AJR 2001; 177:1067-1071
© American Roentgen Ray Society
Radiographic Findings and Complications After Surgical or Endoscopic Repair of Zenker's Diverticulum in 16 Patients
Brian D. Sydow1,
Marc S. Levine,
Stephen E. Rubesin and
Igor Laufer
1
All authors: Department of Radiology, Hospital of the University of
Pennsylvania, Philadelphia, PA 19104.
Received April 27, 2001;
accepted after revision May 18, 2001.
Address correspondence to M. S. Levine.
Abstract
OBJECTIVE. The purpose of our study was to reassess the radiographic
findings and complications associated with surgical or endoscopic repair of
Zenker's diverticulum.
MATERIALS AND METHODS. Sixteen patients who underwent various
procedures for repair of Zenker's diverticulum (diverticulectomy and
cricopharyngeal myotomy in [n = 8], diverticulopexy and
cricopharyngeal myotomy [n = 4], endoscopic stapling diverticulotomy
[n = 3], and cricopharyngeal myotomy alone [n = 1]) had
radiographic studies with water-soluble contrast material, barium, or both
during the early postoperative period (n = 7), late postoperative
period (n = 4), or both (n = 5). The radiologic reports and
images were reviewed to determine the postoperative findings and complications
associated with surgical or endoscopic repair of Zenker's diverticulum.
RESULTS. Radiographic studies revealed leaks during the early
postoperative period in three (27%) of 11 patients after surgical repair of
Zenker's diverticulum and in zero of three patients after endoscopic
diverticulotomy. Pharyngeal dysfunction (pharyngeal paresis, decreased
epiglottic tilt, laryngeal penetration, or tracheobronchial aspiration) was
detected in seven (54%) of 13 patients after surgery and in one (33%) of three
patients after endoscopic diverticulotomy; five of these eight patients had
follow-up barium studies during the late postoperative period, and all five
showed marked improvement in pharyngeal function. An extrinsic cricopharyngeal
impression was detected in six (38%) of these 16 patients, a remnant
diverticulum in four (25%), and mucosal beaking in three (19%). A suspended or
inverted diverticulum was detected in one of the four patients who underwent
surgical diverticulopexy.
CONCLUSION. Radiologists should be aware of the various
postoperative findings and complications associated with surgical or
endoscopic repair of Zenker's diverticulum so that appropriate interventions
can be taken in patients with this condition.
Introduction
Zenker's diverticulum has long been recognized as a major cause of
symptoms, including dysphagia, regurgitation, halitosis, aspiration, and
aspiration pneumonia [1].
Surgical removal of the diverticulum (diverticulectomy) traditionally has been
considered the definitive treatment for symptomatic patients
[2]. Alternatively, these
individuals may undergo diverticulopexy (surgical suspension of the
diverticulum), in which the diverticulum is suspended or inverted and then
tacked to the prevertebral fascia to allow dependent drainage of the
diverticulum and relief of symptoms
[3]. A cricopharyngeal myotomy
is almost always performed in conjunction with diverticulectomy or
diverticulopexy, but occasionally patients may undergo a myotomy without other
surgery [4,
5].
Endoscopic procedures have also increasingly been advocated as a less
invasive form of therapy associated with fewer complications than open
surgical procedures [6]. In
1960, Dohlman and Mattson [7]
described a novel technique that used endoscopic diathermy to obliterate the
diverticulum by dividing the common wall between the diverticular sac and
adjacent esophagus. A more recent variation of the Dohlman procedure uses
endoscopic stapling in place of diathermy to separate this common wall
[8,9,10].
Despite advances in endoscopic technology, debate continues about the best
form of therapy for patients with diverticula. Radiographic studies with
water-soluble contrast material or barium are often performed to evaluate the
postoperative anatomy and rule out complications after surgical or endoscopic
repair of Zenker's diverticulum. Surprisingly, however, little has been
written in the radiologic literature about the radiographic evaluation of
patients after diverticulectomy and cricopharyngeal myotomy
[11,
12] or endoscopic
diverticulotomy [13]. Nor, to
our knowledge, have the radiographic findings after diverticulopexy been
reported in the radiologic literature. The purpose of this investigation,
therefore, was to reassess the radiographic findings and complications
associated with surgical or endoscopic repair of Zenker's diverticulum.
