ORIGINAL ARTICLE
CLINICAL AND PARACLINICAL CORRELATIONS AND TREATMENT OF THE PATIENTS WITH ZENKER’S DIVERTICULUM
Diana Ciuc¹, Rodica Bîrlă², C. Marica2,3, S. Constantinoiu2,3
¹CFR 2 Clinic Hospital Bucharest, ENT Department
² “Carol Davila” University of Medicine and Pharmacy Bucharest,
3The Center of Excellence in Oesophageal Surgery “Sfanta Maria” Clinical Hospital
Corresponding author: Diana Ciuc
Phone no.: 0040724397202 E-mail: [email protected]
Abstract
Zenker’s diverticulum is a rare disease, clinically manifested by dysphagia, particularly at the aged patients, with multiple comorbidities. The aim of this study is to correlate the age of the patients with their gender, number of symptoms upon hospitalization, period of hospitalization, post- interventional symptomatology (remaining dysphagia, degree of dysphagia, sialorrhea), dimension of the diverticulum, dimensional classification of the diverticulum, presence of diverticulitis, type of intervention, myotomy, resection of the diverticulum, re-intervention, intra-procedural complications, post-procedural complications, comorbidities, and to correlate the dimensions of the diverticula with the degrees of dysphagia at the patients with Zenker’s diverticulum. We have included in the study 36 patients with cervicomediastinal Zenker’s diverticula treated in the period 2010/ 2017 in two academic clinics: 7 patients with classic surgical method, at the Clinic of General and Oesophageal Surgery – Clinical Hospital “Sfanta Maria” of Bucharest, and 29 patients with endoscopic procedure, at the Department of Diagnostic and Interventional Digestive Endoscopy within the Regional Institute of Hepatology and Gastroenterology “Prof Dr Octavian Fodor” of Cluj-Napoca. The age of the patients was between 42 and 84 years old, and 15 patients were in their 70s. Comparing the patients aged below 70s (N=21) to the lot of patients aged above 70s (N=15), there is no statistically significant difference as regards gender, symptomatology, degree of dysphagia, dimension or degree of the diverticulum, presence of diverticulitis, type of intervention, period of hospitalization, presence of complications or necessity of re-intervention.
In the study lot, 55.6% of the patients had 2nd degree dysphagia. The ENT-related symptomatology was present at 10 patients out of the 36 who were in the study and consisted in dysphonia, cough, odynophagia, and was associated with oesophageal manifestations at 70% of the patients. Most of the patients had 1st and 2nd degree diverticula, only 4 patients had 3rd degree diverticula.
Comparing the dimensions of the diverticula, expressed in centimetres, with the degrees of dysphagia, upon the patients’ coming to the hospital, no statistical significance can be seen. The patients over 70 years old do not present more advanced stages of the disease, they do not need different treatment and they have no different prognostic as compared to the patients below 70. The patients without dysphagia had 1st and 2nd degree diverticula. Though not significant statistically, all the patients with 3rd degree diverticula had dysphagia.
Keywords: Zenker’s diverticulum, dysphagia, diverticulectomy, cricopharyngeal myotomy
Introduction
Zenker’s diverticulum is defined as a mucosa exteriorisation through the Killian’s triangle, an area of muscular weakness between the transversal fibres of the cricopharynx and the oblique fibres of the inferior constrictor. It was first described by Ludlow in 1767 [1]Zenker & Van Ziemssen reviewed the world literature, later, in 1877, and, since then, this type of diverticulum was called Zenker’s diverticulum [2]
Zenker’s diverticulum, also known as hypopharyngeal diverticulum, is a pouch-shaped excrescence of the mucosa and sub-mucosa, with the origin in pharyngoesophageal junction.
It is placed posteriorly to the pharyngoesophageal wall, through the dehiscence of Killian and it is delimited by the inferior pharyngeal constrictor muscle and by the transversal fibres of the cricopharyngeal muscle, which contributes at the development of the upper sphincter of the oesophagus [3].
