Size Of Diverticulum Research Articles

Unique doubly connected left ventricular diverticulum

This case report describes a unique form of a left ventricular diverticulum in a 17-year-old patient.Echocardiography, angiography, and magnetic resonance imaging including virtual endoscopy complete a detailed picture of the size and texture of a diverticulum, as well as the localisation of the two connections into the left ventricle.

Evaluation of Safety of Endoscopic Harmonic Diverticulostomy

Objective: Review a series of patients with Zenker diverticulum who were treated with endoscopic diverticulostomy using Harmonic Ultrasonic Surgical Instrumentation (Ethicon Endosurgery, Cincinnati, Ohio) in order to evaluate the safety and optimal application of this technology to the treatment of patients with this disorder. Method: Retrospective chart review of patients undergoing endoscopic surgical correction of Zenker diverticulum with Harmonic Ace curved shears between July 1, 2009 and November 1, 2010. Presenting symptoms, size of diverticulum, operative times, length of hospital stay, outcomes, and complications were reviewed. Results: A total of 60 endoscopic diverticulostomies were performed, and 24 were Harmonic-assisted. Eight required hospital stays, with their average stay being 2.13 days (0.7 days for all Harmonic patients). There were 6 complications with Harmonic treatments (25%). Two patients had chest pain with negative work-ups. Two patients had subcutaneous air. One had a documented salivary leak. One patient had diverticulum recurrence. No patients had hemorrhage, mediastinitis, or death. The average diverticulum size was 3.24 cm, and there were no complications with diverticula less than 2 cm. There were two complications with the staple technique (6.45%). Conclusion: Endoscopic staple diverticulostomy is a proven safe treatment for Zenker diverticulum with few limitations. Harmonic instrumentation may be effective with diverticula less than 2 cm. However, based on observed complication rates, additional evaluations are warranted before endoscopic Harmonic diverticulostomy can be recommended as treatment for the majority of cases.

Endoscopic vs Open‐Neck Zenker Diverticulum Surgery

Objective: Compare long-term symptomatic outcomes between open-neck surgery and endoscopic stapling diverticulotomy (ESD) for Zenker diverticulum. Method: Patients at least 1 year after surgery for Zenker diverticulum were telephoned and questioned of dysphagia, choking, regurgitation, and halitosis based on a validated Gastrointestinal Quality-of-Life Index. Symptom degree preoperatively and at phone call was assessed. Patients rated their overall postoperative symptoms as worsened, unchanged, improved, or completely resolved. Results: A total of 55 of 102 patients were contacted. Of these, 24 underwent ESD and 31 had open-neck procedures. Average follow-up time was longer for the open-neck group (5.7 vs 3.1 years, P < .01). Gender, age at operation, diverticulum size, and preoperative symptom scores were not statistically different between the 2 groups. For both techniques, symptom scores showed significant improvement postoperatively ( P < .01). A greater proportion of patients undergoing open-neck procedures reported their symptoms to be completely resolved or improved (93% vs 67%, P = .015). Specifically, complete resolution of symptoms was achieved more often in those who had open-neck surgery (77% vs 50%, P = .047). Conclusion: Both the open neck and ESD surgeries significantly benefit patients, regardless of diverticulum size. Long-term symptomatic outcomes between the 2 populations indicate that patients with open-neck procedures attain a greater degree of resolution of preoperative symptoms. This may be due to fundamental differences between the surgical techniques.

Transoral treatment of Zenker diverticulum: flexible endoscopy versus endoscopic stapling. A retrospective comparison of outcomes

