20 years experience in the management of Zenker's diverticulum in a third-level hospital

Pharyngoesophageal diverticulum: evaluation of treatment results

OBJECTIVE

To evaluate the postoperative outcome of patients with pharyngoesophageal diverticulum submitted to surgical and endoscopic treatments.

METHODS

We retrospectively analyzed 36 patients with pharyngo-esophageal diverticulum treated at the Hospital of the Medical School of Botucatu - UNESP. Patients were divided into two groups, depending on the treatment: group 1 (n = 24): diverticulectomy associated myotomy through a left cervicotomy; group 2 (n = 12): endoscopic diverticulostomy with linear stapler.

RESULTS

Operative mortality was zero in both groups. Early complications: group 1 - two patients developed cervical fistula and two, hoarseness; group 2 - none. Late complications: group 1 - none; group 2: recurrence of dysphagia in four patients (p = .01). Mean follow-up was 33 months for group 1 and 28 months for group 2.

CONCLUSION

Both procedures were effective in remission of dysphagia. Surgical treatment showed superiority to endoscopy, with resolution of dysphagia with a single procedure. Endoscopic treatment should be reserved for the elderly and those with comorbidities.

Surgical treatment of Zenker's diverticulum

BACKGROUND

Different surgical techniques have been indicated for the management of Zenker's diverticulum (ZD), including diverticulectomy, diverticulopexy, and diverticular inversion, with or without myotomy, and myotomy alone. More recently, minimally invasive techniques (such as the transoral endoscopic approach) have become increasingly reliable for this disorder. We therefore conducted this systematic review in order to gain a profound understanding of the current trend and evidence in surgical management of ZD.

METHODS

Medline and PubMed were searched to identify studies on surgical intervention of ZD published in English between January 1990 and March 2011.

RESULTS

We identified 6,915 patients from 93 studies evaluating the effect of the surgical intervention for ZD. No randomized controlled trials comparing one technique with another were identified.

CONCLUSION

Diverticulectomy with myotomy has become the mainstream treatment option for ZD. In certain selected patients, endoscopic diverticulotomy may offer some advantages over open surgery, such as less trauma and a lower complication rate. It is important to individualize optimal therapy for each patient. More randomized controlled trials with long-term follow-up results are required to draw a valid conclusion on the best surgical intervention modality for ZD.

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.

Tratamento cirúrgico do divertículo de Zenker: diverticulopexia versus diverticulectomia

RACIONAL: Divertículo faringoesofágico, conhecido como de Zenker, é herniação adquirida na mucosa faríngea através de um defeito muscular entre as fibras oblíquas do músculo constritor inferior da faringe e as transversas do músculo cricofaríngeo. OBJETIVO: estudo retrospectivo, não randomizado, compararando os resultados da diverticulopexia e diverticulectomia, ambas associadas à miotomia do músculo cricofaríngeo, no tratamento do divertículo de Zenker. MÉTODOS: Quarenta pacientes foram submetidos a tratamento cirúrgico entre 1989 e 2003, dos quais 38 (95%) foram seguidos. Vinte e oito eram do sexo masculino (70%) e 12 femininos, com média de idade de 62,5 anos (21 a 85 anos). Vinte e quatro pacientes (60%) foram submetidos à diverticulopexia ou elevação, e 16 à diverticulectomia ou ressecção, através de cervicotomia esquerda, com miotomia do músculo cricofaríngeo. RESULTADOS: Resultados excelentes (Visick I), foram verificados em 84,6% dos pacientes submetidos à diverticulectomia e 66,6% dos pacientes submetidos à diverticulopexia. Na análise global de todos os casos estudados, 27 (11 ressecções e 16 elevações - 72,9%) apresentaram Visick I; 8 (2 ressecções e 6 elevações - 21,6%) apresentaram Visick II; e 2 (elevações - 5,4%) apresentaram Visick III. Não foi registrado nenhum caso na classificação de Visick IV. A incidência de complicações pós-operatórias registrada nos dois grupos foi semelhante (P>0,05). Foi verificado a presença de neoplasia maligna em um caso submetido a ressecção (2,5%). CONCLUSÃO: A diverticulopexia com miotomia do músculo cricofaríngeo é mais indicada em doentes geriátricos, pequenos divertículos e doentes com risco operatório elevado. A diverticulectomia é boa opção em grandes divertículos e doentes jovens, para prevenir o risco de transformação maligna. Esta casuística mostrou melhores resultados com a diverticulectomia em comparação com a diverticulopexia.