Materials and Methods
A review of the computerized radiology database at our university hospital
and the radiology files at our affiliated Veterans Administration hospital
revealed 16 patients who had postoperative radiographic studies with
water-soluble contrast material or barium after surgical or endoscopic repair
of Zenker's diverticulum from January 1990 to September 2000. Thirteen of the
patients were men and three were women. The mean age at the time of surgery
was 62 years (range, 42-80 years). The primary indications for surgery
included dysphagia in 15 patients and regurgitation in one.
These 16 patients underwent a total of 41 radiographic examinations of the
pharynx and esophagus, including 24 examinations with a high-density barium
suspension (E-Z-HD; E-Z-EM, Westbury, NY), and 17 with water-soluble contrast
material (diatrizoate meglumine and diatriazoate sodium solution, Gastroview;
Mallinckrodt, St. Louis, MO) followed by high-density barium if no leak was
identified with water-soluble contrast material. In all cases, the studies
included spot images and video recordings of the pharynx and esophagus in
frontal, lateral, or oblique projections. Seven patients had radiographic
studies only during the early postoperative period (within 30 days after
repair of the diverticulum), four had radiographic studies only during the
late postoperative period (more than 30 days after repair of the Zenker's
diverticulum), and five had radiographic studies during the early and late
postoperative periods. The average number of radiographic studies per patient
was 2.6 (range, 1-4). Seven (44%) of the 16 patients also had preoperative
barium studies that revealed the Zenker's diverticulum (Figs.
1A and
2A). The average diameter of
the diverticulum in these seven patients was 3.3 cm (range, 2-5 cm). In all
patients, the original radiographic reports were reviewed to determine the
postoperative complications associated with surgical or endoscopic repair of
Zenker's diverticulum. The radiographic images were also reviewed to assess
the postoperative findings in these patients.
View larger version (86K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —73-year-old man with remnant diverticulum after endoscopic
stapling diverticulotomy for dysphagia. Steep oblique view from preoperative
barium study shows 3-cm Zenker's diverticulum (white arrow) above
prominent cricopharyngeus (black arrow).
|
|
View larger version (131K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2A. —80-year-old man with suspended diverticulum after
diverticulopexy and cricopharyngeal myotomy for dysphagia. Lateral view from
preoperative barium study shows 3-cm Zenker's diverticulum
(arrow).
|
|
A review of medical and surgical records revealed that 13 (81%) of the 16
patients underwent surgical repair of the Zenker's diverticulum, including a
combined diverticulectomy and cricopharyngeal myotomy in eight, a combined
diverticulopexy and cricopharyngeal myotomy in four, and cricopharyngeal
myotomy alone in one. The remaining three patients (19%) underwent endoscopic
stapling diverticulotomy and cricopharyngeal myotomy. Medical records were
also reviewed to determine the postoperative course of these patients.
Results
Open Surgical Repair (13 Patients)
Postoperative leaks.—Eleven of the 13 patients who underwent
surgical repair of Zenker's diverticulum had radiographic studies to rule out
leaks during the early postoperative period. Three (27%) of these 11 patients
were found to have postoperative leaks. Two of the patients with leaks had
undergone diverticulectomy and cricopharyngeal myotomy, and one had undergone
diverticulopexy and cricopharyngeal myotomy. In one patient, a leak was
suspected at the time of the radiographic study because of excessive drainage
from the incision site in the neck. In the remaining two patients, the leaks
were not suspected at the time of the radiographic studies. In all three
patients, the leaks appeared on studies with water-soluble contrast material
as thin, blind-ending tracts that extended superiorly or inferiorly 2-4 cm in
the prevertebral space from the posterior aspect of the pharyngoesophageal
segment at the site of the resected (two patients) or inverted (one patient)
diverticulum (Fig. 3).