Transoral stapled diverticulo-esophagostomy (TSDE) has gained increased popularity in surgical treatment of Zenker diverticulum (ZD). One of the advantages of this approach is early rehabilitation with significant decrease in patient morbidity and time to resumption of oral intake as compared with open treatment. The section of the septum between the diverticulum and the esophagus with a flexible endoscopic (ES) approach has also been proposed since mid-90s as an alternative for treatment of ZD. Both these approaches are a minimally invasive approach to treat ZD. We compared the TSDE management of ZD versus the ES treatment in a retrospective consecutive series of patients who were referred to either the ES or surgical unit of our Institute. Fifty-eight consecutive patients underwent treatment for ZD either by TSDE or ES. The two techniques were evaluated for length of hospital stay, diverticulum size, resumption of oral intake, resolution of dysphagia, and complications. Clinical outcome was evaluated throughout a symptom score from 0 to 3, calculated before and after the procedure. The two groups were compared on the various parameters using a Mann--Whitney test. Twenty-eight patients underwent ES and 30 TSDE for ZD. In both groups, a significant decrease in postoperative versus preoperative dysphagia was reported. The average length of hospital stay wasn't significantly different in the two groups (3.38 days for TSDE vs. 2.42 days for ES). The overall complication rate was similar in the two groups. There were two cases in the ES group and three cases in the TDSE group that required an ES revision to take down a residual diverticular wall that produced a mild but persistent dysphagia. Minimally invasive treatment of ZD both with ES and with TSDE is a valuable option for this disease: both techniques are safe and effective, with similar outcome in terms of hospital stay, symptom reduction, and complication rate. Long-term results have to be evaluated.

Tratamiento endoscópico combinado vs. abierto en el divertículo de Zenker

Introduction Zenker's diverticulum is a superior esophagus sphincter disease with a surgical management in symptomatic cases. This treatment has undergone important changes in recent years. Material and method A retrospective review was carried out of 16 patients treated in our department between 2001 and 2008. Conventional open surgery was used as well as a combined endoscopic approach with stapler and CO 2 laser. Type of treatment, diverticulum size, operating time, oral feeding time, surgical complications, hospital stay and occurrence of relapses were analyzed. Results The endoscopic approach was used in 8 patients, with a conversion to conventional open surgery being necessary in 2 cases. Operating time was of 90 min for the open approach and 45 in the endoscopic. Oral feeding could be reintroduced 36 hours after open surgery and 24 h after endoscopic treatment. The average discharge date was 3.8 days after the surgery in the open group and 2 days in the endoscopic group. Complications appeared in the 12.4% of the cases, all related to cervicotomy. There were 2 cases of relapse in the group treated with open surgery, one case was treated with the endoscopic approach and another with the open approach. Conclusions The combined endoscopic approach offers good results in patients with symptomatic Zenker's diverticulum who can be under general anesthesia during the surgery. A conversion to open surgery with cervicotomy should be done when a good endoscopic exposure is not possible.

Endoscopic management of Zenker's diverticulum: Stapler assisted versus Harmonic Ace

Endoscopic repair has become the preferred method of treatment for Zenker's diverticuli. The objective of this study is to compare the endoscopic stapling technique with a novel technique using the Harmonic Ace device (Ethicon Endo-Surgery, Inc., Cincinnati, OH). A retrospective chart review. Medical records of 48 consecutive patients who underwent endoscopic repair of a Zenker's diverticulum were reviewed. Data were gathered for demographics, symptoms, treatment techniques, and outcomes. Analysis was made using standard statistical methods. A total of 52 endoscopic procedures were attempted and 50 performed: 28 stapler assisted, 20 Harmonic Ace assisted, and 2 using both techniques. Three procedures were aborted due to anatomic limitations. Forty-four (88%) patients reported complete resolution of their symptoms. Overall, there were six (12%) reported complications. Five (17.9%) complications involved the stapler technique and 1 (5%) using the Harmonic Ace. The difference between these two groups was not significant (P < .38). The average diverticulum size was smaller in the Harmonic Ace group compared to the stapler group (P < .0017). Patients with diverticuli larger than 2 cm were more likely to have postoperative complications than those with smaller ones. Stapler and Harmonic Ace assisted endoscopic repair of Zenker's diverticulum are two safe and effective minimally invasive techniques. Postoperative complications are more likely due to size of the diverticulum and not the device used. The Harmonic Ace used alone or in combination with the stapler may offer additional advantages over conventional open and stapler assisted techniques, addressing size limitations and persistent symptoms.

