Összefoglaló. Bevezetés: A musculus cricopharyngeus flexibilis endoszkópos myotomiája a tüneteket okozó Zenker-diverticulum hatékony, biztonságos kezelési módszere. Célkitűzés és módszer: Retrospektíven elemeztük a hagyományos flexibilis endoszkópos myotomia eljárással szerzett tapasztalatainkat. Eredmények és megbeszélés: 2012. szeptember és 2020. február között 38 betegnél történt flexibilis endoszkópos myotomia tüneteket okozó Zenker-diverticulum miatt; összesen 47 myotomiát végeztünk. Betegeink többsége férfi (23/38), az átlagéletkor 71,5 év (40–88) volt. A diverticulumok átlagos mérete 3,94 (2–10) cm volt. A legtöbb esetben divertikuloszkópot alkalmaztunk, szabad kezes vágási technikára 8 esetben volt szükség. Betegeink tüneteit a kezelés előtt és azt követően a DRC- (dysphagia, regurgitatio, komplikációk) skála szerint értékeltük. A jelentősebb szövődmények előfordulása 4,2% (2/47) volt, a beavatkozással összefüggésbe hozható mortalitás nem fordult elő. Pneumomediastinum 1 betegnél alakult ki, melyet konzervatívan sikeresen kezeltünk. Beavatkozás közbeni vérzés 8 esetben (17%) jelentkezett, ezeket a beavatkozás során sikeresen megállítottuk. 1 esetben korai, kiújuló masszív vérzés miatt sürgős műtétre volt szükség. Mind a 38 beteget követtük, átlagosan 34,7 hónapig. A klinikai sikeresség 1,5 hónapnál 91,9% volt (34/37). 3 betegnek maradtak tünetei, kettőjüknél remyotomia történt, egyikük később műtétre szorult, 1 beteg pedig percutan endoszkópos gastrostomián esett át 18 hónap után. A hosszú távú követés során a teljes sikeresség (DRC<2) 78,4% volt (29/37), míg lényeges klinikai javulást (DRC: 0/1/2) a betegek 89,2%-ában (33/37) sikerült elérnünk. Következtetés: Eredményeink megerősítik, hogy a hagyományos flexibilis endoszkópos myotomia biztonságos, hatékony a tüneteket okozó Zenker-diverticulum kezelésében. Orv Hetil. 2022; 163(17): 677–687.
Summary. Introduction: In the treatment of symptomatic Zenker’s diverticulum, the flexible endoscopic myotomy of the cricopharyngeal muscle is considered to be a safe and effective technique. Objective and method: We retrospectively analyzed our experiences with conventional flexible endoscopic myotomy. Results and discussion: 38 patients with symptomatic Zenker’s diverticulum were treated with flexible endoscopic myotomy and 47 myotomies were performed from September 2012 until February 2020. Most of our patients were male (23/38), with an average age of 71.5 (40–88) years. The mean size of diverticula was 3.94 (2–10) cm. In most cases, we used diverticuloscope, while free-hand technique was needed in 8 cases. We assessed our patients’ symptoms by applying DRC (dysphagia, regurgitation, complication) score before the treatment and during follow-up. The overall rate of significant complications was 4.2% (2/47), and there was no procedure-related mortality. We observed pneumomediastinum in one patient that was treated conservatively. Intraprocedural bleeding occurred in several (8/47) cases, in all of them the bleeding was successfully stopped during intervention. In one of them, early recurrent massive bleeding required urgent surgery. All 38 patients were followed (mean 34.7 months). Clinical success at 1.5 months was 91.9% among endoscopically treated patients (34/37). 3 patients remained symptomatic, 2 of them were treated with re-myotomy, 1 of them needed surgery later on, another patient underwent percutan endoscopic gastrostomy at 18 months. Over long-term period, complete success (DRC<2) was 78.4% (29/37), while clinical success (DRC: 0/1/2) reached in 89.2% (33/37). Conclusion: Our experiences confirmed that conventional method of flexible endoscopic myotomy is safe and effective for the treatment of Zenker’s diverticulum symptoms. Orv Hetil. 2022; 163(17): 677–687.