It is considered that the incomplete relaxation of the upper sphincter of the oesophagus, determined by the fibrosis of the cricopharyngeal muscle, increases considerably the pressure in the hypopharynx and leads to the development of a pulsion diverticulum (Zenker) [3-5].
Though the diverticulum pathogenesis has not been completely understood yet, it is generally accepted that the diverticulum is the place of manifestation of a disorder of the upper sphincter of the oesophagus. Diverticulum appears because of the intraluminal increased pressure in the oropharynx during deglutition, due to the improper relaxation of the cricopharyngeal muscle and of the incomplete opening of the upper sphincter of the oesophagus, causing the prominence of the mucosa by means of an area of relative weakness, posteriorly to the pharyngoesophageal wall [3,6].
The noncompliant cricopharyngeal muscle presents structural modifications related to the histological decrease of the muscular component, combined with qualitative modifications of the fibres, increase of the fibrotic tissue and significant increase of the collage / elastin ratio [5, 6].
The aging process could play a part, because of the loss of tissue elasticity and the decrease of muscular tonus. Some authors talk about an anatomic predisposition [7].
This belief is backed by the occurring of rare family cases, besides geographical and racial differences [7,8] and also supported by the results of the morphometric and anthropometric studies of the Killian’s triangle, which show that the dimension of the triangle is correlated to the anthropometric features [9].
This could explain the geographic variations of the diverticulum incidence and male predominance. As the gastroesophageal reflux contributed at the cricopharyngeal dysfunction, a connection between the gastroesophageal reflux and the Zenker’s diverticulum has been eventually hypothesised, but never investigated consistently [8].
The changes brought to the modalities of treatment in the latest decades have represented a better understanding of the physiopathological mechanism during years. Focusing at present on the contribution of the cricopharyngeal muscle at the genesis of diverticulum, the treatment requires the myotomy of the cricopharyngeal muscle, independently from the additional procedure (oesophageal diverticulectomy, diverticulectomy or diverticulopexy) [10].
Zenker’s diverticulum has an annual incidence of 2 to 100,000 in the UK [3]. Though the epidemiological data are limited, the estimation of prevalence of dysphagia at persons above 50 years old varies from 16% to 22% [11- 13].
There is a geographical variation of its occurring, being more frequently in the Northern Europe [10]The annual estimated incidence is from 2 to 100,000, the prevalence being between 0.01 and 0.11% [8,11]Exact aetiology still remains unclear, the most accepted theory being the disorder of the pharyngoesophageal motility [11]Zenker’s diverticulum is caused by motor abnormalities of the oesophagus, including diffuse oesophageal spasm, achalasia, hyper-pressure of the lower sphincter of the oesophagus or unspecific abnormalities [14,15].
The most appropriate hypothesis is the increased pressure and the resistance at deglutition caused by abnormalities of the upper sphincter of the oesophagus. Zenker’s
diverticulum is usually seen at older adults, though it was also seen at children. Most patients come to the doctor’s after 60 years old (often, above 75 years old), the period of the symptoms varying from weeks to years. Due to some unclear reasons, most patients are men [16].
Despite all these, though the Zenker’s diverticulum is the most frequent type causing symptoms, its incidence and prevalence being underestimated, because many diverticula can remain clinically silent and many old patients, with small diverticula and minimum symptoms, do not ask for the doctor’s advice [11]. Typical symptoms of the Zenker’s diverticulum include:
dysphagia, regurgitation, chronic cough, aspiration and loss of weight [11]
The development of such diverticulum leads to the retention of food, which leads to a symptomatology characterised by: regurgitation, halitosis, aspiration and swallowing difficulties.
The patients with Zenker’s diverticulum shall usually have a long history of dysphagia, followed by a sensation of food getting stuck in the throat. Up to 98% of the patients accuse dysphagia. Other common symptoms include recurrent cough, fetor ex ore (halitosis) and inexplicable loss of weight [17].