Histopathologic Features and Clinical Outcomes in 71 Cases of Bladder Diverticula

Bladder diverticula often come to clinical attention when complications or malignancy occur, although limited information is available regarding histopathologic features and clinical outcomes. To identify the morphologic findings, neoplastic subtypes, and clinical outcomes by reviewing all bladder diverticula that underwent pathologic sampling for primary diverticular processes at the Cleveland Clinic. Hematoxylin-eosin slides from 71 cases of bladder diverticula were reviewed. Clinicopathologic features and patient outcomes were obtained from a retrospective review of patient records. Patient ages ranged from 1 to 81 years (mean, 55 years), and the ratio of males to females was 68:3. Diverticular size ranged from 1 to 18 cm (mean, 5.3 cm) and often involved the lateral walls (38/71; 54%). Neoplastic changes were present in half of cases (36/71; 51%), including both noninvasive (16/36; 44%) and invasive (20/ 36; 56%) carcinoma. Of the invasive carcinomas, less-common subtypes included small cell carcinoma (n = 3), squamous cell carcinoma (n = 2), and adenocarcinoma (n = 1); 9 cases were pT1 (45%) and 11 cases were pT3 (55%). Follow-up for patients with benign findings demonstrated no subsequent neoplastic bladder disease. Patient follow-up for neoplastic diverticula (median, 27 months) demonstrated 4 cases of local recurrence and 3 cases of subsequent metastases. Of 9 patients with pT1 disease, only 1 patient (11%) developed subsequent metastases, whereas patients with pT3 disease demonstrated a higher rate of both local recurrence (3/11; 27%) and subsequent metastases (2/11; 18%). Patients with invasive carcinoma in diverticula have an increased frequency of less-common bladder cancer subtypes, and those with pT3 disease are at increased risk for subsequent progression.

Surgical experience of the national institution in the treatment of Zenker's diverticula

To review the 8-year experience of the Department of Esophagogastric Surgery, First Surgical University Hospital in Belgrade in the surgical management of Zenker's diverticula (ZD). Between January 2000 and January 2009, 52 patients underwent surgical procedure for the treatment of ZD. Complete preoperative workup including the symptom evaluation and large variety of structural and functional diagnostic procedures were conducted before the surgery. After the operative treatment patients underwent detailed follow-up in regular intervals up to 3 years. Preoperative evaluation marked higher incidence of hiatal hernia and pathologic gastroesophageal reflux (GER) among the patients with ZD then in normal population. According to the preoperative evaluation and size of diverticula, as well as due to the intraopertive findings, a variety of surgical procedures were performed, including myotomy alone (n = 2), diverticulopexy and myotomy (n = 36) and diverticulectomy and myotomy (n = 14). Regardless of the operative treatment no salivary cervical fistulas were observed. Late and early postoperative results revealed low incidence in postoperative transitory dysphagia or regurgitation. The results of this study show that the open surgical procedures are safe and effective in the treatment of ZD. Cricopharyngeal myotomy remains the essential focus of treatment, while the choice of resecting or suspending the diverticulum is brought upon its size. Complete preoperative investigation must be conducted in ZD patients, and the role of pathologic GER must be taken into account when we discuss the origin of this disorder.

Combined endoscopic treatment for Zenker's diverticulum versus open approach; review of our experience

IntroductionZenker's diverticulum is a superior esophagus sphincter disease appropriate for surgical management in symptomatic cases. This treatment has undergone important changes in recent years. Material and methodsA retrospective review was carried out on 16 patients treated in our department between 2001 and 2008. Conventional open surgery was used, as well as a combined endoscopic approach with stapler and CO2 laser. Type of treatment, diverticulum size, operating time, oral feeding time, surgical complications, hospital stay, and occurrence of relapses were analyzed. ResultsThe endoscopic approach was used in 8 patients, converting to conventional open surgery being necessary in 2 cases. Operating time was 90min for the open approach and 45 for the endoscopic. Oral feeding could be reintroduced 36h after open surgery and 24h after endoscopic treatment. The average discharge date was 3.8 days after the surgery in the open group and 2 days in the endoscopic group. Complications appeared in 12.4% of the cases, all related to cervicotomy. There were 2 cases of relapse in the group treated with open surgery; one case was treated with the endoscopic approach and the other with the open approach. ConclusionsThe combined endoscopic approach offers good results in patients with symptomatic Zenker's diverticulum who can be under general anesthesia during the surgery. A conversion to open surgery with cervicotomy should be done when good endoscopic exposure is not possible.