Gyökeres T. Endoscopic treatment of Zenker’s diverticulum. [A Zenker divertikulum endoszkópos kezelése]. In: Bene L, Gyökeres T, Pap Á. (eds.) Emésztőszervi endoszkópia.] Medicina Könyvkiadó, Budapest, 2015; pp. 147–149. [Hungarian]
Nesheiwat Z, Antunes C. Zenker diverticulum. [Updated: 2021 Aug 11.] StatPearls Publishing LLC, Treasure Island, FL), 2022. Available from: http://www.ncbi.nlm.nih.gov/books/nbk499996/ [frissítve: August 11, 2021.]
Ferreira LE, Simmons DT, Baron TH. Zenker’s diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. Dis Esophagus 2008; 21: 1–8.
Herbella FA, Patti MG. Modern pathophysiology and treatment of esophageal diverticula. Langenbecks Arch Surg. 2012; 397: 29–35.
Watemberg S, Landau O, Avrahami R. Zenker’s diverticulum: reappraisal. Am J Gastroenterol. 1996; 91: 1494–1498.
Cook IJ, Blumbergs P, Cash K, et al. Structural abnormalities of the cricopharyngeus muscle in patients with pharyngeal (Zenker’s) diverticulum. J Gastroenterol Hepatol. 1992; 7: 556–562.
Ishaq S, Siau K, Lee M, et al. Long-term success of flexible endoscopic septal division with the stag beetle knife for Zenker’s diverticulum: a tertiary center study. Dis Esophagus 2020; 33: doaa019.
Lara LF, Erim T, Pimentel R. Diamond-shaped flexible endoscopic cricopharyngeal myotomy for treatment of Zenker’s diverticulum. Gastrointest Endosc. 2015; 82: 403.
Pang M, Koop A, Brahmbhatt B, et al. Comparison of flexible endoscopic cricopharyngeal myectomy and myotomy approaches for Zenker-diverticulum repair. Gastrointest Endosc. 2019; 89: 880–886.
Ludlow A. A case of obstructive deglutition from a preternatural dilatation of a bag formed in pharynx. Med Observation Inquiries 1767; 3: 85.
Zenker FA, von Ziemssen H. Handbook of special pathology and therapy. In: von Ziemssen H. (ed.) Diseases of the esophagus. [Handbuch der Speciellen Pathologie und Therapie. Krankheiten des Oesophagus.] FCW Vogel, Leipzig, 1877; 7(Suppl) pp. 1–87. [German]
Dohlman G, Mattsson O. The endoscopic operation for hypopharyngeal diverticula: a roentgencinematographic study. Arch Otolaryngol. 1960; 71: 744–752.
Collard JM, Otte JB, Kestens PJ. Endoscopic stapling technique of esophagodiverticulostomy for Zenker’s diverticulum. Ann Thorac Surg. 1993; 56: 573–576.
Martin-Hirsch DP, Newbegin CJ. Autosuture GIA gun: a new application in the treatment of hypopharyngeal diverticula. J Laryngol Otol. 1993; 107: 723–725.
Andrási L, Ábrahám S, Simonka Z, et al. A comparative study of short- and long-term outcomes for transcervical versus transoral surgery for Zenker-diverticulum. [A Zenker-diverticulumok transcervicalis és transoralis sebészi kezelésének összehasonlító vizsgálata, rövid és hosszú távú eredmények.] Orv Hetil. 2019; 160: 629–635. [Hungarian]
Lázár G, Rovó L, Szentpáli K, et al. Endoscopic stapling diverticulostomy for Zenker-diverticulum. [Endoszkópos varrógéppel képzett diverticulostoma a Zenker-diverticulum kezelésére.] Orv Hetil. 2004; 145: 15–17. [Hungarian]
Bonavina L, Aiolfi A, Scolari F, et al. Long-term outcome and quality of life after transoral stapling for Zenker diverticulum. World J Gastroenterol. 2015; 21: 1167–1172.