Zenker’s diverticulum may produce a variety of symptoms and complications, such as aspiration pneumonia. The consequences of oropharyngeal dysphagia are severe:
dehydration, malnutrition, aspiration, choking, pneumonia and death. Besides, a very rare complication is the occurring of intra- diverticular carcinoma [18]. Ulceration and bleeding have been described due to the retention of aspirin in the diverticulum [19].
Zenker’s diverticulum us usually diagnosed by barium swallow. A second diverticulum is present at approximately 1% to 2% of the patients, but usually is a lot smaller than the first one [16].
Materials and methods
We have included in the study 36 patients with cervicomediastinal Zenker’s diverticula treated in the period 2010/ 2017 in two academic clinics: 7 patients with classic surgical method, at the Clinic of General and
Oesophageal Surgery – Clinical Hospital
“Sfanta Maria” of Bucharest, and 29 patients with endoscopic procedure, at the Department of Diagnostic and Interventional Digestive Endoscopy within the Regional Institute of Hepatology and Gastroenterology “Prof Dr Octavian Fodor” of Cluj-Napoca.
The distribution of the patients on gender was relatively equal - F/M - 15/21. The age of the patients was between 42 and 84 years old, and 15 patients were in their 70s. A large part of the patients included in the lot are in their 70s.
The patients included in the lot had comorbidities. Almost one quarter of the patients did not have comorbidities, and only one patient had an association of 4 comorbidities: atrial fibrillation, high-blood pressure, coronary ischemic disease and sigmoid diverticulosis. Upon hospitalisation, the patients included in the study presented various symptoms, both oesophageal - dysphagia, heartburn, sialorrhea -, and extra-oesophageal - dysphonia, odynophagia, cough. Most patients accused 3 symptoms – 41.7%. Dysphagia was a constant symptom upon their coming to the hospital.
The dimension of the diverticula was calculated both in centimetres and in degrees, depending on the Overbeeck classification, by corroborating the data obtained from the endoscopic exploration and the aspect of the barium swallow (Figure 1).
Most of the patients had 1st and 2nd degree diverticula; only 4 patients had 3rd degree diverticula (Figure 2)
Secondary diverticulitis, occurred because of the food stasis due to the retentive diverticula, was present at only 9 patients. The inflammation was seen at the histopathological exam of the endoscopic biopsy or at the surgical resection pieces (Figures 3 and 4).
The patients who did not have diverticulitis had mainly small sized-diverticula – 14 patients had 1st degree diverticula, and 13 patients had 2nd degree diverticula.
The cervical CT scan, though it is not a well-established method for the diagnosis of the Zenker’s diverticulum, is the principal method of differential diagnosis for the other disorders of the cervical oesophagus. The exploration offers important imagistic information as regards the dimension, content, communication
with the oesophageal lumen, development of the diverticular pouch, in relation with the neighboured structures, quality of the diverticular walls, presence of some associated oesophageal disorder. We sometimes performed this exploration to the patients included in the lot (Figure 5).
Figure 1 - Endoscopic aspect of the retentive Zenker’s diverticulum
Figure 2 - Barium swallow – Zenker’s diverticulum – front and latera views
Figure 3 - Fibro-connective tissue and fat tissue covered with squamous epithelium with reactive modifications with important lymphoplasmacytic inflammatory infiltrate with numerous su- epithelial neutrophils - HP aspect, HEx20
Figure 4 - Squamous epithelium with formation of reactive lymphoid follicles and sub-epithelial focal with intra-epithelial extension - HEx10
Figure 5 - Retentive Zenker’s diverticulum developed retro-pharyngeal, with hydro-air content.
Results
The distribution of the patients depending on gender was relatively equal- F/M- 15/21, as can be seen in Table 1 and Figure 6.
Gender Frequency (Nr)
Percent (%)
Valid
F 15 41.7
M 21 58.3
Total 36 100.0
Table 1 - Distribution of the patients depending on gender.
Figure 6 - Distribution of the patients depending on gender.
