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| __NOTOC__
| | *Genetic predisposition may deem an individual vulnerable to the environmental triggers resulting in EoE. |
| {{Zenker's diverticulum}}
| | *Frequently, patients presenting with EoE have a history of food or aeroallergen hypersensitivity, elevated serum IgE, and responsiveness to diet restriction or anti-allergy therapy. |
| {{CMG}} {{AE}}
| | *Food hypersensitivity has been reported in 19–73% of children and 13–25% of adults with EoE. |
| | | *The reason for lower rates of food hypersensitivity in adults is unclear, but this feature may mean that adults are less responsive to diet restriction. |
| ==Overview==
| | *Regardless, EoE is considered an immunoallergenic disorder, whereby esophageal inflammation results from repeated exposure to food and aeroallergens in genetically susceptible individuals. |
| | | *The documented cytokine expression profile in the esophageal tissue of EoE patients is that of a TH2 inflammatory response. |
| ==Pathophysiology==
| | *The activated TH2 response leads to the recruitment and activation of eosinophils and mast cells, which degranulate, releasing products that instigate tissue damage and repair. |
| The pathophysiology of the Zenker's diverticulum is as follows
| | *Interestingly, TH1 cytokines including tumor necrosis factor (TNF)-α (expressed by esophageal epithelial cells) and interferon (IFN)-γ (up-regulated by peripheral blood T cells) (40) are also found in increased numbers in esophageal biopsies. |
| * Zenker's diverticula (ZD) is thought to be due to the result of motor abnormalities of the esophagus. | | *This may explain the non-IgE, type IV hypersensitivity (cell mediated) mechanism of EoE. |
| * ZD is a defect over the Killian's triangle, a point of weakness in the muscular wall of the hypopharynx. | | *It is postulated that the EoE-defining endoscopic and histologic manifestations are a culmination of the disease process which, may have debilitating long-term effects including strictures and food impactions in untreated or poorly managed cases of EoE. |
| * Killian's triangle is surrounded by the cricopharyngeal sphincter and oblique fibers of the inferior constrictor of the pharyngeal muscle.
| | *Eosinophils originate from CD34+ myeloid precursor cells in the bone marrow, mature to a granulated state and migrate to vascular spaces. |
| * ZD should be considered a pseudodiverticulum as it includes only mucosa and submucosa. | | *They tend to be present in all layers of the esophagus in EoE, but predominate in the lamina propria and submucosal regions. |
| * Chronic strain on the Killian's triangle leads to an evagination of the sphincter, which may be because of the high pressures in the food bolus in the course of swallowing and the abnormalities of the upper esophageal sphincter (UES).
| | *Eosinophils contain many preformed granule proteins including eosinophil cationic protein (ECP), major basic protein (MBP) eosinophil peroxidase (EPO), and eosinophil-derived neurotoxin (EDN), which are released into tissues upon stimulation and degranulation. |
| * This failure to achieve adequate diameter for effective bolus clearance leads to a subsequent increase in the hypopharyngeal pressure gradient. | | *Additionally, eosinophils synthesize and release cytokines including IL-5, IL-13, transforming growth factor (TGF)-α and -β, chemokines (eotaxins and RANTES), and lipid mediators such as platelet activating factor (PAF) and leukotriene C4. |
| * Increased intrabolus pressures found in patients with ZD can be secondary to impaired bolus passage combined with the gastroesophageal reflux disease (GERD) or as a result of the GERD.
| | *The process of eosinophil maturation and migration is stimulated by IL-5, IL-13, and granulocyte-macrophage colony stimulating factor (GM-CSF). |
| * As the diverticulum enlarges, it may compress the pharyngoesophageal segment as well as increased stiffness and the intrabolus pressure.
| | *Eosinophil-derived angiogenic molecules may increase vascularity and facilitate inflammatory cell recruitment. |
| * Increased intrabolus pressure is also increased in older patients who perform multiple swallows to achieve bolus clearance.