Verdonck J, Morton RP. Systematic review on treatment of Zenker’s diverticulum. Eur Arch Otorhinolaryngol. 2015; 272: 3095–3107.
Sakai P. Evolving flexible endoscopic treatment of Zenker’s diverticulum. Gastrointest Endosc. 2019; 89: 887–888.
Richtsmeier WJ. Myotomy length determinants in endoscopic staple-assisted esophagodiverticulostomy for small Zenker’s diverticula. Ann Otol Rhinol Laryngol. 2005; 114: 341–346.
Faiss S, Falck S, Cordruwisch W, et al. New flexible endoscopic controlled stapler technique for the treatment of Zenker’s diverticulum. Scand J Gastroenterol. 2015; 50: 1512–1515.
Mulder CJ, den Hartog G, Robijn RJ, et al. Flexible endoscopic treatment of Zenker’s diverticulum: a new approach. Endoscopy 1995; 27: 438–442.
Ishioka S, Sakai P, Maluf-Filho F, et al. Endoscopic incision of Zenker’s diverticula. Endoscopy 1995; 27: 433–437.
Ishaq S, Sultan H, Siau K, et al. New and emerging techniques for endoscopic treatment of Zenker’s diverticulum: state-of-the-art review. Dig Endosc. 2018; 30: 449–460.
Case DJ, Baron TH. Flexible endoscopic treatment of Zenker’s diverticulum: the Mayo Clinic experience. Mayo Clin Proc. 2010; 85: 719–722.
Costamagna G, Iacopini F, Tringali A, et al. Flexible endoscopic Zenker’s diverticulotomy: cap-assisted technique vs. diverticuloscope-assisted technique. Endoscopy 2007; 39: 146–152.
Rabenstein T, May A, Michel J, et al. Argon plasma coagulation for flexible endoscopic Zenker’s diverticulotomy. Endoscopy 2007; 39: 141–145.
Aiolfi A, Scolari F, Saino G, et al. Current status of minimally invasive endoscopic management for Zenker diverticulum. World J Gastrointest Endosc. 2015; 7: 87–93.
Pugliese F, Dioscoridi L, Forgione A, et al. Cricopharyngeal myotomy with flexible endoscope for Zenker’s diverticulum using hook knife and endoclips (with video describing an objective measurement of the cutting length). Esophagus 2018; 15: 122–126.
Christiaens P, De Roock W, Van Olmen A, et al. Treatment of Zenker’s diverticulum through a flexible endoscope with a transparent oblique-end hood attached to the tip and a monopolar forceps. Endoscopy 2007; 39: 137–140.
Evrard S, Le Moine O, Hassid S, et al. Zenker’s diverticulum: a new endoscopic treatment with a soft diverticuloscope. Gastrointest Endosc. 2003; 58: 116–120.
Vogelsang A, Preiss C, Neuhaus H, et al. Endotherapy of Zenker’s diverticulum using the needle-knife technique: long-term follow up. Endoscopy 2007; 39: 131–136.
Huberty V, El Bacha S, Blero D, et al. Endoscopic treatment for Zenker’s diverticulum: long-term results (with video). Gastrointest Endoosc. 2013; 77: 701–707.
Perbtani Y, Suarez A, Wagh MS. Techniques and efficacy of flexible endoscopic therapy of Zenker’s diverticulum. World J Gastrointest Endosc. 2015; 7: 206–212.
Battaglia G, Antonello A, Realdon S, et al. Flexible endoscopic treatment for Zenker’s diverticulum with the SB knife. Preliminary results from a single-center experience. Dig Endosc. 2015; 27: 728–733.
Nielsen HU, Trolle W, Rubek N, et al. New technique using LigaSure for endoscopic mucomyotomy of Zenker’s diverticulum: diverticulotomy made easier. Laryngoscope 2014; 124: 2039–2042.
