology of ZD, its management and the association here with oesophageal achalasia.

Endoscopic or external approach revision surgery for pharyngeal pouch following primary endoscopic stapling: which is the favoured approach?

This study aimed to assess outcomes of revision endoscopic stapling and external excision of pharyngeal pouch. A 5-year prospective study was performed on all patients requiring revision pouch surgery following primary endoscopic stapling. Data were collected retrospectively. Eighteen patients underwent revision pouch surgery. In seven patients, pouch size was down-graded from 3 to 2, and these were stapled endoscopically. Two leaks resulted. Eleven patients with grade 1 or 3 pouches underwent external excision of pouch, with no post-operative complications. As per results external excision of pouch is safe for grade 1 and 3 pouches. It avoids risking redundant mucosa and recurrence of symptoms which can complicate stapling and enables a myotomy to be performed to reduce cricopharyngeal hypertonicity. The highest predictable success is with grade 2 pouches, whose size is amenable to adequate endoscopic stapling. However, the "staple over staple" effect of revision stapling leads to unpredictable fibrosis, which can contribute to risk of perforation.

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.

Esophageal diverticula and cancer

Esophageal diverticula are rare. The association of cancer and diverticula has been described. Some authors adopt a conservative non-surgical approach in selected patients with diverticula whereas others treat the symptoms by diverticulopexy or myotomy only, leaving the diverticulum in situ. However, the risk of malignant degeneration should be may be taken in account if the diverticulum is not resected. The correct evaluation of the possible risk factors for malignancy may help in the decision making process. We performed a literature review of esophageal diverticula and cancer. The incidence of cancer in a diverticulum is 0.3-7, 1.8, and 0.6% for pharyngoesophageal, midesophageal, and epiphrenic diverticula, respectively. Symptoms may mimic those of the diverticulum or underlying motor disorder. Progressive dysphagia, unintentional weight loss, the presence of blood in the regurgitated material, regurgitation of peaces of the tumor, odynophagia, melena, hemathemesis, and hemoptysis are key symptoms. Risk factors for malignancy are old age, male gender, long-standing history, and larger diverticula. A carcinoma may develop in treated diverticula, even after resection. Outcomes are usually quoted as dismal because of a delayed diagnosis but several cases of superficial carcinoma have been described. The treatment follows the same principals as the therapy for esophageal cancer; however, diverticulectomy is enough in cases of superficial carcinomas. Patients must be carefully evaluated before therapy and a long-term follow-up is advisable.

[Zenker's diverticulum: pro operation]

In case of Zenker's diverticulum, treatment is indicated as soon as the diagnosis is established. Therapy should aim at the elimination of dysphagia and the symptoms of food retention and should reliably prevent recurrence. Currently, three different therapeutic approaches are applied: the classical option is open transcervical myotomy and diverticulectomy/diverticulopexy and alternatively stapled diverticulostomy with a linear stapler or flexible endoscopic diverticulostomy is propagated. As compared to the surgical (open) approach, rigid or flexible endotherapy is less invasive. However, endotherapy is not always feasible for all types of Zenker's diverticulum and the recurrence rate is high. Accordingly, open diverticulectomy is recommended in patients with an adequate life expectancy and good general operability.

Carcinoma arising from pharyngeal diverticula

BACKGROUND

Pharyngeal diverticulum or Zenker's diverticulum carcinoma is a rare malignancy with a poor prognosis. Carcinoma arising in a recurrent pharyngeal diverticulum is even rarer, with only 1 such case reported in the English-language literature. We report 2 patients with pharyngeal diverticulum carcinoma exhibiting an unusual presentation and good long-term, disease-free survival with normal speech and swallowing.

METHODS

A 70-year-old man with a carcinoma in a recurrent pharyngeal diverticulum excised 20 years previously and a 65-year-old man with a neck mass as the only presentation of pharyngeal diverticulum carcinoma.

RESULTS

Our patients were treated with open resection, laryngeal preservation, and postoperative radiotherapy (PORT), resulting in long-term tumor control and disease-free survival of 5 and 15 years (longest reported), respectively.

CONCLUSION

One-stage diverticulectomy with or without radiotherapy is the treatment of choice and can provide long-term control and survival.