Urethral Diverticula in 90 Female Patients: A Study With Emphasis on Neoplastic Alterations

Urethral diverticula are uncommon and occur predominantly in women. We examined a large series of female urethral diverticula to determine associated neoplastic alterations and subsequent clinical outcomes. All pathological evaluations of female urethral diverticulectomies performed at our institution between 1981 and 2007 were retrospectively reviewed and the clinicopathological features were correlated. During this period 90 women underwent urethral diverticulectomy at our institution. Patient age was 24 to 78 years (mean 45). The most common clinical finding was urinary incontinence (29 of 78 women or 37%). Diverticular size was 0.3 to 5.0 cm (mean 1.7). Neoplastic alterations identified in 5 patients (6%) were glandular in nature, including 1 clear cell and 4 invasive adenocarcinomas. Superficial changes associated with invasive carcinoma included villous adenoma in 1 case, intestinal metaplasia in 2 and high grade dysplasia in 3. An additional 3 patients had extensive intestinal metaplasia. Of the 90 patients the remaining 82 demonstrated benign findings, including nephrogenic adenoma in 10 (11%). All 5 patients with invasive carcinoma underwent anterior pelvic exenteration with urinary diversion. In 2 patients with invasive adenocarcinoma metastatic disease subsequently developed, of which they died. Although most cases of surgically resected diverticula demonstrate benign features, approximately 10% show atypical glandular findings, including invasive adenocarcinoma. Due to the risk of malignancy in a subset of patients careful clinical examination and followup are warranted in all patients to exclude neoplastic disease.

Zenker’s Diverticula: Feasibility of a Tailored Approach Based on Diverticulum Size

BackgroundZenker’s diverticula (ZD) can be treated by transoral diverticulostomy or open surgery (upper esophageal sphincter myotomy and diverticulectomy or diverticulopexy). The aim of this study was to compare the effectiveness of a minimally invasive (group A) versus a traditional open surgical approach (group B) in the treatment of ZD. Material and MethodsBetween 1993 and September 2007, 128 ZD patients underwent transoral diverticulostomy (n = 51) or cricopharyngeal myotomy and diverticulectomy or diverticulopexy (n = 77). All patients were evaluated for symptoms using a detailed questionnaire. Manometry recorded upper esophageal sphincter (UES) pressure, relaxations, and intrabolus pharyngeal pressure. The size of the pouch was measured on the barium swallow. The choice of treatment was based on the size of the diverticulum and the patients’ preference. Long-term follow-up data were available for 121/128 (94.5%) patients with a median follow-up of 40 months (interquartile range, 17–83). ResultsMortality was nil. Three patients in group A (5.8%) and ten in group B (13%) had postoperative complications (p = n.s.). Hospital stays were markedly shorter for patients after diverticulostomy (p < 0.01). Postoperative manometry showed a reduction in UES pressure, improved UES relaxation, and lower intrabolus pressure in both groups (p < 0.05). Four patients in the open surgery group (5.2%) complained of severe dysphagia after surgery (three of them required endoscopic dilations). In the transoral diverticulostomy group, 11 patients (21.5%) required additional septal reduction (n = 8) or a surgical myotomy (n = 3) for persistent symptoms (p < 0.01); nine of these 11 patients had a ZD ≤ 3 cm in size. After primary and complementary treatments, symptoms disappeared or improved significantly at long-term follow-up in 93.5% of patients in group A and 96% of those in group B. ConclusionDiverticulostomy is safe, quick, and effective for most patients with medium-sized ZD, but open surgery offers better long-term results as a primary treatment and should be recommended for younger, healthy patients, especially those with small diverticula. Small ZD may represent a formal contraindication to the transoral approach because an excessively short septum prevents a complete division of the sphincter fibers.