A large part of the patients included in the lot are in their 70s. Correlation of the age with other characteristics of the lot of patients is presented in Table 2
Comparing the lot of patients aged under 70s (N=21) to the lot of patients aged above 70s (N=15), there is no statistically significant difference as regards the gender, symptoms, degree of dysphagia, dimension or degree of the diverticulum, presence of diverticulitis, type of intervention, period of hospitalisation, presence of the complications or necessity of the re- intervention.
The patients included in the lot had comorbidities (see Table 3 and Figure 7).
Almost one quarter of the patients did not have comorbidities, and only one patient has an association of 4 comorbidities: atrial fibrillation, high-blood pressure, coronary ischemic disease and sigmoid diverticulosis.
Frequency Percent
Valid
0 8 22.2
1 8 22.2
2 11 30.6
3 8 22.2
4 1 2.8
Total 36 100.0 Table 3 - Distribution of the patients depending on the number of associated comorbidities
Figure 7 - Distribution of the patients depending on the number of associated comorbidities.
Age<=70 (N=21) Age>70 (N=15) P_value (test)
Gender=M 13/21 (61.9%) 8/15 (53.3%) 0.607052 (Pearson Chi-Square) Degree
1 2 3 4
2/21 (9.5%) 12/21 (57.1%) 4/21 (19.0%) 3/21 (14.3%)
0/15 (0.0%) 8/15 (53.3%) 5/15 (33.3%) 2/15 (13.3%)
0.409534 (Likelihood Ratio)
No_symptoms 1
2 3 4 5
7/21 (33.3%) 2/21 (5.9%) 10/21 (47.6%) 1/21 (4.8%) 1/21 (4.8%)
4/15 (26.7%) 3/15 (20.0%) 5/15 (33.3%) 2/15 (13.3%) 1/15 (6.7%)
0.723970 (Likelihood Ratio)
Period of hospitalisation
4.76±4.7424 3.00 [2.00, 6.50]
3.13±2.4746 2.00 [2.00, 3.00]
0.341542 (Mann-Whitney Test)
Symptomatology Post-intervention = Yes
7/21 (33.3%) 4/15 (26.7%) 0.728773 (Fisher's Exact Test)
Remaining dysphagia = Yes
7/21 (33.3%) 4/15 (26.7%) 0.728773 (Fisher's Exact Test)
Degree of dysphagia 0
1 2
14/21 (66.7%) 3/21 (14.3%) 4/21 (19.0%)
11/15 (73.3%) 2/15 (13.3%) 2/15 (13.3%)
0.888190 (Likelihood Ratio)
Sialorrhea=Da 3/21 (14.3%) 1/15 (6.7%) 0.625668 (Fisher's Exact Test) Dimension/Dimension 3.10±1.0910
3.00 [2.00, 4.00]
3.13±1.5522 3.00 [2.00, 4.00]
0.931482 (Student T)
Classification_dim 1
2 3
18/21 (38.1%) 10/21 (47.6%) 3/21 (14.3%)
6/15 (40.0%) 8/15 (53.3%) 1/15 (6.7%)
0.759120(Likelihood Ratio)
Diverticulitis=Yes 16/21 (76.2%) 11/15 (73.3%) 1.000000 (Fisher's Exact Test) Endoscopic
surgical intervention
5/21 (23.8%) 16/21 (76.2%)
2/15 (13.3%) 13/15 (86.7%)
0.673781 (Fisher's Exact Test)
Myotomy=Yes 20/21 (95.2%) 15/15 (100%) 1.000000 (Fisher's Exact Test) Resection_dv=Yes 5/21 (23.8%) 2/15 (13.3%) 0.673781 (Fisher's Exact Test) Re-intervention=Yes 5/21 (23.8%) 2/15 (13.3%) 0.673781 (Fisher's Exact Test) Intra-procedural
complications
2/21 (9.5%) 1/15 (6.7%) 1.000000 (Fisher's Exact Test)
Post-procedural complications
5/21 (23.8%) 1/15 (6.7%) 0.366680 (Fisher's Exact Test)
Comorbidities_ Yes/No 15/21 (71.4%) 13/15 (86.7%) 0.424054 (Fisher's Exact Test) Comorbidities_no
0 1 2 3 4
6/21 (28.6%) 5/21 (23.8%) 5/21 (23.8%) 4/21 (19.0%) 1/21 (4.8%)
2/15 (13.3%) 3/15 (20.0%) 6/15 (40.0%) 4/15 (26.7%) 0/15 (0.0%)
0.546018 (Likelihood Ratio)
High blood pressure 11/21 (52.4%) 8/15 (53.3%) 1.000000 (Fisher's Exact Test) Diabetes mellitus 3/21 (14.3%) 2/15 (13.3%) 1.000000 (Fisher's Exact Test) Dyslipidaemia 8/21 (38.1%) 6/15 (40.0%) 1.000000 (Fisher's Exact Test) Other diverticula 3/21 (14.3%) 1/15 (6.7%) 0.625668 (Fisher's Exact Test) Table 2- Correlation of the age with other characteristics of the lot of patient.