Squamous cell carcinoma in a large epiphrenic esophageal diverticulum

Carcinoma is rare in an esophageal diverticulum. The case of a 53-year-old man with a large mass in a long-standing symptomatic epiphrenic esophageal diverticulum is presented in this study. Squamous cell carcinoma in the diverticulum with pleural invasion was diagnosed after surgical diverticulectomy. The patient underwent subtotal esophagectomy with locoregional lymph node dissection and reconstruction with gastric tube because of micro-invasion at the surgical margin. The patient developed malignant pleural effusion at 6 months after surgery, and he eventually expired 3 months later. Carcinoma can develop in esophageal diverticula and is usually diagnosed at an advanced stage with poor prognosis.

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.

Squamous cell carcinoma and Zenker diverticulum

Squamous cell carcinoma in a Zenker diverticulum is a very rare condition. We report a case of a patient with a Zenker carcinoma, who was primarily functionally inoperable and therefore received neoadjuvant radiochemotherapy before cardiac bypass surgery. After a complicated course with cardiogenic shock and myocardial infarction, a re-evaluation of functional risk analysis and the tumor situation revealed operability. Subsequently, partial hypopharyngectomy and partial cervical esophageal resection with lymphadenectomy was performed. Reconstruction of the gastrointestinal continuity was made by interposition of a free small bowel graft and microvascular anastomosis. The postoperative course showed a small anastomotic leakage of the hypopharyngeal-small bowel anastomosis, which was successfully treated conservatively.

Carcinoma Arising in a Pharyngeal Pouch Previously Treated by Endoscopic Stapling

OBJECTIVES

A case is described in which squamous cell carcinoma was found during surgery for a recurrent pharyngeal pouch previously treated by endoscopic stapling. A search of the English language literature suggests this is the first reported case of a carcinoma developing in a pharyngeal pouch previously treated by endoscopic stapling.

STUDY DESIGN

Case report and literature review.

MATERIALS AND METHODS

The records of a patient who presented with a recurrent pharyngeal pouch after a previous endoscopic stapling procedure were reviewed. The presentation, imaging, and histopathologic findings are presented and the implications of these discussed.

RESULTS

Imaging confirmed a recurrent pharyngeal diverticulum. An endoscopic assessment revealed the presence of tumor in the recurrent pouch that histopathologic evaluation confirmed to be squamous cell carcinoma. The patient underwent an external excision of this diverticulum followed by a course of external beam radiotherapy.

CONCLUSIONS

This is the first reported case of a carcinoma developing in a recurrent pharyngeal diverticulum previously treated by endoscopic stapling and brings to light a rare risk of endoscopic stapling procedures for the treatment of pharyngeal diverticula.

Ten year survival after excision of squamous cell cancer in Zenker's diverticulum: report of a case

Background

Zenker's diverticulum (ZD) has been increasingly recognized as a site of primary epithelial malignancy. Pitt in 1896 described the first case.

Methods

Between 1990 and 2005, 30 patients affected of esophageal diverticulum were referred to our Department.

Results

The pathological results revealed one case of squamous cell carcinoma. On follow-up 10 years after diverticulectomy alone, the patient was alive and well without evidence of recurrence.

Conclusion

Our case reported provides additional data on clinical decision when the tumor is well localized without full-thickness penetration or extension to the line of resection. In this patient, long-term survival and apparent disease control have been effected by diverticulectomy alone. A case of such long survival is very rare.

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.

Surgical interventions for pharyngeal pouch

BACKGROUND

A pharyngeal pouch is an out-pouching or pocket that develops from the posterior wall of the pharynx just above the entrance to the oesophagus (gullet). Pouches may give rise to difficulty in swallowing, sensation of a lump in the throat or of food sticking in the throat and may lead to troublesome regurgitation of food. Food may enter the pouch rather than passing down the oesophagus and this and regurgitation may result in weight loss, hoarseness of voice and/or recurrent chest infections. The management of patients with a pharyngeal pouch may be either conservative or surgical. The surgical management can be further divided into two broad categories: endoscopic and open procedures. In the first half of the twentieth century an open surgical approach to the pouch was most frequently used, and remains common in some parts of the world. In recent decades endoscopic procedures (where the approach is made through the mouth) have become popular. The superiority of one approach over another has yet to be clearly demonstrated.