View larger version (140K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 3. —77-year-old woman with unsuspected leak 1 week after
diverticulectomy and cricopharyngeal myotomy for dysphagia. Steep oblique view
from radiographic study with water-soluble contrast material shows 4-cm,
irregular, blind-ending tract (arrows) posterior to
pharyngoesophageal segment in prevertebral space.
|
|
In the two patients who underwent divertic-ulectomy, the leaks were
detected on the initial radiographic studies 5 and 9 days after surgery. Both
patients were treated with parenteral nutrition and antibiotics. Although
follow-up studies showed no substantial healing of the leaks, both patients
did well clinically and were placed on liquid and then solid diets before
being discharged from the hospital. These leaks, therefore, presumably healed
on conservative therapy.
In the remaining patient who underwent diverticulopexy, a postoperative
leak was not suspected at the time of the initial hospital admission. However,
the patient returned to the hospital soon after discharge because of
increasing drainage from the incision site, and a radiographic study 10 days
after surgery showed the leak. It, therefore, is unclear whether this was a
clinically silent leak during the early postoperative period or a delayed
leak. Whatever the explanation, the patient underwent repeated surgery for
débridement of a neck abscess and was
discharged from the hospital 8 days later in satisfactory condition, although
no subsequent radiographic studies were performed.
Postoperative pharyngeal dysfunction.—Pharyngeal dysfunction
was detected in seven patients (54%) of 13 patients who underwent open
surgical repair, including diverticulectomy and cricopharyngeal myotomy in
four, diverticulopexy and cricopharyngeal myotomy in two, and cricopharyngeal
myotomy alone in one. Three of these patients had preoperative barium studies,
and all three showed normal pharyngeal function. The indications for the
postoperative radiographic studies in these seven patients included left vocal
cord paralysis in one and routine follow-up in six. Four of these patients
showed pharyngeal dysfunction on the initial radiographic studies obtained
during the early postoperative period, an average of 6.3 days (range, 1-15
days) after surgery. The other three patients had pharyngeal dysfunction on
radiographic studies performed during the late postoperative period, an
average of 1.9 months (range, 1.2-3 months) after surgery. The findings in
these seven patients included pharyngeal paresis in three, decreased
epiglottic tilt in five, laryngeal penetration in six, and tracheobronchial
aspiration in six (Fig. 4A). In
four patients, repeat barium studies an average of 8.6 months later (range,
1-36 months) revealed marked improvement in pharyngeal function
(Fig. 4B), so the initial
findings were attributed to the prior pharyngeal surgery. In the remaining
three patients, repeat barium studies were not performed. One of these
patients had a poor postoperative course, complicated by cardiac arrest,
pancreatitis, sepsis, and death 2 months after surgery.
View larger version (75K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4A. —44-year-old man with transient pharyngeal dysfunction after
open diverticulectomy and cricopharyngeal myotomy for dysphagia. Lateral spot
view from barium study 5 weeks after surgery shows marked pharyngeal paresis
with retention of barium in hypopharynx and aspirated barium in larynx and
trachea (arrow).
|
|
View larger version (101K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4B. —44-year-old man with transient pharyngeal dysfunction after
open diverticulectomy and cricopharyngeal myotomy for dysphagia. Lateral spot
view from repeated barium study 4 weeks later shows improved emptying of
hypopharynx and only minimal penetration of barium into larynx
(arrows), so marked improvement in swallowing function has occurred
in interim.
|
|
Endoscopic Stapling Diverticulotomy (Three Patients)
Postoperative leaks.—No leaks were detected on radiographic
studies during the early or late postoperative periods in any of the three
patients who underwent endoscopic stapling diverticulotomy.
Postoperative pharyngeal dysfunction.—Pharyngeal dysfunction
was detected on a barium study in one patient (33%) with reflux symptoms who
underwent endoscopic stapling diverticulotomy 2 months earlier; findings
included laryngeal penetration and trace aspiration into the trachea. A repeat
barium study 9 months later revealed normal pharyngeal function.
Other Findings After Surgical Repair or Endoscopic Diverticulotomy
(16 Patients)
Remnant diverticulum.—A remnant diverticulum was detected on
radiographic studies in four patients (25%) who underwent surgical or
endoscopic repair of Zenker's diverticulum, including endoscopic stapling
diverticulotomy in two, surgical diverticulectomy in one, and surgical
diverticulopexy in one. The indications for postoperative barium studies in
three of these four patients included reflux symptoms in two and dysphagia in
one. In the fourth patient, the barium study was performed as a routine
follow-up examination.