Upon hospitalisation, the patients included in the study had various symptoms, both oesophageal - dysphagia, heartburn, sialorrhea -, and extra-oesophageal: dysphonia, odynophagia, cough. Most patients accused 3 symptoms – 41.7% (see Table 4 and Figure 8).
Frequency (Nr)
Percent (%)
Valid
1 11 30.6
2 5 13.9
3 15 41.7
4 3 8.3
5 2 5.6
Total 36 100.0
Table 4 - Distribution of the patients depending on the number of symptoms present upon hospitalisation.
Dysphagia was a constant symptom of the patients, upon coming to the hospital. The determination of this symptom was made according to the dysphagia classification proposed by Mellow-Pinkas depending on the type of food that cannot be swallowed – degree 0 – no dysphagia, 1st degree - dysphagia for solid food, 2nd degree - dysphagia for semisolid food, 3rd degree - dysphagia for solid food and liquids and 4th degree – total dysphagia (incapacity to swallow the saliva). In the lot studied, 55.6% of the patients had 2nd degree dysphagia (see Table 5 and Figure 9).
Figure 8 - Distribution of the patients depending on the number of symptoms present upon hospitalization.
Frequency (Nr)
Percent (%)
Valid
1 2 5.6
2 20 55.6
3 9 25.0
4 5 13.9
Total 36 100.0
Table 5 - Distribution of the patients depending on the degree of dysphagia.
Figure 9 - Distribution of the patients depending on the degree of dysphagia.
The ENT-related symptomatology was present at 10 out of the 36 patients of the study and consisted of dysphonia, cough, odynophagia, and was associated to the oesophageal manifestations at 70% of the patients (see Table 6 and Figure 10).
sympt_ENT=Ye s (N=10)
sympt_ENT=No (N=25)
No_sy mpt 1 2 3 4 5
0/10 (0.0%) 0/10 (0.0%) 7/10 (70.0%) 1/10 (10.0%) 2/10 (20.0%)
11/26 (42.3%) 5/26 (19.2%) 8/26 (30.8%) 2/26 (7.7%) 0/26 (0.0%)
Table 6 - Distribution of the patients depending on the presence of ENT manifestations in relation to the general symptomatology.
Figure 10 - Distribution of the patients depending on the presence of ENT manifestations in relation to the general symptomatology of the patients.
The dimension of the diverticula was calculated both in centimetres and in degrees, depending on the Overbeeck classification, corroborating the data obtained from endoscopic exploration and the aspect of the barium swallow. A large part of the patients had 1st and 2nd degree diverticula, only 4 patients had 3rd degree diverticula (see Table 7 and Figure 11).
Classification of the dimension of diverticula Frequency
(Nr)
Percent (%)
Valid
1 14 38.9
2 18 50.0
3 4 11.1
Total 36 100.0
Table 7 - Distribution of the patients depending on the dimension of the diverticula.
Correlation between the degree of dysphagia and the dimensions of the diverticulum expressed in centimetres is shown in Table 8.