S175 – Endoscopic and Open Approaches for Zenker's Diverticulum

Objectives To compare 1) long-term symptomatic outcomes and 2) patient satisfaction between open-neck surgery and endoscopic stapling diverticulotomy (ESD) for Zenker's diverticulum. Methods Patients undergoing operation for Zenker's diverticulum during the last 10 years (1998 through 2007) at our institution were telephoned and questioned of dysphagia, coughing and choking, regurgitation, halitosis, weight loss, and recurrent pneumonia based on a validated Gastrointestinal Quality-of-Life Index. Symptom degree pre-operatively, one-month postoperatively, and time of phone call were recorded. Results 39 of 81 patients were contacted. Of these, 14 underwent ESD and 25 had open-neck procedures. Average follow-up time was longer for the open-neck group (4.6 vs. 1.8 years, p&lt;0.01, t-test). Age at operation, diverticulum size, pre-operative symptom scores, and long-term follow-up scores at phone call were not statistically different between the two groups. When patients were asked if symptom relief was complete, improved, unchanged, or worse, a greater proportion of open-neck patients claimed a complete response (67% vs. 43%, p=0.09, contingency analysis) at longer follow-up times. The recurrence of symptoms leading to re-operation was higher for ESD (4 versus 2). Conclusions Long-term symptomatic outcomes between the 2 populations are similar. However, a greater proportion of patients with open-neck procedures claimed complete response. Since the Zenker's location is unchanged in ESD, this may explain persistent symptoms the patient may be experiencing. Greater patient numbers are needed for statistical significance.

Endoscopic Management of Zenker's Diverticulum: Factors Predictive of Success or Failure

We review our experience with endoscopic management of Zenker's diverticulum. We sought to analyze and determine risk factors for success or failure of endoscopic diverticulum treatment. We performed a retrospective review of 72 consecutive patients who underwent attempted endoscopic management of a Zenker's diverticulum between January 2000 and April 2006. The procedures were performed by either of 2 otolaryngologists. There were 50 men and 22 women ranging in age from 44 to 93 years. A total of 85 procedures were performed. The medical records were reviewed for preoperative diverticulum size (small, 1 to 2 cm; moderate, 2.1 to 3.0 cm; and large, more than 3.0 cm), intraoperative diverticulum characteristics, patient anatomic limitations that prevented adequate endoscopic visualization, surgical complications, and management of recurrences. Of our 72 patients, 61 (85%) were able to undergo endoscopic cricopharyngeal myotomy with diverticulum elimination. Of the 61 endoscopic procedures, 47 (77%) resulted in complete symptom resolution. The most common risk factors for recurrence were diverticulum size (more than 3 cm) and amount of redundant mucosa. Of the 14 patients with a recurrence, 10 (71%) underwent a repeat procedure. Six of the 14 (43%) had a successful excision via a cervical approach, and 4 of the 14 (29%) underwent a repeat endoscopic myotomy. There was 1 major complication (esophageal tear), and there were 3 minor complications (mucosal abrasions). Most patients with a Zenker's diverticulum are good candidates for endoscopic management. In our series, 84% of those who underwent endoscopic treatment ultimately achieved relief of symptoms. The patient morbidity is minimal. A large diverticulum with redundant mucosa is a risk factor for recurrence after endoscopic treatment.

Surgical Treatment of Epiphrenic Diverticula: A 30-Year Experience

Epiphrenic diverticula are rare and associated with esophageal motility abnormalities. Their optimal surgical treatment is debated, mortality being 9% in the largest reported surgical series of 33 patients. Our experience with a traditional thoracic approach was reviewed to provide benchmark data against which newer surgical techniques can be measured. A retrospective review of 35 patients operated on for epiphrenic diverticula from 1976 to 2005 was conducted. All underwent open transthoracic operations: resection of the diverticulum, long esophagomyotomy, and antireflux operations (modified Belsey, 29 patients; Nissen, 4 patients) in 33 patients; resection and long myotomy alone in 1 patient; and plication, long myotomy, and Collis-Nissen in 1 patient. Preoperative assessment included barium esophagogram, flexible esophagoscopy, manometry, and standard acid reflux test. Operative complications and functional results were assessed. Median age was 71 years (range, 36 to 87 years). Diverticulum size averaged 6.4 cm (range, 3 to 14 cm). Sixty-eight percent presented to the right of the esophagus. The median duration of symptoms was 3 years. Presenting complaints included dysphagia (83%), regurgitation (69%), and chest pain (26%). Eighteen had a mean weight loss of 19 pounds. There was 1 perioperative death (2.8%) from a plicated diverticulum leak and one nonfatal suture line leak. Median hospital stay was 7 days. Mean follow-up was 45.3 months. Twenty-six patients (74%) had an excellent result (no residual symptoms). Seven required a periodic esophageal dilatation for intermittent mild dysphagia. Traditional transthoracic resection, long esophagomyotomy, and an antireflux procedure provide excellent long-term functional results with relatively low postoperative morbidity in patients with epiphrenic diverticula.