| | *TGF-β1 and matrix metalloproteinase 9 (MMP)-9 are fibrogenic mediators implicated in airway remodeling. |
| * Various hypothesis involved in the pathogenesis of the Zenker's diverticulum are as follows<ref name="pmid1397879">{{cite journal |vauthors=Cook IJ, Gabb M, Panagopoulos V, Jamieson GG, Dodds WJ, Dent J, Shearman DJ |title=Pharyngeal (Zenker's) diverticulum is a disorder of upper esophageal sphincter opening |journal=Gastroenterology |volume=103 |issue=4 |pages=1229–35 |year=1992 |pmid=1397879 |doi= |url=}}</ref><ref name="pmid1283083">{{cite journal |vauthors=Cook IJ, Blumbergs P, Cash K, Jamieson GG, Shearman DJ |title=Structural abnormalities of the cricopharyngeus muscle in patients with pharyngeal (Zenker's) diverticulum |journal=J. Gastroenterol. Hepatol. |volume=7 |issue=6 |pages=556–62 |year=1992 |pmid=1283083 |doi= |url=}}</ref><ref name="pmid1634178">{{cite journal |vauthors=Fulp SR, Castell DO |title=Manometric aspects of Zenker's diverticulum |journal=Hepatogastroenterology |volume=39 |issue=2 |pages=123–6 |year=1992 |pmid=1634178 |doi= |url=}}</ref><ref name="pmid12928096">{{cite journal |vauthors=Sasaki CT, Ross DA, Hundal J |title=Association between Zenker diverticulum and gastroesophageal reflux disease: development of a working hypothesis |journal=Am. J. Med. |volume=115 Suppl 3A |issue= |pages=169S–171S |year=2003 |pmid=12928096 |doi= |url=}}</ref><ref name="pmid7923848">{{cite journal |vauthors=Resouly A, Braat J, Jackson A, Evans H |title=Pharyngeal pouch: link with reflux and oesophageal dysmotility |journal=Clin Otolaryngol Allied Sci |volume=19 |issue=3 |pages=241–2 |year=1994 |pmid=7923848 |doi= |url=}}</ref><ref name="pmid11715923">{{cite journal |vauthors=Mulder CJ, Costamagna G, Sakai P |title=Zenker's diverticulum: treatment using a flexible endoscope |journal=Endoscopy |volume=33 |issue=11 |pages=991–7 |year=2001 |pmid=11715923 |doi=10.1055/s-2004-826106 |url=}}</ref><ref name="pmid5428852">{{cite journal |vauthors=Hunt PS, Connell AM, Smiley TB |title=The cricopharyngeal sphincter in gastric reflux |journal=Gut |volume=11 |issue=4 |pages=303–6 |year=1970 |pmid=5428852 |pmc=1411416 |doi= |url=}}</ref> | | *Additionally, MBP and MMP-9 have been implicated in the disruption of esophageal epithelial integrity though their involvement in smooth muscles, fibroblasts, and cell-adhesion molecules. |
| # Zenker's diverticulum is a disorder of diminished upper esophageal sphincter, incomplete sphincter opening is probably the cause of dysphagia. Increased hypopharyngeal pressures throughout swallowing are probably important in the pathogenesis of the diverticulum.
| | *These processes may culminate in overall esophageal dysfunction through the consequent tissue remodeling. |
| # The nemaline bodies and red ragged fibers are usually the normal cricopharyngeous findings. whereas the Zenker's diverticulum is characterized by adipose tissue deposition and degeneration of the fiber these structural modifications can impair the UES opening and dysphagia ensues.
| | *Eosinophils are considered the main effector cells in fibrosis in a variety of hypereosinophilic syndromes and eosinophil-related allergic diseases including asthma and EoE. |
| # Nineteen patients in the sample were found to have reflux and 20 had dysmotility. These findings suggest that pharyngeal pouches are not a purely localized incoordination of the cricopharyngeal sphincter but are associated with a generalized oesophageal muscle dysfunction.
