手术疗法在Zenker憩室中的应用研究进展

Zenker憩室是最常见食管憩室类型,早期通常无症状或偶有短暂的吞咽不畅,当憩室增大时,可并发感染、炎症、溃疡或出血等,甚至可能出现恶变。通常在Zenker憩室无症状时不予干预治疗或进行保守治疗,多在患者症状加重或反复出现炎症、出血甚至穿孔时考虑干预治疗。传统认为外科手术切除憩室是惟一的治疗选择,近年来,内窥镜下隔膜切开术、经腋窝无充气微创憩室切除术、内窥镜二氧化碳激光憩室切除术、经口内窥镜下吻合术等内窥镜微创治疗凭借手术时间短、并发症发生率低、住院及禁食时间短逐渐成为治疗Zenker憩室的主流。对Zenker憩室的手术治疗进行探讨,有利于寻找Zenker憩室手术治疗中更为有效的干预方式。

Z-per-oral endoscopic myotomy as definitive prevention of a bleeding ulcer in Zenker’s diverticulum:A case report

BACKGROUND Bleeding from Zenker’s diverticulum is extremely rare.At present,there are no guidelines for the management of bleeding Zenker’s diverticulum because of its rarity.Per-oral endoscopic myotomy(Z-POEM)is a precision myotomy technique and minimally invasive procedure for the treatment of Zenker’s diverticulum.We present a systematic review and a rare case of bleeding Zenker’s diverticulum that was effectively treated using Z-POEM.CASE SUMMARY A 72-year-old presented after 3 d of hematemesis.He had a 2-year history of progressive dysphagia and reported no antiplatelet,anticoagulant,or nonsteroidal anti-inflammatory drug use.His vital signs were stable,and the hematocrit was 36%.Previous gastroscopy and barium swallow had revealed Zenker’s diverticulum before the bleeding occurred.We performed gastroscopy and found a 5-mm ulcer with a minimal blood clot and spontaneously resolved bleeding.Z-POEM for definitive treatment was performed to reduce accumulation of food and promote ulcer healing.He had no complications and no bleeding;at the follow-up 6 mo later,the ulcer was healed.CONCLUSION Z-POEM can be definitive prevention for bleeding ulcer in Zenker’s diverticulum that promotes ulcer healing,reducing the risk of recurrent bleeding.Z-POEM is also a definitive endoscopic surgery for treatment of Zenker’s diverticulum.

吞咽视频内镜检查对Zenker′s憩室手术效果的评估作用

目的探讨吞咽视频内镜检查(VESS)中观察到的潮汐症(RTS)现象对Zenker′s憩室的诊断及手术疗效评估作用。方法收集1998年5月—2010年4月法国巴黎Tenon医院耳鼻咽喉头颈颌面外科确诊并接受手术治疗的148例连续性Zenker′s憩室病例的临床资料。对手术前和手术后VESS中RTS出现的情况进行回顾性分析;随机选择病例38例,记录术前VESS中RTS出现前的吞咽次数,并分析其与术前食道吞钡检查中记录的Zenker′s憩室大小的关系;在VESS视频记录中回顾性寻找25例非Zenker′s憩室的食道上段括约肌功能障碍患者吞咽过程中的RTS表现。结果 148例患者术前VESS中均有RTS表现。症状出现前吞咽次数与食道憩室大小无明显关联(P>0.05)。术后对121例患者的随访发现,111例患者术后症状明显改善且VESS中RTS完全消失;10例患者症状复发,其中7例患者在平均随访37个月时VESS中再次出现RTS表现。25例非Zenker′s憩室的食道上段括约肌功能障碍患者的VESS记录中未发现RTS表现。结论 VESS中观察到的RTS是Zenker′s憩室的特征性表现。VESS可作为诊断Zenker′s憩室的一项辅助检查及在随访过程中评估手术疗效的有效手段。

Ⅳ期Zenker憩室1例报道

Zenker憩室,又名咽食管憩室,是指咽食管壁局限性向外突出,形成与食管腔相通的具有完整覆盖上皮的盲袋,多为后天性,国外报道多见,国内罕见。1病例介绍患者,男,52岁。2014年4月1日因吞咽困难1年余入住我院。患者自觉胸骨后隐痛不适,无恶心、呕吐、返酸、嗳气、咳嗽、口臭等症状,体格检查未见明显异常。

经胃镜检查发现Ⅳ期Zenker憩室1例报告

Zenke憩室是咽与食管移行处管壁向外突出而形成的囊袋状结构，常位于下咽缩肌与环咽肌之间的左后方，为下咽部良性病变，最常见的临床症状为不同程度的吞咽闲难及反流。

Long-term results of endosurgical and open surgical approach for Zenker diverticulum