The average diameter of the remnant diverticulum was 2.3 cm (range, 1-4
cm). In all four patients, the diverticulum arose from the posterior aspect of
the pharyngoesophageal segment and extended inferiorly in the retropharyngeal
space, with slightly delayed emptying of contrast material from the
diverticulum into the pharynx (Fig.
1B). In three of these patients, radiographic studies were
performed during the late postoperative period, an average of 5.7 months
(range, 2-11 months) after surgery. In the remaining patient, the study was
performed during the early postoperative period, 5 days after surgery.
View larger version (84K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —73-year-old man with remnant diverticulum after endoscopic
stapling diverticulotomy for dysphagia. Steep oblique view from repeat barium
study 2 months after diverticulotomy shows 1-cm remnant diverticulum
(straight arrow) in same location above prominent cricopharyngeus
(curved arrow). Note retention of barium in diverticulum.
|
|
Suspended diverticulum.—A suspended or inverted diverticulum
was observed on radiographic studies in one of the four patients who underwent
surgical diverticulopexy. This patient had a residual diverticulum that had
been suspended from the posterior aspect of the pharyngoesophageal segment, so
that the base of the diverticular sac was located above the orifice, with
rapid emptying of contrast material from this structure
(Fig. 2B). The initial
radiographic study was performed to rule out a leak during the early
postoperative period 2 days after surgery. Two follow-up studies during a
6-month period revealed progressive shrinkage of the inverted diverticulum
(Fig. 2C).
View larger version (105K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2B. —80-year-old man with suspended diverticulum after
diverticulopexy and cricopharyngeal myotomy for dysphagia. Lateral radiograph
with water-soluble contrast material and barium 2 days after surgery, shows
2-cm diverticulum, which has been suspended from posterior aspect of
pharyngoesophageal segment so that base of diverticular sac (straight
arrow) is located above orifice (curved arrow). Note how
contrast material has emptied from diverticulum.
|
|
View larger version (98K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 2C. —80-year-old man with suspended diverticulum after
diverticulopexy and cricopharyngeal myotomy for dysphagia. Lateral view from
repeat barium study 6 months after surgery shows 1-cm suspended diverticulum
(arrow), which has contracted considerably since earlier
postoperative study.
|
|
Mucosal beaking.—Mucosal beaking was detected on
radiographic studies in three patients (19%) who underwent surgical or
endoscopic repair of Zenker's diverticulum, including diverticulopexy in one,
endoscopic diverticulotomy in one, and cricopharyngeal myotomy alone in one.
The indications for these studies included left vocal cord paralysis in one
and routine follow-up in two. In all three patients, mucosal beaking was
characterized on radiographic studies by triangular outpouching or tenting of
the posterior aspect of the pharyngoesophageal segment just above the level of
the cricopharyngeus (Fig. 5),
with rapid emptying of contrast material from this beaklike outpouching. In
all patients, the radiographic studies were performed during the early
postoperative period, an average of 4.3 days (range, 1-9 days) after
surgery.
View larger version (93K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 5. —61-year-old man with mucosal beaking after endoscopic
stapling diverticulotomy for dysphagia. Lateral radiograph with water-soluble
contrast material and barium 9 days after procedure shows tenting of posterior
aspect of pharyngoesophageal segment (white arrow) just above
prominent cricopharyngeus (black arrow), which fails to relax
normally during swallowing.
|
|
Cricopharyngeal impression.—A smooth, extrinsic
cricopharyngeal impression was detected on the posterior aspect of the
pharyngoesophageal segment in six patients (38%) who underwent surgical or
endoscopic repair of Zenker's diverticulum and cricopharyngeal myotomy (Figs.
1B and
5), including endoscopic
stapling diverticulotomy in three, open diverticulectomy in one,
diverticulopexy in one, and cricopharyngeal myotomy alone in one. The
indications for radiography in these six patients included reflux symptoms in
one, dysphagia in one, vocal cord paralysis in one, and routine follow-up in
three. Of the three patients who underwent endoscopic diverticulotomy, this
cricopharyngeal impression was associated with a remnant diverticulum in two
and mucosal beaking in one.