Comparing the dimensions of the diverticula expressed in centimetres with the degree of dysphagia upon presentation, no statistical significance is obtained (p_value=0.120283, Kruskal-Wallis Test).
Correlation between the degree of dysphagia and the dimensions of the diverticulum is shown in Table 9.
Figure 11 - Distribution of the patients depending on the dimension of the diverticula
Using the Overbeeck classification depending on the dimensions of the diverticulum and the implications of the degree of diverticulum in the occurring of dysphagia at the patients included in the study has led to the following conclusions: weak, statistically insignificant correlation (p_value= 0.068187) between the degrees of dysphagia and the dimensional degree of the diverticulum. The Table can be commended from the point of view of the percentages, per lines and columns:
At the 14 patients with 1st degree diverticulum, the degrees of dysphagia were: no dysphagia - 11 patients (78.6%), 1st degree dysphagia - one patient (7.1%) and 2 patients with 2nd degree dysphagia (14.3%). At the 18 patients with 2nd degree diverticula, the degrees of dysphagia were: no dysphagia - 14 patients (77.8%), 1st degree dysphagia – 2 patients (11.1%) and 2 patients had 2nd degree dysphagia (11.1%). At the 4 patients with 3rd degree diverticula, the degrees of dysphagia were: no dysphagia – no patient (0.0%), 1st degree dysphagia - 2 patients (50.0%) and 2nd degree dysphagia - 2 patients (50.0%). No dysphagia for 25 patients - 11 patients with 1st degree diverticula (44.0%), 14 patients with 2nd degree diverticula (56.0%) and no patient with 3rd degree diverticulum (0.0%).
Degree of dysphagia =0 (N=25)
Degree of dysphagia =1 (N=5)
Degree of dysphagia =1 (N=6)
P_value (test)
dim 2.76±0.7788 3.00
[2.00, 3.00]
4.40±2.3021 4.00
[2.50, 6.50]
3.50±1.3784 3.50
[2.00, 5.00]
0.120283 (Kruskal-Wallis Test)
Table 8 - Correlation between the degree of dysphagia and the dimensions of the diverticulum.
Degree of dysphagia
Total
0 1 2
Classification _dim
1
Count 11a 1a 2a 14
% within classification_dim 78.6% 7.1% 14.3% 100.0%
% within grad dysphagia 44.0% 20.0% 33.3% 38.9%
2
Count 14a 2a 2a 18
% within classification_dim 77.8% 11.1% 11.1% 100.0%
% within grad dysphagia 56.0% 40.0% 33.3% 50.0%
3
Count 0a 2b 2b 4
% within classification_dim 0.0% 50.0% 50.0% 100.0%
% within grad dysphagia 0.0% 40.0% 33.3% 11.1%
Total
Count 25 5 6 36
% within classification_dim 69.4% 13.9% 16.7% 100.0%
% within grad dysphagia 100.0% 100.0% 100.0% 100.0%
Each subscript letter denotes a subset of the degree of dysphagia categories whose column proportions do not differ significantly from each other at the .05 level.
Spearman's rho=0.307 (p_value= 0.068187)
Table 9 - Correlation between the degree of dysphagia and the dimensions of the diverticulum
Discussions
Zenker’s diverticulum is a pulsion diverticulum which takes place due to a natural weakness: the triangular area of the posterior wall of the hypopharynx, which is bordered by oblique muscular fibres of the lower pharyngeal constrictor muscle and by the horizontal muscular fibres of the cricopharyngeal muscle, called Killian’s triangle. The cricopharyngeal muscle marks the upper limit of the oesophagus and is part of the upper sphincter of the oesophagus [20-22].
The patients included in the lot were middle-aged and 41% of the patients were old persons, particularly in their 70s and 80s, aspect similar with other studies. Comparing the lot of
patients below 70s (N=21) to the lot of patients above 70 (N=15), we did not observe differences as regards gender, symptomatology, degree of dysphagia, dimension or degree of diverticulum.