AIM: To assess the effectiveness of minimally invasive versus traditional open surgical approach in the treatment of Zenker diverticulum. METHODS: Between 1976 and 2006, 297 patients underwent transoral stapling (n = 181) or stapled diverticulectomy and cricopharyngeal myotomy (n = 116). Subjective and objective evaluations of the outcome of the two procedures were made at 1 and 6 mo after operation, and then every year. Long-term follow-up data were available for a subgroup of patients at a minimum of 5 and 10 years. RESULTS: The operative time and hospital stay were markedly reduced in patients undergoing the endosurgical approach. Overall, 92% of patients undergoing the endosurgical approach and 94% of those undergoing the open approach were symptom-free or were significantly improved after a median follow-up of 27 and 48 mo, respectively. At a minimum follow-up of 5 and 10 years, most patients were asymptomatic after both procedures, except for those individuals undergoing an endosurgical procedure for a small diverticulum (< 3 cm). CONCLUSION: Both operations relieve the outflow obstruction at the pharyngoesophageal junction, indicating that cricopharyngeal myotomy has an important therapeutic role in this disease independent of the resection of the pouch and of the surgical approach. Diverticula smaller than 3 cm represent a formal contraindication to the endosurgical approach because the common wall is too short to accommodate one cartridge of staples and to allow complete division of the sphincter.

Current status of minimally invasive endoscopic management for Zenker diverticulum

Surgical resection has been the mainstay of treatment of pharyngoesophageal(Zenker) diverticula over the past century. Developments in minimally invasive surgery and new endoscopic devices have led to a paradigm change. The concept of dividing the septum between the esophagus and the pouch rather than resecting the pouch itself has been revisited during the last three decades and new technologies have been investigated to make the transoral operation safe and effective. The internal pharyngoesophageal myotomy accomplishedthrough the transoral stapling approach has been shown to effectively relieve outflow obstruction and restore physiological bolus transit in patients with medium size diverticula. Transoral techniques, either through a rigid device or by flexible endoscopy, are gaining popularity over the open surgical approach due the low morbidity, the fast recovery time and the fact that the procedure can be safely repeated. We provide an analysis of the the current status of minimally invasive endoscopic management of Zenker diverticulum.

New flexible endoscopic controlled stapler technique for the treatment of Zenker's diverticulum:A case series

AIMTo report about the combination and advantages of a stapler-assisted diverticulotomy performed by flexible endoscopy.METHODSFrom November 2014 till December 2015 17 patients (8 female, 9 male, average age 69.8 years) with a symptomatic Zenker diverticulum (mean size 3.5 cm) were treated by inserting a new 5 mm fully rotatable surgical stapler (MicroCutter30 Xchange, Cardica Inc.) next to an ultrathin flexible endoscope through an overtube. The Patients were under conscious sedation with the head reclined in left position, the stapler placed centrally and pushed forward to the bottom of the diverticulum. The septum was divided by the staple rows under flexible endoscopic control.RESULTSIn eleven patients (64.7%) the stapler successfully divided the septum completely. Mean procedure time was 21 min, medium size of the septum was 2.8 cm (range 1.5 cm to 4 cm). In four patients the septum was shorter than 3 cm, in seven longer than 3 cm. To divide the septum, averagely 1.3 stapler cartridges were used. Two minor bleedings occurred. Major adverse events like perforation or secondary haemorrhage did not occur. After an average time of two days patients were discharged from the hospital. In 6 patients (35.3%) the stapler failed due to a thick septum or insufficient reclination of the head. Follow up endoscopy was performed after an average of two months in 9 patients; 4 patients (44.4%) were free of symptoms, 5 patients (55.6%) stated an improvement. A relapse of symptoms did not occur.CONCLUSIONFlexible endoscopic Zenker diverticulotomy by using a surgical stapler is a new, safe and efficient treatment modality. A simultaneously tissue opening and occlusion prevents major complications.

Long-term outcome and quality of life after transoral stapling for Zenker diverticulum