In two patients, the cricopharyngeal impression was detected during the
early postoperative period 2 days and 7 days after surgery. One of these
patients underwent a repeat myotomy the same day as the initial radiographic
study, and a follow-up study 5 days later showed no evidence of a residual
cricopharyngeal impression. In the remaining four patients, the
cricopharyngeal impression was detected during the late postoperative period
an average of 3.9 months (range, 1.5-8 months) after surgery. During the early
postoperative period (1 day and 2 days after surgery), two of these patients
also had radiographic studies, which showed no evidence of a cricopharyngeal
impression, so this finding developed in the interim. One of the patients with
a cricopharyngeal impression during the late postoperative period underwent
repeat endoscopic diverticulotomy, and a follow-up radiographic study 6 months
later revealed a persistent cricopharyngeal impression on the posterior aspect
of the pharyngoesophageal segment. A dilatation procedure, therefore, was
performed.
Discussion
A major complication of surgery for Zenker's diverticulum is a leak or
fistula from the surgical site. Such leaks have been reported in 1-20% of
patients who undergo these procedures
[14]. In our series,
sealed-off perforations were detected in three (27%) of 11 patients who had
radiographic studies within 30 days after surgery for Zenker's diverticulum.
Such leaks almost always originate at the site of the diverticulectomy or
cricopharyngeal myotomy on the posterior aspect of the pharyngoesophageal
segment [12]. As in our
series, these leaks may appear on radiographs with water-soluble contrast
material as blindending tracts that extend superiorly or inferiorly several
centimeters in the prevertebral space from the site of surgery
(Fig. 3). Other patients may
develop larger collections in the retropharyngeal space or pharyngocutaneous
fistulas [12]. Although none
of the patients in our series had evidence of leaks on radiographic studies
after endoscopic diverticulotomy, such leaks occasionally have been documented
in the surgical literature at the site of endoscopic stapling
[10,
15,
16].
Some leaks may be suspected after surgical or endoscopic repair of Zenker's
diverticulum because of fever, neck pain, excessive drainage from the incision
site, or the development of a neck abscess or pharyngocutaneous fistula
[12]. However, other leaks
that originate from the posterior aspect of the pharyngoesophageal segment and
are confined to the retropharyngeal space may not be recognized from clinical
evidence, as occurred in two of our patients. We, therefore, believe that
radiographic evaluation of these patients with water-soluble contrast material
is warranted on a routine basis during the early postoperative period even in
the absence of clinical signs of a leak.
Functional impairment of the pharynx or larynx is another common
complication of surgery for Zenker's diverticulum; both vocal cord paralysis
and swallowing dysfunction (aspiration, pharyngeal paresis, and defective
relaxation or premature closure of the cricopharyngeus) have been documented
in the surgical and radiologic literature
[11,
17,18,19,20,21].
Because of the proximity of the recurrent laryngeal nerve to the operative
field, damage to this structure could account not only for vocal cord
paralysis but also for some of the swallowing abnormalities in these patients
[11,
17,18,19].
In one study from the surgical literature, vocal cord paralysis was observed
as a temporary finding after open surgical repair of Zenker's diverticulum;
full recovery of vocal cord function occurred within 3 months after surgery
[19]. In our series, seven
(54%) of the 13 patients who underwent open surgical procedures had pharyngeal
dysfunction, manifest on radiographic studies by pharyngeal paresis, decreased
epiglottic tilt, laryngeal penetration, and tracheobronchial aspiration
(Fig. 4A). However, four of
these seven patients had marked improvement in swallowing function on
follow-up radiographs (Fig.
4B). Our findings, therefore, suggest that pharyngeal dysfunction
commonly occurs as a transient phenomenon after surgery for Zenker's
diverticulum. Although one of our three patients who underwent endoscopic
stapling diverticulotomy also had transient pharyngeal dysfunction, it remains
unclear whether this procedure is associated with a comparable frequency of
swallowing abnormalities.