Dzeletovic I, Ekbom DC, Baron TH. Flexible endoscopic and surgical management of Zenker’s diverticulum. Expert Rev Gastroenterol Hepatol. 2012; 6: 449–466.
Ishaq S, Hassan C, Antonello A, et al. Flexible endoscopic treatment for Zenker’s diverticulum: a systematic review and meta‐analysis. Gastrointest Endosc. 2016; 83: 1076–1089.e5.
Weusten BLAM, Barret M, Bredenoord AJ, et al. Endoscopic management of gastrointestinal motility disorders – part 2: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 600–614. Erratum: Endoscopy 2020; 52(7): C7.
Repici A, Pagano N, Romeo F, et al. Endoscopic flexible treatment of Zenker’s diverticulum: a modification of the needle-knife technique. Endoscopy 2010; 42: 532–535.
Rouquette O, Abergel A, Mulliez A, et al. Usefulness of the Hook knife in flexible endoscopic myotomy for Zenker’s diverticulum. World J Gastrointest Endosc 2017; 9: 411–416.
Gölder SK, Brueckner J, Ebigbo A, et al. Double incision and snare resection in symptomatic Zenker’s diverticulum: a modification of the stag beetle knife technique. Endoscopy 2018; 50: 137–141.
Albers DV, Kondo A, Bernardo WM, et al. Endoscopic versus surgical approach in the treatment of Zenker’s diverticulum: systematic review and meta-analysis. Endosc Int Open 2016; 4: E678–E686.
Yuan Y, Zhao YF, Hu Y, et al. Surgical treatment of Zenker’s diverticulum. Dig Surg. 2013; 30: 207–218.
Costamagna G, Iacopini F, Bizzotto A, et al. Prognostic variables for the clinical success of flexible endoscopic septotomy of Zenker’s diverticulum. Gastrointest Endosc. 2016; 83: 765–773.
Brueckner J, Schneider A, Messmann H, et al. Long-term symptomatic control of Zenker diverticulum by flexible endoscopic mucomyotomy with the hook knife and predisposing factors for clinical recurrence. Scand J Gastroenterol. 2016; 51: 666–671.
Antonello A, Ishaq S, Zanatta L, et al. The role of flexible endotherapy for the treatment of recurrent Zenker’s diverticula after surgery and endoscopic stapling. Surg Endosc. 2016; 30: 2351–2357.
Yang J, Zeng X, Yuan X, et al. An international study on the use of per-oral endoscopic myotomy (POEM) in the management of esophageal diverticula: the first multicenter D-POEM experience. Endoscopy 2019; 51: 346–349.
Brewer Gutierrez OI, Ichkhanian Y, Spadaccini M, et al. Zenker’s diverticulum per-oral endoscopic myotomy techniques: changing paradigms. Gastroenterology 2019; 156: 2134–2135.
Li QL, Chen WF, Zhang XC. Submucosal tunneling endoscopic septum division: a novel technique for treating Zenker’s diverticulum. Gastroenterology 2016; 151: 1071–1074.
Ishaq S, Kuwai T, Siau K, et al. Is Z-POEM for Zenker’s the same as POEM for achalasia? Or we are barking up the wrong tree? Gastrointest Endosc. 2020; 91: 204–205.
Jones D, Aloraini A, Gowing S, et al. Evolving management of Zenker’s diverticulum in the endoscopic era: A North American experience. World J Surg 2016; 40: 1390–1396.
Repici A, Pagano N, Fumagalli U, et al. Transoral treatment of Zenker-diverticulum: flexible endoscopy versus endoscopic stapling. A retrospective comparison of outcomes. Dis Esophagus 2011; 24: 235–239.
Gyökeres T, Rusznyák K, Adorján K. Endoscopic treatment of Zenker’s diverticulum with flexible endoscope. The first Hungarian case. Z Gastroenterol. 2013; 51: 458–483.A21.