| | *TGF-β and eosinophilic granule proteins MBP and EPO (46) are the key eosinophil effector proteins. The importance of eosinophils in mediating tissue fibrosis is supported by evidence in both murine and human models. |
| # Acid reflux induces longitudinal esophageal shortening, which in turn increases the chance for the development of herniation between two spatially associated structures, the pharyngeal constrictors and cricopharyngeus muscles, leading to the development of Zenker diverticulum
| | *Interestingly, a recent study on fibrosis reversal with dietary and steroid therapy showed that improvement in esophageal eosinophilia and eosinophil degranulation within the epithelium was strongly associated with fibrosis reversal and symptom improvement. |
| # Zenker's diverticulum is thought to result from disordered coordination among the pharynx and upper esophageal sphincter.
| | *This finding is consistent with Kagalwalla et al. (45), who found improvements in epithelial remodeling in both dietary and corticosteroid therapy, and also found these improvements to be directly associated with improvement in esophageal eosinophilia (47). |
| #* Manometric studies of the upper esophagus were used in testing the hypothesis of dysmotility in the formation and growth of a Zenker's diverticulum; however, the data have provided conflicting evidence.
| | *These findings not only highlight the importance of targeting fibrosis reversal in treatment of EoE, but also underline the importance of eosinophils in tissue remodeling. |
| #* Manometric studies show that resting upper esophageal sphincter strain is normal in some patients with Zenker's diverticulum and decreased in others. abnormal premature relaxation and contraction of the upper esophageal sphincter seen in some patients with Zenker's diverticulum may be accompanied with the aid of pharyngeal contractions against a closed sphincter.
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| #* This abnormality is thought by a few investigators to be the cause of Zenker's diverticulum, but not by others who have found normal upper sphincter relaxation.
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| # In summary, in-coordination of pharyngeal contraction and UES opening has also been variably demonstrated by some investigator.
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| * All the above-mentioned hypotheses lead to herniation within the Killian's triangle, inclusive of disorders associated with altered UES function, unusual esophageal motility, esophageal shortening.
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| * This leads to the creation of a sac with a narrow neck that can trap liquid and food, the distended sac may compress the cervical esophagus.
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| * Impaired bolus passage leads to increases intrabolus pressure which leads to herniation in the Killians triangle. | |
| * Acid reflux is thought to lead to increased spasm of the UES which in turn increases the intrabolus pressures during swallowing, given that swallowing is frequently distinct from episodes of acid reflux disease.
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| === Histopathological Findings: Zenker's diverticulum ===
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| {{#ev:youtube|CEYU0Dq9n2s}}
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| ==References==
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| {{reflist|2}}
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| ==Classification==
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| Esophageal diverticula are classified on the basis of location into three types
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| 1. Phrenoesophageal (Zenker's diverticulum-70%),
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| 2. Epiphrenic (20%)
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| 3. Thoracic and mediastinal (10%)
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| Almost all esophageal diverticula are acquired pulsion diverticula.