A variety of anatomic abnormalities may also be detected on radiographs
after surgical or endoscopic repair of Zenker's diverticulum. Some patients
have a residual outpouching from the posterior aspect of the
pharyngoesophageal segment, also known as a "remnant" diverticulum
[8,
13,
17,
22,
23]. A remnant diverticulum is
particularly common after endoscopic diverticulotomy because this procedure
entails separating the partition between the diverticulum and adjacent
esophagus without resecting the diverticulum
[13,
23]. If a remnant diverticulum
is identified on radiographic studies after endoscopic diverticulotomy,
however, the partition between the diverticulum and adjacent esophagus may
have a reduced height in relation to preoperative studies, with improved
emptying of contrast material from the residual pouch
[13]. As a result, this
remnant diverticulum often is not associated with postoperative symptoms of
dysphagia or regurgitation
[23]. In our series, remnant
diverticula were observed in two of three patients after endoscopic
diverticulotomy (Fig. 1B) and
in one of eight patients after surgical diverticulectomy. Remnant
diverticulum, therefore, represents a frequent finding on radiographic studies
after endoscopic diverticulotomy or incomplete surgical diverticulectomy.
When patients undergo diverticulopexy (in which the diverticulum is
suspended in the prevertebral fascia to facilitate emptying of its contents
and to alleviate symptoms such as dysphagia, regurgitation, and aspiration), a
residual diverticulum may also be shown on postoperative radiography
[5]. In our series, however,
the suspended diverticulum was recognized in one of four patients as an
inverted diverticular sac with the base of the sac located above the orifice,
so that on radiographic studies, contrast material emptied from this structure
into the esophagus (Fig. 2B).
In this patient, the inverted diverticulum was also found to shrink
considerably on two follow-up barium studies during a 6-month period
(Fig. 2C). Radiologists,
therefore, should be aware of the expected appearance of the suspended
diverticulum after diverticulopexy and of the temporal changes that may occur
in this structure on serial radiography.
Mucosal beaking is another previously unreported radiographic finding that
was detected during the early postoperative period in three patients (19%)
after surgical or endoscopic repair of Zenker's diverticulum. Mucosal beaking
was characterized on radiography by a distinctive triangular outpouching from
the posterior aspect of the pharyngoesophageal segment just above the level of
the cricopharyngeus (Fig. 5).
This finding most likely results from postoperative edema or scarring in the
region of the diverticulectomy or cricopharyngeal myotomy and is of doubtful
clinical importance.
A prominent cricopharyngeal impression on the posterior aspect of the
pharyngoesophageal segment is another common postoperative finding that was
seen on radiographs in six (38%) of our patients
[12,
17] (Figs.
1B and
5). When this finding is
detected during the early postoperative period, it could indicate an
incomplete cricopharyngeal myotomy, as presumably occurred in one of our
patients who underwent repeat myotomy with no residual cricopharyngeal
impression on a follow-up study. However, our series also included two
patients who had cricopharyngeal impressions that were detected during the
late, but not the early, postoperative periods. In such cases, this finding
could be related to gradual regeneration or fibrosis of the cricopharyngeal
remnant [12,
24]. A cricopharyngeal
impression may even be more likely in patients who undergo endoscopic stapling
procedures, in which only a partial endoscopic myotomy is performed. In our
series, all three patients who underwent endoscopic stapling diverticulotomy
had cricopharyngeal impressions on the posterior aspect of the
pharyngoesophageal segment associated with a remnant diverticulum or mucosal
beaking.
In conclusion, Zenker's diverticulum may be repaired by open surgical
procedures (either diverticulectomy or diverticulopexy with cricopharyngeal
myotomy) or by endoscopic stapling diverticulotomy. Radiologists should be
aware of the various postoperative findings and complications associated with
surgical or endoscopic repair of Zenker's diverticulum, so that appropriate
interventions can be taken in patients with this condition.
References
-
Ellis FH. Pharyngoesophageal (Zenker's) diverticulum.
Adv Surg
1995;28:171
-189[Medline]
-
Westrin KM, Ergun S, Carlsoo B. Zenker's diverticulum: a historical
review and trends in therapy. Acta Otolaryngol
1996;116:351
-360[Medline]
-
Belsey R. Functional disease of the esophagus. J Thorac
Cardiovasc Surg
1966;52:164
-188[Medline]
-
Zuckerbraun L, Bahna MS. Cricopharyngeus myotomy as the only
treatment for Zenker diverticulum. Ann Otol Rhinol
Laryngol 1979;88:798
-803[Medline]
-
Laccourreye O, Menard M, Cauchois R, et al. Esophageal
diverticulum: diverticulopexy versus diverticulectomy.