AIM: To investigate long-term results and quality of life after transoral stapling of Zenker diverticulum.METHODS: The data of all patients admitted to our institution for the surgical treatment of Zenker diverticulum were entered into a prospective database. Demographics, symptoms, intraoperative and post-operative data, morbidity, time to oral feeding, and length of hospital stay were recorded. All patients underwent upper gastrointestinal endoscopy and a barium swallow study to measure the length of the diverticulum from the apex of the septum to the bottom of the pouch. Transoral stapling was performed using a Weerda diverticuloscope under general anesthesia. Over time, the technique was modified by applying traction sutures to ease engagement of the common septum inside the stapler jaws. Perioperative variables, symptoms, long-term outcome, and quality of life were analyzed. The operation was considered successful if the patient reported complete remission(grade 1) or marked improvement(grade 2) of dysphagia, regurgitation, and respiratory symptoms. Statistical analysis was performed using Statistical Package for Social Science(SPSS, Version 15, SPSS, Inc., Chicago, IL).RESULTS: Between 2001 and 2013, the transoral approach was successfully completed in 100 patients with a median age of 75 years. Patients with a larger(≥3 cm) diverticulum were older than those with a smaller pouch(P < 0.038). Complications occurred in 4% of the patients but there was no mortality. A statistically significant improvement of dysphagia and regurgitation scores(P < 0.001) was recorded over a median followup of 63 mo. Similarly, a significant decrease in the median number of pneumonia episodes per year(P < 0.001) was recorded after surgery. The overall longterm success rate of the procedure was 76%. The success rate of the operation was greater in patients of 70 years of age or older compared to younger individuals(P = 0.038). Use of traction sutures on the septum was associated with an improved success rate compared with the standard procedure(P = 0.04). All items of the health related quality of life questionnaire were significantly higher compared to baseline(P < 0.05).CONCLUSION: Transoral stapling is safe and effective. The operation significantly improves patients' quality of life. It appears that elderly patients with large diverticula significantly benefit from the procedure and that the modified surgical technique including traction sutures can further improve the success rate.

Usefulness of the Hook knife in flexible endoscopic myotomy for Zenker's diverticulum

To investigate the outcome of flexible endoscopic myotomy performed with the Hook knife in patients with symptomatic Zenker’s diverticulum (ZD). METHODSAll consecutive patients treated for ZD at our institution between 7/2012 and 12/2016 were included. The flexible endoscopic soft diverticuloscope-assisted technique with endoclips placement and Hook knife myotomy were performed in all patients. Here we report a retrospective review of prospectively collected data. Demographics, dysphagia score (Dakkak and Bennett), associated symptoms and adverse events were collected pre-procedure, at 2 and 6 mo post-procedure, and at the end of the follow-up period. Clinical success was defined as at least 1-point improvement in dysphagia score and a residual dysphagia score ≤ 1, with no need for reintervention. Dysphagia scores were compared before treatment and at end-of-follow-up using the Wilcoxon test. RESULTSTwenty-four patients were included. Mean size of ZD was 3.0 cm (range 2-8 cm). Mean number of sessions was 1.17/patient (range 1-3 sessions). Overall clinical success was 91.7%. Two adverse events (8.3%) occurred, and both were managed conservatively. No bleeding or perforation was reported. Mild pain was reported by 9 patients (37.5%). Median hospital stay was 1 d (range 1-6). Median follow-up was 19.5 mo (range 6-53). Mean ± SD dysphagia score was 2.25 ± 0.89 before treatment and decreased to 0.41 ± 0.92 at end-of-follow-up (P < 0.001). Regurgitation and cough dropped from 91.7% and 50% to 12.5% and 0% at the end of follow-up, respectively. Recurrence was observed in 3 patients, and all 3 were symptom-free after one more session. CONCLUSIONThe Hook knife, used in the soft diverticuloscope-assisted technique setting, is efficient and safe for treatment of ZD.

Techniques and efficacy of flexible endoscopic therapy of Zenker's diverticulum

Zenker's diverticulum(ZD) is an abnormal hypopharyngeal pouch often presenting with dysphagia. Treatment is often sought with invasive surgical management of the diverticulum being the only mode of definitive therapy.Primarily done by an open transcervical approach in the past, nowadays treatment is usually provided by otolaryngologists using a less invasive trans-oral technique with a rigid endoscope. When first described, this method grew into acceptance quickly due to its similar efficacy and vastly improved safety profile compared to the open transcervical approach. However, the main limitation with this approach is that it may not be suitable for all patients. Nonetheless, progress in the field of natural orifice endoscopic surgery over the last 10-20 years has led to the increase in utilization of the flexible endoscope in the treatment of ZD. Primarily performed by interventional gastroenterologists, this approach overcomes the prior limitation of its surgical counterpart and allows adequate visualization of the diverticulum independent of the patient's body habitus. Additionally, it may be performed without the use of general anesthesia and in an outpatient setting, thus further increasing the utility of this modality, especially in elderly patients with other comorbidities. Today, results in more than 600 patients have been described in various published case series using different techniques and devices demonstrating a high percentage of clinical symptom resolution with low rates of adverse events. In this article, we present our experience with flexible endoscopic therapy of Zenker's diverticulum and highlight the endoscopic technique, outcomes and adverse events related to this minimally invasive modality.

