Tratamento cirúrgico do divertículo de zenker

Andreollo, Nelson Adami; Soares Júnior, Cleber; Coelho Neto, João de Souza; Lopes, Luiz Roberto; Brandalise, Nelson Ary; Leonardi, Luiz Sergio

doi:10.1590/S0100-69911998000100004

Resumos

O divertículo de Zenker (DZ) é uma doença muito pouco freqüente, cujo sintoma mais importante é a disfagia cervical. Os aspectos de sua etiopatogenia ainda são motivos de várias pesquisas na literatura, através de estudos manométricos e cinerradiográficos. O tratamento mais empregado é o cirúrgico, favorecendo quase a totalidade dos doentes, com índices de recidiva muito baixos. Porém, algumas publicações enfatizam as vantagens do tratamento endoscópico. Foram revisados 39 doentes, tratados no Serviço nos últimos 15 anos, sendo que 28 foram do sexo masculino (71,8%). A idade do grupo variou de 18 a 86 anos (média 54,5 anos). Os principais sintomas foram a disfagia cervical (89,8%), a regurgitação alimentar (71,8%), a tosse repetitiva (30.7%) e o emagrecimento importante (25,6%). Dois pacientes apresentaram diverticulite aguda e perfuração (5,1 %). O diagnóstico foi estabelecido através de radiografias contrastadas em 37 pacientes (94,8%) e de endoscopia digestiva em 28 (71,7%). A eletromanometria foi realizada em 13 casos (33,3%). O tratamento consistiu de diverticulectomia seguida de miotomia do esfincter do músculo cricofaríngeo em 24 pacientes (61,5%) e diverticulopexia seguida da mesma miotomia em 15 pacientes (38,5%). No seguimento a longo prazo de 35 pacientes (89,8%), variando de cinco meses a 12 anos (média 4,5 anos), ocorreu melhora importante com desaparecimento da disfagia em todos os casos. Três pacientes (7,7%) persistiram sintomas disfágicos leves e inconstantes. Um paciente faleceu em decorrência de complicações cardíacas e pulmonares. Os estudos histopatológicos dos divertículos ressecados mostraram a presença de tumor maligno neuroendócrino em um paciente (2,5%). Os doentes submetidos a diverticulopexia receberam alta hospitalar mais precocemente. Os autores discutem os aspectos atuais da fisiopatologia do DZ, analisam as opções de tratamento e os resultados da literatura, comparando com os obtidos neste estudo. Concluindo, os resultados mostram que tanto a diverticulectomia como a diverticulopexia podem ser utilizadas, ambas seguidas de miotomia do músculo cricofaríngeo. A diverticulopexia mostrou ser uma opção muito satisfatória para os divertículos de tamanhos pequenos e médios.

Divertículo de Zenker; Diverticulectomia; Diverticulopexia

The Zenker’s diverticulum is a not frequent disease and the main symptom is the cervical dysfagia. The aspects of the pathophysiology had motivated many researchs in the literature, using manometric and cinerradiographic studies. The surgical treatment is most commonly employed, favouring the most number of patients, with low recurrence rates. However, some publications show the advantages of the endoscopic treatment. Thirty nine patients with Zenkers diverticulum were operated on in the last 15 years, being 28 males (71.8%), with the age ranging from 18 to 86 years (mean 54.5 years). The main symptoms were: cervical dysphagia (89.8%), food regurgitation (71.8%), cough (30.7%) and losting weight (25.6%). Two patients presented diverticulitis and perforated diverticulum (5.1%). The diagnosis were established using esophagogram in 37 patients (94.8%) and digestive endoscopy in 28 (71.7%). The manometric studies were performed in 13 cases (33.3%). The treatment consisted of diverticulectomy followed by the cricopharyngeal sphyncter myotomy in 24 patients (61.5%) or diverticulopexy also followed by the same myotomy in 15 patients (38.5%). The late follow-up of 35 patients (89.8%) ranging from five months to 12 years (mean 4.5 years) showed that all oft hem were without symptoms of dysphagia. Three patients (7. 7%) presented light and inconstant dysphagia. One patient died due to pulmonary and cardiac problems (2.5%). The histopathology studies of the diverticulum showed a malignant tumor in one case (2.5%). The patients submitted to diverticulopexy were discharged early. The authors discuss the modern aspects of the physiopathology of the Zenker’s diverticulum, they analyse the choices of treatment and the results of literature, comparing to the obtained in the present study. Concluding, the results of this study showed that either the diverticulectomy as the diverticulopexy are indicated, both followed by cricopharyngeal sphincter myotomy. The diverticulopexy is a very good choice to treat small and middle diverticulum.