OBJECTIVES

To assess the effectiveness and safety of open and endoscopic surgical procedures for the management of a pharyngeal pouch.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 3, 2004, MEDLINE (1966 to 2004) and EMBASE (1974 to 2004). Reference lists of all identified trials and previous reviews were searched for additional trials. Further electronic searches for key authors identified were made. There were no language restrictions. The date of the last search was September 2004.

SELECTION CRITERIA

We sought to identify all randomised controlled trials (RCTs) comparing two or more interventions.

DATA COLLECTION AND ANALYSIS

Three reviewers assessed the eligibility of trials for inclusion in the review, based on pre-determined criteria.

MAIN RESULTS

No trials were identified which fulfilled the criteria.

AUTHORS' CONCLUSIONS

There is no evidence from high quality randomised controlled trials to demonstrate the effectiveness of endoscopic compared with open procedures for pharyngeal pouch. There is no good evidence to establish whether one endoscopic procedure is superior to another.

Conservative management of a large postlaryngectomy neopharyngeal diverticulum

Dysphagia is common following total laryngectomy. Postlaryngectomy neopharyngeal diverticulae are known to cause postlaryngectomy dysphagia but are more frequently asymptomatic. We report a case presenting with late-onset postlaryngectomy dysphagia and a suprastomal swelling secondary to such a diverticulum. The patient was managed conservatively.

Evolution of surgical treatment for pharyngeal pouch

BACKGROUND

The development of endoscopic techniques, particularly endoscopic stapling, has led to a re-evaluation of the treatment of pharyngeal pouch. The pathophysiology and treatment of the condition is reviewed.

METHODS

An electronic literature search was undertaken on the pathophysiology, history and surgery of pharyngeal pouch (Zenker's diverticulum). These last two terms were used to the search the Cochrane, Medline and Embase databases (from 1966 to date) and the bibliographies of extracted articles.

RESULTS AND CONCLUSION

With recognition of the central role of the cricopharyngeus muscle in the pathogenesis of pouch formation, the emphasis on treatment has shifted from diverticulectomy to cricopharyngeal myotomy. Minimally invasive techniques have become established since the advent of endoscopic stapling devices. Although randomized controlled data are lacking, the endoscopic approach appears to offer advantages in terms of a shorter duration of anaesthesia, more rapid resumption of oral intake, shorter hospital stay and quicker recovery. It is associated with excellent success rates and minimal morbidity.

Endoscopic treatment of Zenker's diverticulum using CO2 laser

OBJECTIVES

The objective of the present study was to review the technique of endoscopic laser-assisted esophagodiverticulostomy (ELAED) for the treatment of Zenker's diverticulum.

METHODS

We reviewed 83 cases of ELAED performed for the treatment of Zenker's diverticuli during the past decade.

RESULTS

ELAED-treated patients had a reduced hospital stay and were able to start an oral diet earlier than were patients who underwent other surgical procedures. Two (2.4%) of our patients developed small fistulas, which closed spontaneously. An additional 2 (2.4%) of our patients required conversion to an open approach due to inadequate endoscopic exposure, and 5 (6%) required a revision endoscopic procedure for persistent symptoms.

CONCLUSIONS

Our series of 83 patients treated at 2 large academic centers during the past decade with an average follow-up of 4 years demonstrates that ELAED is a safe and effective procedure for the management of Zenker's diverticulum.

Pharyngeal pouch (Zenker's diverticulum)

Pharyngeal pouches occur most commonly in elderly patients (over 70 years) and typical symptoms include dysphagia, regurgitation, chronic cough, aspiration, and weight loss. The aetiology remains unknown but theories centre upon a structural or physiological abnormality of the cricopharyngeus. A diagnosis is easily established on barium studies. Treatment is surgical via an endoscopic or external cervical approach and should include a cricopharyngeal myotomy. Unfortunately pharyngeal pouch surgery has long been associated with significant morbidity, partly due to the surgery itself and also to the fact that the majority of patients are elderly and often have general medical problems. External approaches are associated with higher complication rates than endoscopic procedures. Recently, treatment by endoscopic stapling diverticulotomy has becoming increasingly popular as it has distinct advantages, although long term results are not yet available. The small risk of developing carcinoma within a pouch that is not excised remains a contentious issue and is an argument for long term follow up or treating the condition by external excision, particularly in younger patients.