Laryngoscope
1994;104:889
-892[Medline]
-
Philippsen LP, Weisberger EC, Whiteman TS, Schmidt JL. Endoscopic
stapled diverticulotomy: treatment of choice for Zenker's diverticulum.
Laryngoscope
2000;110:1283
-1286[Medline]
-
Dohlman G, Mattson O. The endoscopic operation for hypopharyngeal
diverticula. Arch Otolaryngol
1960;71:744
-752
-
Collard JM, Otte JB, Kastens PJ. Endoscopic stapling technique of
esophagodiverticulostomy for Zenker's diverticulum. Ann Thorac
Surg 1993;56:573
-576[Abstract]
-
Scher RL, Richtsmeier WJ. Endoscopic staple-assisted
esophagodiverticulostomy for Zenker's diverticulum.
Laryngoscope
1996;106:951
-956[Medline]
-
Van Eeden S, Lloyd RV, Tranter RM. Comparison of the endoscopic
stapling technique with more established procedures for pharyngeal pouches:
results and patient satisfaction survey. J Laryngol
Otol 1999;113:237
-240[Medline]
-
Ekberg O, Lindgren S. Effect of cricopharyngeal myotomy on
pharyngoesophageal function: pre- and postoperative cineradiographic findings.
Gastrointest Radiol
1987;12:1
-6[Medline]
-
Ekberg O, Besjakov J, Lindgren S. Radiographic findings after
cricopharyngeal myotomy. Acta Radiol
1987;28:555
-558[Medline]
-
Hadley JM, Ridley N, Djazaeri B, Glover G. The radiological
appearances after the endoscopic cricopharyngeal myotomy: Dohlman's procedure.
Clin Radiol
1997;52:613
-615[Medline]
-
Laing MR, Murthy P, Ah-See KW, Cockburn JS. Surgery for pharyngeal
pouch: audit of management with short and long term follow-up. J R
Coll Surg Edinb
1995;40:315
-318[Medline]
-
Siddiq MA, Patel PJ. Pharyngeal pouch surgery: a five year review.
Rev Laryngol Otol Rhinol
2000;121:37
-40
-
Hilton M, Brightwell AP. Oesophageal perforation during stapling of
a pharyngeal pouch: adverse clinical incident report. J Laryngol
Otol 2000;114:549
-550[Medline]
-
Zeitoun H, Widdowson D, Hammad Z, Osborne J. A video-fluoroscopic
study of patients treated by diverticulectomy and cricopharyngeal myotomy.
Clin Otolaryngol
1994;19:301
-305[Medline]
-
Witterick IJ, Gullane PJ, Yeung E. Outcome analysis of Zenker's
diverticulectomy and cricopharyngeal myotomy. Head
Neck 1995;17:382
-388[Medline]
-
Bonafede JP, Lavertu P, Wood BG, Eliachar I. Surgical outcome in 87
patients with Zenker's diverticulum. Laryngoscope
1997;107:720
-725[Medline]
-
Zbaren P, Schar P, Tschopp L, Becker M, Hausler R. Surgical
treatment of Zenker's diverticulum: transcutaneous diverticulectomy versus
microendoscopic myotomy of the cricopharyngeal muscle with CO2
laser. Otolaryngol Head Neck Surg
1999;121:482
-487[Medline]
-
Feeley MA, Righi PD, Weisberger EC, et al. Zenker's diverticulum:
analysis of surgical complications from diverticulectomy and cricopharyngeal
myotomy. Laryngoscope
1999;109:858
-861[Medline]
-
Scher RL, Richtsmeier WJ. Long-term experience with endoscopic
staple-assisted esophagodiverticulostomy for Zenker's diverticulum.
Laryngoscope
1998;108:200
-205[Medline]
-
Ong CC, Elton PG, Mitchell D. Pharyngeal pouch endoscopic stapling:
are postoperative barium swallow radiographs of any value? J
Laryngol Otol
1999;113:233
-236[Medline]
-
Cruse JP, Edwards DA, Smith JF, Wyllie JH. The pathology of
cricopharyngeal dysphagia. Histopathology
1979;3:223
-232[Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Abstract
Introduction
