Management of Zenker's diverticulum using flexible endoscopy.
ABSTRACT: Background and Aims:Zenker's diverticulum is a false diverticulum through Killian's dehiscence. Symptoms include halitosis, dysphagia, regurgitation, cough, and aspiration pneumonia. Treatment options include open transcervical cricopharyngeal myotomy, trans-oral rigid endoscopic stapling, and minimally invasive endoscopic myotomy. Although open surgical techniques have historically been the criterion standard for treatment, endoscopic options have become increasingly used. We propose the use of flexible endoscopy in the management of Zenker's diverticulum. Methods:We present a retrospective case series of 9 patients undergoing endoscopic cricopharyngeal myotomy from 2014 to 2018 using our endoscopic technique. Results:We demonstrate that endoscopic technique provided adequate symptomatic relief in 7 of 9 patients, with no operative adverse events. Conclusions:Cricopharyngeal myotomy using flexible endoscopy is a safe and effective technique for the management of Zenker's diverticulum. Potential benefits of this approach include shorter operative times, shorter postoperative admissions, and earlier progression of diet. Initial treatment with endoscopic technique does not preclude future open repairs.
Project description:<h4>Objective</h4>To describe the outcome of patients undergoing flexible endoscopic therapy for symptomatic Zenker diverticulum.<h4>Patients and methods</h4>We retrospectively evaluated the outcome of 22 consecutive patients who underwent flexible endoscopic cricopharyngeal myotomy using needle-knife electrocautery performed by a single endoscopist from March 2006 through January 2010.<h4>Results</h4>Of the 22 patients with symptomatic Zenker diverticulum, 13 were men and 9 were women (median age, 84.5 years). Moderate sedation was used in all but 3 (14%) of the patients. Postprocedural free air occurred in 6 patients (27%) and resolved uneventfully in all. Another patient developed a neck abscess 1 week after endoscopic treatment, which was surgically drained. All procedures were performed on an outpatient basis, although 8 patients (36%) required subsequent hospitalization. The mean (SD) length of stay in the hospital was 2.9 (1.64) days. All patients had initial symptomatic improvement, and 18 (82%) maintained improvement at a mean (SD) follow-up of 12.7 (9.2) months.<h4>Conclusion</h4>Flexible endoscopic cricopharyngeal myotomy is an effective treatment of symptomatic Zenker diverticulum, with low recurrence rates and with the benefit of no general anesthesia and hospitalization in most cases. Esophageal perforation is the most common procedural complication.
Project description: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.
Project description:Zenker's diverticulum is the most frequent symptomatic diverticulum of the esophagus, but the prevalence is <0.1%. The optimal treatment is surgery. Here, we present a nasomediastinal drainage approach to treatment of a mediastinal abscess, developing in the late postoperative period and attributable to leakage from the staple line.
Project description:Background and Aims:Definitive treatment options for refractory dysphagia due to cricopharyngeal bar are limited. We aimed to demonstrate a novel adaptation of peroral endoscopic myotomy to treat this condition (cricopharyngeal peroral endoscopic myotomy [c-POEM]). Methods:The approach to c-POEM is similar to that in the distal esophagus for the treatment of achalasia. A submucosal injection and overlying mucosal incision are performed, ideally 1.5 to 2 cm upstream of the upper esophageal sphincter, and then a submucosal tunnel is extended beyond the level of the cricopharyngeus. The target muscle is then transected before closure of the mucosotomy. Results:In 3 cases of refractory cricopharyngeal bar, c-POEM was successfully performed. Although no major adverse events occurred, significant postprocedural edema at the level of the upper esophageal sphincter prolonged hospitalization in 2 of the 3 patients. After recovery, all patients reported complete resolution of dysphagia and tolerated an unrestricted diet. Conclusions:C-POEM allows reliable and complete muscular division in patients with refractory cricopharyngeal bar who have limited treatment options.
Project description:We discuss an unusual presentation of Zenker's Diverticulum (ZD). A 76-year-old man presented with a left sided neck mass which was misdiagnosed as a thyroid mass due to the anatomical location and size. The ultrasound and fine needle-aspiration cytology findings were inconclusive, and a CT scan was then considered which reported a large pharyngeal pouch. Our recommendation is to consider an early CT scan in patient's where there is a clinical suspicion or risk factors for the development of pharyngeal pouch specially when the fine-needle aspiration cytology findings are inconclusive. This would reduce the risk of a delayed diagnosis which can prevent potential perforation of the pharyngeal pouch and development of mediastinitis.