超声检查诊断Zenker憩室1例

Zenker憩室是一种相对罕见的食管憩室,本文回顾2020年7月28日诸暨市人民医院经超声检查诊断Zenker憩室1例,探讨超声检查对Zenker憩室的诊断价值。

胃镜检查发现Ⅳ期Zenker憩室1例

Zenker憩室为下咽部局限性黏膜膨出,位于咽与食管交界处,又称咽食管憩室。是临床上较为少见的良性疾病,好发于60~70岁男性,常见向咽食管左侧壁膨出,临床多无症状,少数患者可见口臭反流、吞咽困难、饮水呛咳、咽部不适、胸骨后疼痛、慢性咳嗽、复发性肺炎或表现为甲状腺水平部结节。本文对我院胃镜检查发现Ⅳ期Zenker憩室1例报告并分析,以进一步诊断治疗。

CO_2激光内窥镜处理Zenker憩室

憩室(ZD)系咽下缩肌斜行和横行肌纤维间软弱部位(Killian缺陷区)的咽粘膜疝出,其形成与该区较大和环咽肌力增强有关,典型表现为吞咽障碍、咽异感、返流、腹鸣、口臭、误咽、复发性肺炎、营养不良等,确诊靠食管钡餐X线片及内窥镜检查,根据ZD囊袋的大小可分为0级(无憩室、仅有环咽肌痉挛)。

高频彩色多普勒超声诊断咽食管Zenker憩室3例

病历资料例1：患者,女,39岁,因咽部不适,吞咽梗阻感3个月就诊,行颈部超声检查。自述2年前曾因头晕行颈椎CT检查,疑甲状腺左侧叶结节。超声检查示：甲状腺大小正常,实质回声均匀,颈部未见肿大淋巴结回声。

内镜下黏膜剥离术联合金属夹封闭术治疗食管Zenker憩室1例(含视频)

Zenker憩室是常见的食管发育畸形,可导致食管支气管瘘等严重并发症,传统治疗手段以外科手术为主,创伤大,并发症多。目前多采取内镜下治疗,本文报道1例经内镜下黏膜剥离术联合金属夹封闭术成功治疗的食管入口处Zenker憩室,创伤小,效果好,基本无并发症,旨在为该类疾病的临床治疗提供参考。

高频超声诊断Zenker憩室的临床价值

目的探讨高频超声诊断Zenker憩室的临床价值。方法采用高频线阵探头在887例颈部结节患者相当于甲状腺区域进行扫查,当检测到病灶并怀疑Zenker憩室时行钡餐检查确诊,超声检查Zenker憩室时记录病灶的位置、大小、形状和回声,观察病灶是否与毗邻的食道壁相连。饮水后,观察病灶的形状、回声的变化,及是否有液体进入病灶。结果本组共9例Zenker憩室,其中饮水前二维超声诊断Zenker憩室3例,诊断甲状腺腺瘤6例,诊断符合率33.3%(3/9);饮水后二维超声检查诊断食管憩室8例,诊断甲状腺腺瘤1例,诊断符合率88.9%(8/9),后者诊断符合率较前者高(P<0.05)。9例Zenker憩室有3种不同的声像图表现:(1)病灶为较均匀的低回声区,内部可见细小点状高回声区,后方不伴声影及彗星尾征4例;(2)病灶为不均匀回声,边界不清,内部可见点线状强回声及无回声区1例;(3)病灶周边为低回声,中央为气体高回声区,后方伴有彗星尾征4例。结论高频超声检查对饮水后Zenker憩室的诊断符合率明显大于饮水前,对鉴别Zenker憩室和甲状腺结节有一定的临床价值,可以使患者避免不必要的穿刺和手术治疗。

高频超声在Zenker憩室诊断中的价值

Zenker憩室即咽食管憩室，系食管壁通过环咽肌与咽下缩肌之间的薄弱区向后膨出形成。由于Zenker憩室缺乏特异性的临床症状及影像学表现，易被误诊为甲状腺结节。笔者对本院近年经手术或食管X线钡餐造影证实的13例Zenker憩室进行同顺性分析并总结其声像图特征，旨在提高超声诊断Zenker憩室的准确性。

内镜发现Zenker憩室一例

患者男,47岁,德国人,因间歇性进食哽咽感伴口臭、夜间反流、进食时偶有颈部特殊＂咯咯＂响声5年,曾就诊于国外7家医院末能明确诊断,近日上述症状加重,遂于2008年12月9日于我院内镜中心就诊.年轻医生反复插镜失败,找不到食管入口,上级医生会诊发现食管入口处一大小约2.5 cm×3.0 cm巨大广口较深憩室,底部光滑,未见食物残留,并见散在片状浅溃疡,表面被白苔,食管入口在憩室旁呈裂隙状,憩室口黏膜色同食管正常黏膜,经仔细辨认,内镜经食管、胃到达十二指肠降部.

Zenker憩室超声检查误诊为甲状腺结节一例

患者女，50岁。仵外院体检行甲状腺B超检查发现“双侧甲状腺结节”半月余，要求于术治疗，门诊拟诊为双侧甲状腺结节收住人院。患并有轻度叫部异物感1月余，无恶心呕吐，无反酸及烧心感，无声嘶、乔咽闹难。