Zenker's diverticulum; Diverticulectomy; Diverticulopexy

ARTIGOS ORIGINAIS

Tratamento cirúrgico do divertículo de zenker

Surgical treatment of the zenker's diverticulum

Nelson Adami Andreollo, TCBC-SP^I; Cleber Soares Júnior^II; João de Souza Coelho Neto^II; Luiz Roberto Lopes, TCBC.SP^III; Nelson Ary Brandalise, TCBC-SP^IV; Luiz Sergio Leonardi, TCBC.SP^V

^IProfessor Livre-Docente

^IIResidentes do Departamento de Cirurgia

^IIIProfessor Assistente

^IVProfessor Adjunto

^VProfessor Titular

^{Endereço para correspondência} Endereço para correspondência: Nelson Adami Andreollo Rua Nelson Souza Barbosa, 227 13080-260 - Campinas - SP

RESUMO

O divertículo de Zenker (DZ) é uma doença muito pouco freqüente, cujo sintoma mais importante é a disfagia cervical. Os aspectos de sua etiopatogenia ainda são motivos de várias pesquisas na literatura, através de estudos manométricos e cinerradiográficos. O tratamento mais empregado é o cirúrgico, favorecendo quase a totalidade dos doentes, com índices de recidiva muito baixos. Porém, algumas publicações enfatizam as vantagens do tratamento endoscópico. Foram revisados 39 doentes, tratados no Serviço nos últimos 15 anos, sendo que 28 foram do sexo masculino (71,8%). A idade do grupo variou de 18 a 86 anos (média 54,5 anos). Os principais sintomas foram a disfagia cervical (89,8%), a regurgitação alimentar (71,8%), a tosse repetitiva (30.7%) e o emagrecimento importante (25,6%). Dois pacientes apresentaram diverticulite aguda e perfuração (5,1 %). O diagnóstico foi estabelecido através de radiografias contrastadas em 37 pacientes (94,8%) e de endoscopia digestiva em 28 (71,7%). A eletromanometria foi realizada em 13 casos (33,3%). O tratamento consistiu de diverticulectomia seguida de miotomia do esfincter do músculo cricofaríngeo em 24 pacientes (61,5%) e diverticulopexia seguida da mesma miotomia em 15 pacientes (38,5%). No seguimento a longo prazo de 35 pacientes (89,8%), variando de cinco meses a 12 anos (média 4,5 anos), ocorreu melhora importante com desaparecimento da disfagia em todos os casos. Três pacientes (7,7%) persistiram sintomas disfágicos leves e inconstantes. Um paciente faleceu em decorrência de complicações cardíacas e pulmonares. Os estudos histopatológicos dos divertículos ressecados mostraram a presença de tumor maligno neuroendócrino em um paciente (2,5%). Os doentes submetidos a diverticulopexia receberam alta hospitalar mais precocemente. Os autores discutem os aspectos atuais da fisiopatologia do DZ, analisam as opções de tratamento e os resultados da literatura, comparando com os obtidos neste estudo. Concluindo, os resultados mostram que tanto a diverticulectomia como a diverticulopexia podem ser utilizadas, ambas seguidas de miotomia do músculo cricofaríngeo. A diverticulopexia mostrou ser uma opção muito satisfatória para os divertículos de tamanhos pequenos e médios.

Unitermos: Divertículo de Zenker; Diverticulectomia; Diverticulopexia.