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| ==Clinical examination==
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| [[Asymptomatic]] in patients with small [[Zenker's diverticulum|Zenker's]] [[diverticulum]], the severity of the symptoms is proportional to the size of the diverticulum.<ref name="urlZenkers diverticulum: exploring treatment options">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3773964/ |title=Zenker's diverticulum: exploring treatment options |format= |work= |accessdate=}}</ref><ref name="urlZenkers diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. - PubMed - NCBI">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmed/18197932 |title=Zenker's diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. - PubMed - NCBI |format= |work= |accessdate=}}</ref><ref name="urlZenkers Diverticulum. - PubMed - NCBI">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmed/24055983 |title=Zenker's Diverticulum. - PubMed - NCBI |format= |work= |accessdate=}}</ref><ref name="url[Hypopharyngeal Zenkers diverticulum as a clinical and surgical problem]. - PubMed - NCBI">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmed/16989439 |title=[Hypopharyngeal Zenker's diverticulum as a clinical and surgical problem]. - PubMed - NCBI |format= |work= |accessdate=}}</ref><ref name="urlSimultaneously occurring Zenkers diverticulum and Killian-Jamieson diverticulum: case report and literature review. - PubMed - NCBI">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmed/28625183 |title=Simultaneously occurring Zenker's diverticulum and Killian-Jamieson diverticulum: case report and literature review. - PubMed - NCBI |format= |work= |accessdate=}}</ref><ref name="pmid18197932">{{cite journal |vauthors=Ferreira LE, Simmons DT, Baron TH |title=Zenker's diverticula: pathophysiology, clinical presentation, and flexible endoscopic management |journal=Dis. Esophagus |volume=21 |issue=1 |pages=1–8 |year=2008 |pmid=18197932 |doi=10.1111/j.1442-2050.2007.00795.x |url=}}</ref>
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| '''Common symptoms'''
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| [[Dysphagia]]
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| Local pain
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| Food [[regurgitation]]
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| [[Halitosis]]
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| [[Coughing]]
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| [[Hoarseness]]
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| [[Aspiration pneumonia]]
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| [[Bronchitis]]
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| '''Less common symptoms'''
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| [[Pill (pharmacology)|Pill]] [[dysphagia]]- pills stuck in the throat
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| [[Drooling]] of the [[saliva]]
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| [[Choking]] on the food
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| [[Globus sensation]]
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| Weight loss
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| [[Cervical]] [[borborgymi]]
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| [[Hemoptysis]]
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| [[Hematemesis]]
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| ==Natural history==
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| Zenker’s diverticulum presents as a progressive dysphagia. Initially, the patient presents with
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| minor throat irritation, foreign body sensation, and coughing.
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| Symptoms worsen as the diverticulum enlarges, and pouch becomes large enough to contain food, sputum or even medications. Patients can complain of food regurgitation several hours after a meal and typically describe weight loss.
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| Cachexia and malnutrition can develop with Zenker’s Diverticulum, particularly in the elderly who develop a “fear of
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| eating” secondary to choking spells.
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| ==Links==
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| https://throatdisorder.com/zenkers-diverticulum/
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| [[Category:Gastroenterology]]
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| [[Category:Otolaryngology]]
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| [[Category:Needs patient information]]
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| [[Category:Disease]]
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| <references />
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| ==Surgery==
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| ==Surgery==
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| =Indications=
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| * The indications of the surgery are as follows<ref name="urlPrinciples of surgical treatment of Zenker diverticulum">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307087/ |title=Principles of surgical treatment of Zenker diverticulum |format= |work= |accessdate=}}</ref> | |
| * Severe dysphagia
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| * Weight loss
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| * Age- Elderly
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| *
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| =Procedure=
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| *The steps of the procedure is as follows<ref name="urlZenkers Diverticulum: Carbon Dioxide Laser Endoscopic Surgery">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3963375/ |title=Zenker's Diverticulum: Carbon Dioxide Laser Endoscopic Surgery |format= |work= |accessdate=}}</ref>
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| *The surgery is done under general anesthesia. | |
| *Classic rigid oesophagoscopy was performed to prove the typical location of the diverticular inlet at the posterior wall of the hypopharynx,
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| *Diverticular inlet is cleared for any food debris and the meticulous search for the cancerous growths should be done.
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| *The diverticular sac is exposed using a Weerda distending diverticuloscope.
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| *The anterior lip of the diverticuloscope is placed into the esophagus while the posterior lip of the diverticuloscope is passed into the diverticulum.
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| *The diverticuloscope is advanced to the bottom of the diverticulum.
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| *The tissue bridge between the esophagus anteriorly and the diverticulum posteriorly is set between the two lips of the diverticuloscope.