Endoscopic Treatment of Vesicoureteral Reflux Associated With Paraureteral Diverticula in Children

Paraureteral or Hutch diverticula are congenital bladder diverticula that occur at or adjacent to the ureteral hiatus and are associated with vesicoureteral reflux in the majority of cases. Surgical treatment has traditionally been ureteral reimplantation with or without diverticulectomy. We present our experience with endoscopic treatment of vesicoureteral reflux associated with paraureteral diverticula. Of 745 patients undergoing endoscopic treatment for vesicoureteral reflux between 2002 and 2006, 17 (2.3%) had paraureteral diverticula located at the refluxing ureter. The hydrodistention implantation technique was used and dextranomer/hyaluronic acid copolymer was used as bulking material. Success was defined as vesicoureteral reflux grade 0 on postoperative voiding cystourethrogram at 1 to 3 months after a single treatment. A total of 20 refluxing ureters with associated paraureteral diverticula were treated in 17 patients. Of the cases 14 were unilateral and 3 were bilateral. Reflux was grade I in 6 patients, grade II in 4, grade III in 8, grade IV in 1 and grade V in 1. A mean of 1.2 ml bulking agent was injected per ureter. Overall success was 81% (13 of 16 patients) after a single injection. Success per vesicoureteral reflux grade was 100% (6 of 6 patients) for grade I, 100% (3 of 3) for grade II, 63% (5 of 8) for grade III, 100% (1 of 1) for grade IV and 100% (1 of 1) for grade V. Endoscopic treatment failed in 3 patients. Multivariate analysis identified large diverticular size and high bulking agent volume as predictors of treatment failure. Age, reflux grade and the presence of unilateral vs bilateral paraureteral diverticula did not impact outcome. Endoscopic injection of dextranomer/hyaluronic acid copolymer is an excellent choice for the treatment of vesicoureteral reflux associated with paraureteral diverticula because it has a high success rate and avoids open surgery.

Dysphagia After Endoscopic Repair of Zenker's Diverticulum

To determine whether patient outcomes after endoscopic staple-assisted diverticulectomy(ESD) were correlated with demographic or disease-specific patient characteristics. Retrospective chart review with followup. A survey was sent to all eligible subjects who had undergone ESD from February 1995 to June 2004 to gather information about their postoperative weight, diet, dysphagia symptoms, distress, and overall satisfaction. Thirty-five individuals responded(49% response rate) at a mean of 29 (range,3-83) months postoperative. There was a significant reduction in the following symptoms: food avoidance,regurgitation, dysphagia for pills, choking, coughing,difficulty finishing a meal, heartburn/reflux, and halitosis. There was no significant difference for dysphonia.Swallow-related distress had decreased from a preoperative level of 7.86 to 2.23 at follow-up (P <.001). Overall satisfaction with the surgery was high. There were no significant differences in outcome by any demographic characteristic, duration of preoperative symptoms, presence of gastroesophageal reflux disease, Zenker's diverticulum size, time since surgery,or number of surgeries. Ninety-one percent of subjects reported improvement in their swallowing after surgery, but 22% reported some decline since that time. Symptomatic subjects reported significantly higher swallow-related distress and lower satisfaction(P < .01). Preoperative variables were not correlated with a return of symptoms. Individuals who underwent multiple procedures had similar levels of benefit and satisfaction as those who underwent a single ESD procedure. ESD results in high levels of patient satisfaction, significant reduction in postoperative symptoms, low levels of complications,and the opportunity to safely and successfully repeat the procedure if necessary.