ABSTRACT

The Zenkers diverticulum is a not frequent disease and the main symptom is the cervical dysfagia. The aspects of the pathophysiology had motivated many researchs in the literature, using manometric and cinerradiographic studies. The surgical treatment is most commonly employed, favouring the most number of patients, with low recurrence rates. However, some publications show the advantages of the endoscopic treatment. Thirty nine patients with Zenkers diverticulum were operated on in the last 15 years, being 28 males (71.8%), with the age ranging from 18 to 86 years (mean 54.5 years). The main symptoms were: cervical dysphagia (89.8%), food regurgitation (71.8%), cough (30.7%) and losting weight (25.6%). Two patients presented diverticulitis and perforated diverticulum (5.1%). The diagnosis were established using esophagogram in 37 patients (94.8%) and digestive endoscopy in 28 (71.7%). The manometric studies were performed in 13 cases (33.3%). The treatment consisted of diverticulectomy followed by the cricopharyngeal sphyncter myotomy in 24 patients (61.5%) or diverticulopexy also followed by the same myotomy in 15 patients (38.5%). The late follow-up of 35 patients (89.8%) ranging from five months to 12 years (mean 4.5 years) showed that all oft hem were without symptoms of dysphagia. Three patients (7. 7%) presented light and inconstant dysphagia. One patient died due to pulmonary and cardiac problems (2.5%). The histopathology studies of the diverticulum showed a malignant tumor in one case (2.5%). The patients submitted to diverticulopexy were discharged early. The authors discuss the modern aspects of the physiopathology of the Zenkers diverticulum, they analyse the choices of treatment and the results of literature, comparing to the obtained in the present study. Concluding, the results of this study showed that either the diverticulectomy as the diverticulopexy are indicated, both followed by cricopharyngeal sphincter myotomy. The diverticulopexy is a very good choice to treat small and middle diverticulum.

Key words: Zenker's diverticulum; Diverticulectomy; Diverticulopexy

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Full text available only in PDF format.

REFERÊNCIAS

1. Ludlow A. A case of obstructed deglutition, from a preter natural dilatation of and bag formed in the pharynx. Med Soc Phys 1767; 3:35-101.

2. Zenker FA, Von Ziemssen H. Krankheiten des Oesophagus. In: Von Ziemssen H, ed. Hankbuch der Speciellen Pathologie und Therapie, vol7 (suppl). Leipzig: FCW Vogel, 1877:1-87.

3. Van Overbeek JJM. Meditation on the pathogenesis of hypopharyngeal (Zenker's) diverticulum and a report of endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol 1994; 103:178-185.

4. Migliore M, Payne H, Jeyasingham K. Pathophysiologic basis for operation on Zenker's Diverticulum. Ann Thorac Surg 1994; 57: 1.616-21.

5. Pinotti HW, Cecconello I, Zilberstein B, Pollara WM. Tratamento cirúrgico do divertículo faringoesofágico. In: Pinotti HV et al (eds.): Atlas de Cirurgia do Esôfago. I^aEd. São Paulo, 1983, pp 54-59.

6. Andreollo NA, Lopes LR, Brandalise NA. Distúrbios motores do esôfago. In: Endoscopia Digestiva. I^a Edição. Rio de Janeiro: Sobed, Medsi, 1994. pp 58-68.

7. 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;7:556-62.

8. Lerut T, Van Raemdonck D, Ouelinckx P, et al. Zenker's diverticulum: is a myotomy of the cricopharyngeus useful ? How long should it be? Hepatogastroenterology 1992;39:127-31.

9. Andreollo NA, Brandalise NA, Leonardi LS. Esfíncter esofágico superior - estudo manométrico em indivíduos normais. Rev Col Brasil Cirurg 1984;11:1-4.

10. Ellis FH, Schlegel JF, Lynch VP, Payne WS. Crycopharyngeal myotomy for pharyngoesophageal div~rticulum. Ann Surg 1969; 170:340-9.