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| *An operating microscope Carl Zeiss OPMI Sensera with attached carbon dioxide laser micromanipulator is set on working distance 400 mm with the laser beam focused on the tissue bridge. | |
| *Carbon dioxide laser Lumenis AcuPulse with super-pulse delivery in a repeat mode, coupled with an AcuSpot micromanipulator, until 2009. Since March 2010, a robotic digital AcuBlade scanning micromanipulator system was used.
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| *The esophageal mucosa is protected from accidental laser injury by a moist swab.
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| *Using the laser at 5–10 W, the septum is transected at the midline down to the bottom of the diverticular sac. Occasionally electrocautery was used to control bleeding. * A feeding tube was introduced in all patients.
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| *Postoperative oesophagogram is performed at 5-6th day followed by a removal of the feeding tube and the discharge from the hospital on the same day or the day after.
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| *Antibiotic treatment with cefuroxime is routinely administered for one week following the surgery to prevent the post-operative infection. | |
| *Control contrast esophagogram and subjective evaluation of swallowing were performed at least three months after the treatment
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| =Complications=
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| *Fistula
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| *Post operative [[hematoma]]
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| *Mediastinitis
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| *Neck emphysema
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| *Mucosal perforation or tearing
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| *Tooth fracture
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| *Postoperative bleeding
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| *Aspiration pneumonia
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| *Transient left recurrent laryngeal nerve paralysis
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| *Edema of the laryngeal inlet and left pyriform sinus
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| <references />
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| ==Causes==
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| *Zenker's diverticulum also known as pharyngosophageal diverticulum.
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| *It is an acquired sac-like outpouching of the mucosa and submucosa layers originating from the pharyngoesophageal junction.
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| *Since it involves only the mucosa and submucosa it is a false diverticulum.
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| *Killian's dehiscence- pulsion false diverticulum occurring dorsally at the pharyngoesophageal wall bounded by the propulsive oblique inferior pharyngeal constrictor muscle and the transversal fibers of the cricopharyngeal muscle
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| *ZD occurs due to increased intraluminal pressure in the oropharynx during swallowing, against an inadequate relaxation of the cricopharyngeal muscle, and subsequent incomplete opening of the UES, causing the protrusion of the mucosa through an area of relative weakness at the dorsal pharyngoesophageal wall.
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| ==Historical Perspective==
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| The history of the ZD is as follows:<ref name="urlZenkers diverticulum: exploring treatment options">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3773964/ |title=Zenker's diverticulum: exploring treatment options |format= |work= |accessdate=}}</ref><ref name="urlZenkers diverticulum: exploring treatment options2">{{cite web |url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3773964/ |title=Zenker's diverticulum: exploring treatment options |format= |work= |accessdate=}}</ref><ref name="urlwww.annalsthoracicsurgery.org">{{cite web |url=http://www.annalsthoracicsurgery.org/article/0003-4975(91)90153-H/pdf |title=www.annalsthoracicsurgery.org |format= |work= |accessdate=}}</ref><ref name="urlEndoscopic treatment of Zenkers diverticulum - Gastrointestinal Endoscopy">{{cite web |url=http://www.giejournal.org/article/S0016-5107(99)70452-9/pdf |title=Endoscopic treatment of Zenker's diverticulum - Gastrointestinal Endoscopy |format= |work= |accessdate=}}</ref><ref>Ludlow A. A case of obstructed deglutition, from a preternatural dilatation of, and bag formed in, the pharynx. Med Observations and Inquiries 1767;3:85-101</ref><ref>Bell C. Surgical observations. London: Longmans, Greene
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| and Co, 1816:6470</ref><ref>Rokitansky C. Divertikel am Pharynx. Jahrb Dkk Osterr | |
| Staates 1840;30:222-5</ref><ref>Zenker FA, von Ziemssen H. Krankheiten des Oesophagus.