Videofluoroscopic Findings in Dysphagic Patients with Cricopharyngeal Dysfunction: Before and after Open Cricopharyngeal Myotomy

Functional outcomes after open cricopharyngeal myotomy (CPM) for Zenker's diverticulum (ZD) and cricopharyngeal dysfunction without diverticulum (CPD) have not been uniformly measured by videofluorographic swallow study (VFSS). Here we characterize preoperative VFSS findings in these groups and evaluate the effect of CPM on swallowing via postoperative VFSS. We performed a retrospective review of paired preoperative and postoperative VFSS results from 50 patients (36 with ZD and 14 with CPD) over 6 years. Semiquantitative scales were used to assess 1) degree of stasis in the pharyngeal recesses; 2) degree of narrowing at the pharyngoesophageal sphincter (PES); 3) aspiration; and 4) diverticular size. Findings were compared between the groups and across subjects. Pharyngeal stasis was more severe in subjects with CPD than in subjects with ZD, both before and after CPM (p = .02 and p = .0002, respectively). The CPM improved PES narrowing in both groups (p = .03; p = .06) and reduced diverticular size in the ZD group (p < .001), but it did not significantly reduce the stasis severity or the proportion of patients with aspiration. According to VFSS, CPM opens up the PES and decreases diverticular size. More severe stasis in CPD suggests that diffuse pharyngeal weakness may play a role in this disease, and may partially explain the variable post-CPM outcomes that have been observed in CPD.

The Endoscopic Management of Zenker Diverticulum: CO2 Laser versus Endoscopic Stapling

The purpose of this project was to analyze the endoscopic management of Zenker diverticulum (ZD) using both the CO2 laser and endoscopic stapling techniques. This study compares the two techniques in terms of diverticulum size, onset to oral intake, hospital stay, resolution of symptoms (dysphagia and regurgitation), and complications. A retrospective consecutive case series was performed at an academic medical center. Forty patients underwent an attempted endoscopic resection of the ZD using either the CO2 laser or the endoscopic stapling technique. The two techniques were compared on a variety of parameters, including diverticulum size, hospital stay, onset to oral intake, resolution of symptoms, and complications. Symptom scores were obtained before and after surgery with a patient self-reported scoring report (scale 0-3 for both dysphagia and regurgitation with 0 indicating asymptomatic and 3 severe symptoms). Forty patients underwent an attempted endoscopic management of ZD. Five patients (12.5%) failed endoscopic exposure (four converted to open, one observed). Sixteen patients underwent CO2 laser management and 19 underwent endoscopic stapling. The mean diverticulum size (3.8 cm CO2 laser versus 4.4 cm stapling) was not significantly different for the two groups. Both groups demonstrated a significant decrease in preoperative versus postoperative dysphagia and regurgitation symptoms scores, respectively, CO2 laser dysphagia scores decreasing from 2.75 to 1.38 and the regurgitation score dropping from 1.51 to 0.68, whereas endoscopic stapling dysphagia score decreased from 2.74 to 1.21 and the regurgitation score dropped from 1.37 to 0.53. Overall, 86% of patients demonstrated an onset of liquid intake on postoperative day 1 and the average length of stay was 3.4 days in the CO2 laser group and 1.5 days in the endoscopic stapling (P < .0015). Complications included dental trauma in four patients (two CO2 laser and two stapling) and subcutaneous air in three patients (all three CO2 laser). There were no cases of mediastinitis, recurrent laryngeal nerve injury, fistula, or perioperative death. The endoscopic management of ZD is a safe and effective technique. The endoscopic stapling technique appears to have an improved efficacy and safety when compared with the CO2 laser technique. The two techniques are compared and contrasted.

Urethral diverticulum in a female child

A urethral diverticulum in a female arises from the wall of the urethra and consists mainly of fibrous tissue lined with epithelium. It is uncommon, and usually presents between decades 3 and 5. Most patients present with non-specific, refractory, lower urinary tract symptoms, unrelated to the diverticulum size or number. The diverticulum may also present as a mass at the introitus. We report a case of urethral diverticulum in a female child that presented as an introital mass.

Prenatal diagnosis of a right ventricular diverticulum complicated by pericardial effusion in the first trimester

A ventricular diverticulum associated with a large pericardial effusion was diagnosed at 13 weeks of gestation. The pericardial effusion resolved spontaneously by 20 weeks and the diverticular size remained the same during pregnancy. In the postnatal period the neonate underwent surgical correction of both the diverticulum and associated ventricular and atrial septal defects. Our case indicates that congenital ventricular diverticulum may be associated with a good perinatal outcome.