11. Knuff TE, Benjamin SB, Castell DO. Pharyngoesophageal (Zenker's) diverticulum: a reappraisal. Gastroenterology 1982;82:734-6.

12. Duranceau A, Lafontaine ER, Taillefer R, Jamieson DD. Oropharyngeal dysphagia and operation on the upper esophageal sphincter. Surg Ann 1987;19:317-64.

13. Belsey R. Functional diseases of the esophagus. J Thorac Cardiovasc Surg 1962;43:114-26.

14. Hunt PS, Connel AM, Smiley TB. The cricopharyngeal sphincter in gastric reflux. Gut 1970; 34:1.590-9.

15. Smiley TB, Caves PK, Porter DC. Relationship between posterior pharyngeal pouch and hiatus hernia. Thorax 1970; 25: 725-31

16: Aggerholm K, Illum D. Surgical treatment of Zenker 's Diverticulum. J Laryngol Otol 1990;104:312-14.

17. Gullane PJ, Willet JM, Heeneman H. Zenker's Diverticulum. J Otolaryngol 1983;12:53-57.

18. Laccourreye O, Ménard M, Cauchois R, et al. Esophageal diverticulum: diverticulopexy versus diverticulectomy. Laryngoscope 1994; 104:889-92.

19. Konowitz PM & Biller HF. Diverticulopexy and cricopharyngeal myotomy: Treatment for the high-risk patients with a pharyngoesophageal (Zenker's) diverticulum. Otolaryngol Head Neck Surg 1989;100:146-153.

20. Louie HW & Zuckerbraun L. Staged Zenker's diverticulectomy with cervical esophagostomy and secondary esophagostomy closure for treatment of massive diverticulum in severely debilitated patients. Am Surg 1993;59:842-845.

21. Wittrick IJ, Gullane PJ, Yeung E. Outcome analysis of Zenker's diverticulectomy and cricopharyngeal myotomy. Head & Neck 1995;17:382-88.

22. Mosher HP. Webs and pouches of the esophagus, their diagnosis and treatment. Surg Gynecol Obst 1917;25:175-87.

23. Dohlman G, Mattsson O. The endoscopic operation for hypo-pharyngeal diverticula. A roentgencinematographic study. Arch Otolaryngol 1960;71 :744-52.

24. Ishioka L, Sakai P, Maluf Filho F. Endoscopic incision of Zenker's diverticula. Endoscopy 1995;27:433-437.

Recebido em 22/1/97

Aceito para publicação em 11/8/97

Trabalho realizado na Disciplina de Moléstias do Aparelho Digestivo, Departamento de Cirurgia e Gastrocentro, Faculdade de Ciências Médicas da Universidade Estadual de Campinas, UNICAMP. Campinas - SP