Male gender predominated: B/F 21/15 comparatively to the data from literature [8, 11].
Associated diseases had 28/36 patents included in the lot, respectively: atrial fibrillation, high-blood pressure, coronary ischemic disease, sigmoid diverticulosis, characteristic similar to the data from literature [23].
The patients included in the study presented various symptoms, both oesophageal:
dysphagia, heartburn, sialorrhea, and extra- oesophageal: dysphonia, odynophagia, cough.
Most patients accused 3 symptoms – 41.7%.
Dysphagia was a constant symptom when they came to the hospital, more than half of the patients included in the study had 2nd degree dysphagia, aspect met in other studies [24, 25].
The regurgitation of the food residues, non-digested because of the food retention in the diverticulum, the pharyngeal stasis of secretion, chronic cough, chronic aspiration, halitosis, sensation of foreign body stuck in the throat, hoarseness and cervical gurgling were aspects that we met at the patients of the lot [11].
The retention of the pills in the diverticulum is an additional preoccupation at the patients with severe comorbidities, who receive medication therapy [26].
Other authors have also signalled other manifestations, such as morning regurgitations – the patient can observe the presence of the food on the pillow after waking up in the morning [3].
All the patients included in the lot have been subject to imagistic explorations, such as barium swallow. A barium studio is the main element in the diagnosis of the Zenker’s diverticulum, which allows the determination of its dimension and place. The dimensional evaluation of the diverticula has led to an average of 3 cm without significant age-related differences. The careful endoscopic evaluation is compulsory, in order to exclude the malignity, exploration that we made as a routine on our patients from the lot, aspects also emphasised in other studies in literature [7,10].
The Lahey, Mortons and Van Overbeek systems are used to evaluate the Zenker’s diverticulum. These measurement systems are used to describe the degree of the Zenker’s diverticulum, depending on the dimension of the pouch. The barium swallow with videofluoroscopy is the radiological method used to decide on the stage of the disease [27].
We have used this quantification method at the patients included in the lot. Most patients had 1st degree diverticula - 14 patients and 2nd degree diverticula 2 – 18 patients, only 4 patients had 3rd degree diverticula.
The treatment for Zenker’s diverticulum is indicated, no matter its dimension, in order to improve the symptoms of oropharyngeal dysphagia, regurgitation and to prevent life-
threatening complications - aspiration pneumonia and pulmonary abscess, which occur frequently at old aged persons. The low nutritional intake associated to the swallowing problem and the tendency of the diverticulum to increase gradually represent additional arguments in favour of precocious treatment.
Conclusions
The patients above 70 years old do not present more advanced stages of diseases, do not require a different treatment and do not have a different prognosis in comparison to the patients above 70 years old.
The patients who did not have dysphagia had 1st and 2nd degree diverticula. Though not statistically significant proven, all the patients with 3rd degree diverticula had dysphagia.
References
[1]Ludlow A. A case of obstructive deglutition from a preternatural dilatation of a bag formed in pharynx. Med Observation Inquiries.
1767;3:85.
[2]Zenker FA, Van Ziemssen H. Krankheiten des oesophagus. In: Van Ziemssen H, editor.
Handbuch der specielen pathologie und therapie.
Leipzig: Fc Vogel; 1877. p. P.1.
[3]Cook IJ, Gabb M, Panagopoulos V, et al.
Pharyngeal (Zenker's) diverticulum is a disorder of upper esophageal sphincter opening.
Gastroenterology. 1992;103:1229–1235.
[4]Shaw DW, Cook IJ, Jamieson GG, Gabb M, Simula ME, Dent J. Influence of surgery on deglutitive upper oesophageal sphincter mechanics in Zenker's diverticulum. Gut.
1996;38:806–811.
[5]Venturi M, Bonavina L, Colombo L, Antoniazzi L, Bruno A, Mussini E, Peracchia A.
Biochemical markers of upper esophageal sphincter compliance in patients with Zenker's diverticulum. J Surg Res. 1997;70:46–48.
[6]Zaninotto G, Costantini M, Boccù C, et al.