Project description:To evaluate outcomes following endoscopic management of Zenker's diverticula using a carbon dioxide laser (CO2) or stapler-assisted technique, a systematic review and meta-analysis were conducted. Seven retrospective, uncontrolled case series including 391 procedures met selection criteria. No higher quality studies were identified. Outcomes favoring the stapler technique included a shorter duration of nil per os (NPO) status (2 studies), length of hospitalization (LOH, 2 studies), and fewer postoperative fevers and abnormal chest x-rays (1 study). Outcomes favoring the CO2 technique included greater improvement in postoperative dysphagia and regurgitation scores (2 studies) and a lower revision rate (1 study). Meta-analysis demonstrated increased nondental complications in the CO2 group (odds ratio 3.81; 95% confidence interval, 1.37-10.59; P = .01) but no difference in duration of NPO (P = .06), LOH (P = .07), overall complications (P = .08), dental complications (P = .57), major complications (P = .38), or revision surgery (P = .82). Implications are limited by the quality of studies identified.
Project description:Achalasia and Treatment of esophageal Adenocarcinoma are commonly associated to surgical resection. Newer technologies in interventional endoscopy gave way to a substantial paradigm shift in the management of these conditions. In the case of achalasia, endoscopic myotomy is rapidly displacing Heller's myotomy as the gold standard in many centers. Early stage neoplasia in Barrett's esophagus (BE) comprising high-grade dysplasia (HGD), intramucosal and, in some cases, submucosal carcinoma is now being treated without the need of esophagectomy. This review presents a summary of the most relevant endoscopic techniques for both achalasia and esophageal cancer. Endoscopic advances in diagnostic and therapeutic arenas allow for minimally invasive therapies and organ preservation in most settings of achalasia and early stage neoplasia of the esophagus provided that the clinical setting and physician's expertise are prepared for this approach.
Project description:BACKGROUND: The histopathology of the muscularis propria (MP) is unknown in patients with achalasia. Endocytoscopy (EC) was developed as an ultra-high magnification endoscopy, and the submucosal tunnel created during peroral endoscopic myotomy (POEM) not only provides access to the MP but also enables subsequent endoscopic assessment of the MP. PATIENTS AND METHODS: In seven patients with achalasia (mean ± SD; 35 ± 18.1 years; men:women, 4:3) who underwent POEM (myotomy length: 12 ± 2.2 cm), subsequent EC examination was performed from the mid-esophagus to the gastric side. EC images were compared to the results of histopathologic examination (two biopsies from the mid-esophagus and lower esophageal sphincter), which was the standard. RESULTS: In all patients, favorable EC images were obtained, and spindle-shaped smooth muscle cells were detected. In our series, we observed no notable features such as atrophy or hypertrophy of smooth muscle cells. In addition, the EC assessment was consistent with the results of biopsy. No complications were encountered during any of the procedures. CONCLUSION: In a clinical setting, real-time assessment of the MP using EC is feasible. This technique may play an important role in determining the pathology of achalasia and other diseases that affect gastrointestinal function.
Project description:We report a unique case of a superficial esophageal cancer arising in a single diverticulum, diagnosed with magnifying image-enhanced endoscopy and then successfully treated by endoscopic submucosal dissection (ESD).A 66-year-old man with alcohol-related liver injury visited our hospital for endoscopy for investigation of varix. Esophagogastroduodenoscopy showed no varix but a large epiphrenic diverticulum with an area of fainted redness just above the esophagogastric junction. Narrow band imaging revealed a sharply demarcated brownish dotted area, and dilated intra-epithelial papillary capillary loops (IPCL) were subsequently seen after magnification. Chromoendoscopy with 1% Lugol's iodine solution demonstrated a well-demarcated unstained area, approximately 20 mm in diameter. Endoscopic biopsy revealed a squamous cell carcinoma (SCC).The tumor was completely resected by ESD without perforation. Histologically, it was an intraepithelial SCC without lympho-vascular invasion of cancer cells. No local recurrence or metastasis was detected at the last follow-up of 42 months.
Project description:Longitudinal flexor hallucis longus (FHL) tendon tears are sometimes complicated by posterior ankle impingement syndrome (PAIS), especially in ballet dancers. In recent years, PAIS has been treated endoscopically, but it is difficult to suture FHL tendon tears endoscopically. In this report, we describe how to suture the FHL tendon endoscopically with the Meniscal Viper Repair system (Arthrex, Naples, FL). Without our endoscopic technique, when a patient is found to have a longitudinal tear of the FHL under endoscopy, we must choose to either neglect the tear or convert to an open repair. Open tendon suture techniques have reportedly had relatively good results but require a longer skin incision than endoscopic surgery for PAIS. Compared with the open repair, the advantages of our technique include earlier recovery, less pain, a lower rate of soft tissue complications, and improved healing through better preservation of the blood supply. This technique is an attractive and useful option because it is an easy and safe method for longitudinal FHL tendon tears.