ZENKER'S DIVERTICULUM, A RARE CAUSE OF UPPER

Rev. Med. Chir. Soc. Med. Nat., Iaşi – 2013 – vol. 117, no. 2

INTERNAL MEDICINE - PEDIATRICS

ORIGINAL PAPERS

ZENKER’S DIVERTICULUM, A RARE CAUSE OF UPPER GASTROINTESTINAL BLEEDING C. Bălălău1 , S. Stoian1 , I. Motofei 1, B. Popescu 2, F. Popa1, R.V. Scăunaşu2 ”Carol Davila” University of Medicine – Bucharest 1. “St. Pantelimon” Emergency Universitary Hospital 2. “Coltea” Universitary Hospital ZENKER’S DIVERTICULUM, A RARE CAUSE OF UPPER GASTROINTESTINAL BLEEDING (Abstract): The most common complication of Zenker’s diverticulum is aspiration pneumonia, compression of the trachea and esophageal obstruction with large diverticulum, and increased risk of development of carcinoma. Thus bleeding occurs rarely, can be massive and life threatening, with ulceration being the most common cause. Material and methods: We describe a patient with sever upper gastrointestinal bleeding as a result of a Zenker’s diverticulum. A 75 year-old woman was referred to the emergency room and hospitalized for hematemesis, melena, asthenia and total dysphagia. In this parti cular case we preferred open technique because of the diverticulum dimensions and bleeding episode. Left cervicotomy was practiced on the anterior edge of the sternocleidomastoid muscle, being known that Zenker diverticulum extend into the left neck 90% of the time, fact also confirmed by radiology in this case. Results: Postoperatively, the patient showed a complication free recovery. Five days after treatment the patient resumed nourishment. Several days later our patient was able to return home. Follow-up at 12 months after the operation showed complete recovery. Ulcer of the basis of Zenker's diverticulum is a rare entity and, only a few cases were reported in the literature to date. Omitting thecricomyotomy predisposes to fistula or diverticulum recurrence due to the persistence of a high pharyngeal intraluminal pressure that acts on the posterior wall just proximal to the upper esophageal sphincter. Conclusions:Zenker's diverticulum is an unusual site of origin for clinically significant u pper gastrointestinal hemorrhage and differential diagnosis must include other more frequent causes of upper gastrointestinal bleeding. In our opinion, classicalsurgical therapy is indica ted when distal esophageal imaging cannot be obtained during endoscopic examination, there is a large diverticulum or in an emergency setting when fast control over the bleeding source is required. Keywords: ZENKER’S DIVERTICULUM, GASTROINTESTINAL BLEEDING, CERVICOTOMY

Zenker’s diverticulum is a pulsion-type diverticulum of the hypo pharynx, the result of herniation of the esophageal mucosa and submucosa through the area of natural weakness known as Killian’s triangle. It is hypothesized that abnormal activity in the cricopharyngeus muscle results in an

uncoordinated swallowing mechanism, which, coupled with increased intraluminal pressure, results in the slow, progressive distention and herniation of the pharynx mucosa (1). The incidence of Zenker’s Diverticulum is estimated at 2 per 100,000, with highest prevalence rates in the 7th and

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8th decades of life. Risk factors for development of Zenker’sdiverticulum include presence of hiatal hernia and/or gastro esophageal reflux disorder (GERD), male gender and age (1, 2). The most common complication of Zenker’s diverticulum is aspiration pneumonia, compression of the trachea and esophageal obstruction with large diverticulum, and increased risk of development of carcinoma (3). Thus bleeding occurs rarely, can be massive and life threatening, with ulceration being the most common cause. Since its description by Zenker and von Ziemssen in 1877, numerous surgical techniques have been developed to treat the diverticulum. Initially, transcervical resec-

tion of the diverticular pouch has been the procedure of choice (4). However, the diverticular sac is in fact a consequence of the high pharyngeal pressure secondary to a lack of compliance of the cricopharyngeus muscle in relation to local fibrosis. Consequently, due to unacceptably high rate of recurrence, cricopharyngeal myotomy (CPM) was recommended for the management of the physiologic abnormality (5, 6). Endoscopic therapy can be applied in two forms, either by the application of diathermic or laser coagulation, or stapling technique, which allowed an endoscopic suture of the cut margins (7, 8, 9, 10) (tab. I). Size of the diverticulum determines which procedure to carry out (11, 12) (tab. II).