1. Ludlow A. A case of obstructed deglutition, from a preter natural dilatation of and bag formed in the pharynx. Med Soc Phys 1767; 3:35-101.
²
Zenker FA, Von Ziemssen H. Krankheiten des Oesophagus. In: Von Ziemssen H, ed. Hankbuch der Speciellen Pathologie und Therapie, vol7 (suppl). Leipzig: FCW Vogel, 1877:1-87.
3. Van Overbeek JJM. Meditation on the pathogenesis of hypopharyngeal (Zenker's) diverticulum and a report of endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol 1994; 103:178-185.
4. Migliore M, Payne H, Jeyasingham K. Pathophysiologic basis for operation on Zenker's Diverticulum. Ann Thorac Surg 1994; 57: 1.616-21.
⁵
Pinotti HW, Cecconello I, Zilberstein B, Pollara WM. Tratamento cirúrgico do divertículo faringoesofágico. In: Pinotti HV et al (eds.): Atlas de Cirurgia do Esôfago. I^a Ed. São Paulo, 1983, pp 54-59.
⁶
Andreollo NA, Lopes LR, Brandalise NA. Distúrbios motores do esôfago. In: Endoscopia Digestiva. I^a Edição. Rio de Janeiro: Sobed, Medsi, 1994. pp 58-68.
7. 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;7:556-62.
8. Lerut T, Van Raemdonck D, Ouelinckx P, et al. Zenker's diverticulum: is a myotomy of the cricopharyngeus useful ? How long should it be? Hepatogastroenterology 1992;39:127-31.
9. Andreollo NA, Brandalise NA, Leonardi LS. Esfíncter esofágico superior - estudo manométrico em indivíduos normais. Rev Col Brasil Cirurg 1984;11:1-4.
10. Ellis FH, Schlegel JF, Lynch VP, Payne WS. Crycopharyngeal myotomy for pharyngoesophageal div~rticulum. Ann Surg 1969; 170:340-9.
11. Knuff TE, Benjamin SB, Castell DO. Pharyngoesophageal (Zenker's) diverticulum: a reappraisal. Gastroenterology 1982;82:734-6.
12. Duranceau A, Lafontaine ER, Taillefer R, Jamieson DD. Oropharyngeal dysphagia and operation on the upper esophageal sphincter. Surg Ann 1987;19:317-64.
13. Belsey R. Functional diseases of the esophagus. J Thorac Cardiovasc Surg 1962;43:114-26.
14. Hunt PS, Connel AM, Smiley TB. The cricopharyngeal sphincter in gastric reflux. Gut 1970; 34:1.590-9.
15. Smiley TB, Caves PK, Porter DC. Relationship between posterior pharyngeal pouch and hiatus hernia. Thorax 1970; 25: 725-31
¹⁶
: Aggerholm K, Illum D. Surgical treatment of Zenker 's Diverticulum. J Laryngol Otol 1990;104:312-14.
17. Gullane PJ, Willet JM, Heeneman H. Zenker's Diverticulum. J Otolaryngol 1983;12:53-57.
18. Laccourreye O, Ménard M, Cauchois R, et al. Esophageal diverticulum: diverticulopexy versus diverticulectomy. Laryngoscope 1994; 104:889-92.
19. Konowitz PM & Biller HF. Diverticulopexy and cricopharyngeal myotomy: Treatment for the high-risk patients with a pharyngoesophageal (Zenker's) diverticulum. Otolaryngol Head Neck Surg 1989;100:146-153.
20. Louie HW & Zuckerbraun L. Staged Zenker's diverticulectomy with cervical esophagostomy and secondary esophagostomy closure for treatment of massive diverticulum in severely debilitated patients. Am Surg 1993;59:842-845.
21. Wittrick IJ, Gullane PJ, Yeung E. Outcome analysis of Zenker's diverticulectomy and cricopharyngeal myotomy. Head & Neck 1995;17:382-88.
22. Mosher HP. Webs and pouches of the esophagus, their diagnosis and treatment. Surg Gynecol Obst 1917;25:175-87.
23. Dohlman G, Mattsson O. The endoscopic operation for hypo-pharyngeal diverticula. A roentgencinematographic study. Arch Otolaryngol 1960;71 :744-52.
24. Ishioka L, Sakai P, Maluf Filho F. Endoscopic incision of Zenker's diverticula. Endoscopy 1995;27:433-437.

Endereço para correspondência:

Nelson Adami Andreollo

Rua Nelson Souza Barbosa, 227

13080-260 - Campinas - SP

Datas de Publicação

Publicação nesta coleção
27 Jul 2010
Data do Fascículo
Fev 1998

Histórico

Aceito
11 Ago 1997
Recebido
22 Jan 1997

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Ludlow A. A case of obstructed deglutition, from a preter natural dilatation of and bag formed in the pharynx. Med Soc Phys 1767; 3:35-101.

[2] ²
Zenker FA, Von Ziemssen H. Krankheiten des Oesophagus. In: Von Ziemssen H, ed. Hankbuch der Speciellen Pathologie und Therapie, vol7 (suppl). Leipzig: FCW Vogel, 1877:1-87.

[3] 3. Van Overbeek JJM. Meditation on the pathogenesis of hypopharyngeal (Zenker's) diverticulum and a report of endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol 1994; 103:178-185.