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| In: von Ziemssen H, ed. Handbuch der Speaellen Pathologie
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| und Therapie, vol 7 (suppl). Leipzig: FC Vogel, 18rn1-87</ref><ref>Killian G. La boudre de I’oesophage. Ann Ma1 Orielle Larynx
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| 1908;Xl</ref><ref>Bensaude R, Gregoire R, Guenaux G. Diagnostic et traitement
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| des diverticules oesophagiens. Arch Ma1 App Digest
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| 1922; 12: 145-203</ref><ref>Bell C. Cited by Bensaude R, Gregoire R, Guenaux G.
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| Diagnostic et traitement des diverticules oesophagiens. Arch
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| Ma1 App Digest 1922;12:145-203</ref><ref>Nicoladoni K. Behandlung der Oesophagusdivertikel. Wien
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| Med Wochenschr 1877;25:606-607</ref><ref>Kluge. Cited by Konig F. Die Krankheiten des unteren
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| Theiles des Pharynx und des Oesophagus. Deutsche Chir
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| 1880;35:94</ref><ref> Niehans. Cited by Girard C. Du traitement des diverticules
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| de Yoesophage. Congres Franc Chir 1896;10:392407</ref><ref>Wheeler WI. Pharyngocele and dilatation of pharynx, with
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| existing diverticulum at lower portion of pharynx lying
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| posterior to the oesophagus, cured by pharyngotomy, being
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| the first case of the kind recorded. Dublin J Med Sci 1886;82
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| 349-57</ref><ref>Von Bergmann E. Ueber den Oesophagusdivertikel und
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| seine Behandlung. Arch Klin Chir 1892;43:1-30</ref><ref>Kocher T. Das Oesophagusdivertikel und dessen Behandlung.
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| Correspondblatt Schweiz Aerzte 1892;22:23?-44</ref><ref>Butlin HF. On the removal of a pressure pouch of the
| |
| oesophagus. Med Chir Trans 1893;76:269-78</ref><ref>Schwarzenbach E. Zur operativen Behandlung und Aetiologie
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| der Oesophagusdivertikel. Wien Klin Wochenschr 1893;
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| 6:43540, 453-5, 474-6</ref>
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| *It was named in 1877 by German [[pathologist]] [[Friedrich Albert von Zenker]].
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| *The first description of Zenker's diverticulum dates back to 1769 by Ludlow | |
| *A century later, a German pathologist, Friedrich Albert von Zenker, recognized and further characterized the physiopathology of this diverticulum.
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| *In 1877 Zenker and Ziemssen reviwed the world literature on the Zenker's diverticulum. | |
| *In 1840 Rokitansky first described traction diverticula of the thoracic esophagus. | |
| *Until 1816 publication,ZD was thought to be congenital or traumatic in origin.
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| *In 1877, von Zeimssen, Professor in Munich, published "Krankheiten des Oesophagus" on the esophageal ulceration and diverticula.
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| *Preliminary thoughts on managing pharyngoesophageal diverticula originated as early as 1830, when Bell proposed the establishment of a fistula to empty the diverticulum of its contents. | |
| *The first recorded practice of this was by Nicoladoni in Vienna in 1877.
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| *An unsuccessful attempt at excision of the diverticulum, first suggested by Kluge in 1850, was performed in 1884 by Niehans.
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| *The first successful resection was by Wheeler in 1885, followed by additional favorable reports of von Bergmann and Kocher in 1892 and Butlin and Billroth in 1893. | |
| *In 1896 Girard devised a method of invaginating the diverticulum into the esophagus, oversewing the resultant dimple. | |
| *In some cases this procedure led to very satisfactory results, although at least one complete recurrence was documented by Waggett and Davis [17] in a patient after a fit of violent sneezing.
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| *Diverticulopexy was also described in this early period by Schmid, and was first performed by Hill in 1917.
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| *In 1910 that Stetton was able to publish a list of all cases operated on up to that time organized according to surgical technique. | |
| *These methods included primary excision, excision after preliminary gastrostomy, invagination of the sac, mucosal destruction without excision, and two-stage excision.
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| <references />
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