TABLE I Endoscopic and open techniques Endoscopic techniques Open techniques Endoscopic stapled diverticulostomy CPM CPM with diverticulectomy CO2 laser / Electrocautery CPM with diverticulopexy TABLE II Criteria of the Morton and Bartley Criteria Surgical technique I. Small sacs are less than 2 cm in length CP myotomy alone is sufficient II. Intermediate sacs are 2-4 cm in length Endoscopic or open procedure can be used III. Large sacs are greater than 4 cm in Open surgery length We describe a patient with sever upper gastrointestinal bleeding as a result of a Zenker’s diverticulum. A 75 year-old woman was referred to the emergency room and hospitalized for hematemesis, melena, asthenia and total dysphagia. She was known to have endured various respiratory tract infections in the previous several months and had difficulty to swallow solid foods for a few months. During the

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previous few days the ingestion of fluids had become impossible. The clinical exam reveals pallor, evidence of dehydration and a 5 by 3 cm palpable tumor on the left side of the neck. Patient was tachycardic but with normal blood pressure. Blood exams shows moderate anemia. Esophagography with barium revealed a medium to voluminous pharyngo-esophageal diverticulum.

Zenker’s diverticulum, a rare cause of upper gastrointestinal bleeding

Surgical treatment was decided. In this particular case we preferred open technique because of the diverticulum dimensions and bleeding episode. Left cervicotomy was practiced on the anterior edge of the sternocleidomastoid muscle, being known that Zenker diverticulum extend into the left neck 90% of the time, fact also confirmed by radiology in this case. The omohyoid muscle was cleaved and the superior thyroidian artery and vein were ligated and cleaved, in order to obtain suita-

ble diverticulum exposure. The recurrent laryngeal nerve was identified and protected. The diverticulum, with a diameter of approximately 3-4 cm, is identified and dissected (fig. 1). A Faucher probe was passed with some difficulty into the distal esophagus. Esophageal and crico-pharyngeus muscles are longitudinally divided for 3-4 cm. Mechanical suture at the base of the diverticulum is practices with aid of a TA 30/3.5 stapler (fig. 2). The diverticulum is sectioned close to the stapler (fig. 3).

Fig. 1. The diverticulum, identified and dissected

Fig. 2. Mechanical suture at the base of the diverticulum

Fig. 3 The diverticulum is sectioned close to the stapler Final aspect after removing stapler and control of suture sealing and hemostasis (fig. 4). The excised diverticulum containing traces of barium from previous exami-

nation (fig. 5). Paraesophageal drainage through counter incision was preferred ostoperatively, the patient showed a complication free recovery. Five days after

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treatment the patient resumed nourishment. Several days later our patient was able to

return home. Follow-up at 12 months after the operation showed complete recovery.

Fig. 4. Final aspect after removing stapler

Fig. 5. The excised diverticulum

DISCUSSION AND CONCLUSIONS As a summary, the case is rare complication of Zenker's diverticulum that was initially misdiagnosed as having esophageal varices. Ulcer of the basis of Zenker's diverticulum is a rare entity and, only a few cases were reported in the literature to date (1, 5, 6). The diverticulum had a deep ulceration that was the source of the bleeding. The cause of the ulceration is unknown but it is possible that the ulcer has been caused by chronic NSAID or other ulcerogenicdrugs prescribed for prior respiratory infections. Chronic alcohol abuse was the other contributing factor, known to predispose ulcer formation by facilitating the development of gastroesophageal reflux and stimulation of acid secretion (7, 8, 9).