[4] 4. Migliore M, Payne H, Jeyasingham K. Pathophysiologic basis for operation on Zenker's Diverticulum. Ann Thorac Surg 1994; 57: 1.616-21.

[5] ⁵
Pinotti HW, Cecconello I, Zilberstein B, Pollara WM. Tratamento cirúrgico do divertículo faringoesofágico. In: Pinotti HV et al (eds.): Atlas de Cirurgia do Esôfago. I^a Ed. São Paulo, 1983, pp 54-59.

[6] ⁶
Andreollo NA, Lopes LR, Brandalise NA. Distúrbios motores do esôfago. In: Endoscopia Digestiva. I^a Edição. Rio de Janeiro: Sobed, Medsi, 1994. pp 58-68.

[7] 7. 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;7:556-62.

[8] 8. Lerut T, Van Raemdonck D, Ouelinckx P, et al. Zenker's diverticulum: is a myotomy of the cricopharyngeus useful ? How long should it be? Hepatogastroenterology 1992;39:127-31.

[9] 9. Andreollo NA, Brandalise NA, Leonardi LS. Esfíncter esofágico superior - estudo manométrico em indivíduos normais. Rev Col Brasil Cirurg 1984;11:1-4.

[10] 10. Ellis FH, Schlegel JF, Lynch VP, Payne WS. Crycopharyngeal myotomy for pharyngoesophageal div~rticulum. Ann Surg 1969; 170:340-9.

[11] 11. Knuff TE, Benjamin SB, Castell DO. Pharyngoesophageal (Zenker's) diverticulum: a reappraisal. Gastroenterology 1982;82:734-6.

[12] 12. Duranceau A, Lafontaine ER, Taillefer R, Jamieson DD. Oropharyngeal dysphagia and operation on the upper esophageal sphincter. Surg Ann 1987;19:317-64.

[13] 13. Belsey R. Functional diseases of the esophagus. J Thorac Cardiovasc Surg 1962;43:114-26.

[14] 14. Hunt PS, Connel AM, Smiley TB. The cricopharyngeal sphincter in gastric reflux. Gut 1970; 34:1.590-9.

[15] 15. Smiley TB, Caves PK, Porter DC. Relationship between posterior pharyngeal pouch and hiatus hernia. Thorax 1970; 25: 725-31

[16] ¹⁶
: Aggerholm K, Illum D. Surgical treatment of Zenker 's Diverticulum. J Laryngol Otol 1990;104:312-14.

[17] 17. Gullane PJ, Willet JM, Heeneman H. Zenker's Diverticulum. J Otolaryngol 1983;12:53-57.

[18] 18. Laccourreye O, Ménard M, Cauchois R, et al. Esophageal diverticulum: diverticulopexy versus diverticulectomy. Laryngoscope 1994; 104:889-92.

[19] 19. Konowitz PM & Biller HF. Diverticulopexy and cricopharyngeal myotomy: Treatment for the high-risk patients with a pharyngoesophageal (Zenker's) diverticulum. Otolaryngol Head Neck Surg 1989;100:146-153.

[20] 20. Louie HW & Zuckerbraun L. Staged Zenker's diverticulectomy with cervical esophagostomy and secondary esophagostomy closure for treatment of massive diverticulum in severely debilitated patients. Am Surg 1993;59:842-845.

[21] 21. Wittrick IJ, Gullane PJ, Yeung E. Outcome analysis of Zenker's diverticulectomy and cricopharyngeal myotomy. Head & Neck 1995;17:382-88.

[22] 22. Mosher HP. Webs and pouches of the esophagus, their diagnosis and treatment. Surg Gynecol Obst 1917;25:175-87.

[23] 23. Dohlman G, Mattsson O. The endoscopic operation for hypo-pharyngeal diverticula. A roentgencinematographic study. Arch Otolaryngol 1960;71 :744-52.

[24] 24. Ishioka L, Sakai P, Maluf Filho F. Endoscopic incision of Zenker's diverticula. Endoscopy 1995;27:433-437.