Functional and morphological study of the cricopharyngeal muscle in patients with Zenker's diverticulum. Br J Surg.
1996;83:1263–1267.
[7]Overbeek JJ. Pathogenesis and methods of treatment of Zenker's diverticulum. Ann Otol Rhinol Laryngol. 2003;112:583–593.
[8]Ferreira LE, Simmons DT, Baron TH.
Zenker's diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. Dis Esophagus. 2008;21:1–8.
[9]Anagiotos A, Preuss SF, Koebke J.
Morphometric and anthropometric analysis of Killian's triangle. Laryngoscope.
2010;120:1082–1088.
[10]Herbella FA, Patti MG. Modern pathophysiology and treatment of esophageal diverticula. Langenbecks Arch Surg.
2012;397:29–35.
[11]Siddiq MA, Soods S, Strachan D. Zenker's diverticulum. Postgraduate Med J. 2001 Aug;77(910):506–11.
[12]Bloem BR, Lagaay AM, Van Beek W, Haan J, Roos Rac, Wintzen AR. Prevalence of subjective dysphagia in community residents aged over 87. Br Med J. 1990;300(6726):721–
722.
[13]Lindgren S, Janzon L. Prevalence of swallowing complaints among 50 - 70 years old men & women in an urban population.
Dysphagia. 1991;6(4):187–192
[14]D'ugo D, Cardillo G, et al. Oesophageal diverticula, physiopathological basis of surgical treatment. Eur J cardiothorac Surg.
1992;6(6):330–4.
[15]Fekete F, Vonns C. Surgical management of oesophageal thoracic diverticula.
Heptogastroenterology. 1992 Apr;39(2):97–9.
[16]Mulder CJ, Costamagna G, Sakai P.
Zenker's diverticulum: treatment using a flexible endoscope. Endoscopy.2001 Nov;33(11):991–7.
[17].Nesheiwat Z, Antunes C.Zenker Diverticulum. SourceStatPearls [Internet]Treasure Island (FL): StatPearls Publishing; 2018-.2018 Apr 15.
[18]Payne WS. The treatment of pharyngoesophageal diverticulum: the simple &
complex.Hepatogastroenterology. 1992 Apr;39(2):109–14.
[19]Kensing KP, et al. Massive bleeding from Zenker's diverticulum: a case report & review of literature. South Med J. 1994 Oct;87(10):1003–
4.
[20]Bizotto A, Iacopini F, Landi R, et al.
Zenker's diverticulum: exploring treatment options. Acta Otorhinolaryngol Ital 2013;33:219–29.
[21]Verdonck J, Morton RP. Systematic review on treatment of Zenker's diverticulum. Eur Arch Otorhinolaryngol2015;272:3095–107.
[22]Aggarwal N, Thota PN. Are there alternatives to surgery for Zenker diverticulum?
Cleve Clin J Med2016;83:645–7.
[23]David J. Case, Todd H. Baron Flexible Endoscopic Management of Zenker Diverticulum: The Mayo Clinic Experience Mayo Clin Proc. 2010 Aug; 85(8): 719–722.
[24]Siboni S, Asti E, Sozzi M, Bonitta G, Melloni M, Bonavina L.Respiratory Symptoms and Complications of Zenker Diverticulum:
Effect of Trans-Oral Septum Stapling. J Gastrointest Surg. 2017 Sep;21(9):1391-1395.
[25]Moawia Elbalal, Abu Baker Mohamed, Anas Hamdoun, Khalid Yassin, Elhadi Miskeen, Osman Khalaf Alla Zenker's diverticulum: a case report and literature review Pan Afr Med J.
2014; 17: 267.
[26]Hannan SA, Alusi G. Images in clinical medicine. Zenker's diverticulum. N Engl J Med.
2006;354:e24.
[27].Nesheiwat Z, Antunes C.Zenker Diverticulum. SourceStatPearls [Internet]Treasure Island (FL): StatPearls Publishing; 2018-.2018 Apr 15.