Zenker's diverticulum is an unusual site of origin for clinically significant upper gastrointestinal hemorrhage and differential diagnosis must include other more frequent causes of upper gastrointestinal bleeding (10, 11). In our opinion, classical surgical therapy is indicated when distal esophageal imaging cannot be obtained during endoscopic examination, there is a large diverticulum or in an emergency setting when fast control over the bleeding source is required. Omitting thecricomyotomy predisposes to fistula or diverticulum recurrence due to the persistence of a high pharyngeal intraluminal pressure that acts on the posterior wall just proximal to the upper esophageal sphincter (12, 13).

REFERENCES 1. Ferreira L, Simmons D, Baron T. Zenker’s diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. Dis Esophagus 2008; 21: 1−8. 2. D’souza JN, Underbrink M. The University Of Texas Medical Branch, Department Of Otolaryngology, Grand Rounds Presentation, May 28, 2010. 3. Dionigi G, Sessa F, Rovera F, Boni L, Carrafiello G, Dionigi R. Ten year survival after excision of squamous cell cancer in Zenker’s diverticulum: report of a case. World J SurgOncol 2006; 4: 17-21.

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4. Aly A, Devitt PG, Jamieson GG. Evolution of surgical treatment for pharyngeal pouch. Br J Surg 2004; 9: 657-664. 5. Keck T, Rozsasi A, Grün PM. Surgical treatment of hypopharyngeal diverticulum (Zenker’s diverticulum). Eur Arch Otorhinolaryngol 2010; 267: 587−592. 6. Leporrier J, Salamé E, Gignoux M, Ségol P. Zenker’sdiverticulum: diverticulopexy versus diverticulectomy. Ann Chir 2001; 126: 42−45. 7. Hang CWD, Urkey BB, Netterville JI, Courey MS, Garrett CG, Bayles WS. Carbon dioxide laser endoscopic diverticultomy versus open diverticulotomy for Zenker’s diverticulum. Laryngoscope 2004; 114 (3): 519-527. 8. Bonavina L, Bona D, Abraham M, Saino G, Abate E. Long-term results of Endosurgical and open surgical approach for Zenker diverticulum. World J Gastroenterol 2007; 13(18): 2586-2589. 9. Vogelsang A, Schumacher B, Neuhaus H. Therapy of Zenker’s diverticulum. DtschArzteblInt 2008; 105: 120−126. 10. Sen P, Lowe Da, Farnan T. Surgical interventions for pharyngeal pouch. Cochrane Database Syst Rev 2005: Cd004459 11. C. Ummels C, Konsten J, Janzing H, SassenS. Classical operative therapy for Zenker’s diverticulum. ActaChirBelg 2007; 107: 557-559. 12. Sideris L, Chen LQ, Ferraro P, et al. The treatment of Zenker’s diverticula: a review. SeminThoracCardiovascSurg 1999; 11: 337–51. 13. Hauters Ph, SegolPh, Leroux Y, Et Al. Place de la myotomie du cricopharyngien associée à une diverticulopexie dans le traitement du diverticule de Zenker (quinze années d’experience). Ann Chir 1988; 42: 726–730.

NEWS NOUTĂȚI MALIGNANT MESOTHELIOMA: NONASBESTOS-RELATED ASSOCIATIONS It should be realized that although there is a strong link between the development of malignant mesothelioma (MM) and asbestos exposure, not all cases are etiologically related to asbestos exposure. The proportion of cases attributable to asbestos exposure varies between the sexes and country, according to occupation and use of amphibole asbestos. A number of other agents have been implicated in the causation of MM but the best evidence appears to relate to another mineral fiber (erionite) and to irradiation. However, there is strong experimental, epidemiologic and molecular evidence to suggest a possible carcinogenic or cocarcinogenic role of viruses such as simian virus 40 (SV40), a monkey polyoma virus, in the induction of MM. Malignant mesothelioma has followed 20 years after plombage therapy with lucite spheres for tuberculosis. Additional cases have been associated with chronic empyema, chronic peritonitis, induced pneumothroax for tuberculosis, and familial Mediterranean fever. (Jasani B, Gibbs A. Mesothelioma not associated with asbestos exposure. Arch Pathol Lab Med. 2012;136:262–267). Doina Butcovan

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