[Our experience with pharyngo-esophageal Zenker's diverticulum]

Zenker's diverticulum is the single most common diverticular event arising in the esophagus. Its physiopathology is universally recognized. Lack of coordination between the propulsive pharyngeal contractions and the release of the upper esophageal sphincter creates abnormally high pressure in the pharyngeal chamber, resulting in the collapse of the posterior wall of the hypopharynx, i.e., the Laimer-Killian triangle (or Killian's dehiscence). The mucosal hernia that develops constitutes the diverticulum, which grows in volume and above all in length and is compressed between two rigid structures, namely, the spine posteriorly and the trachea anteriorly. Swallowing progressively fills the diverticulum, which in turn leads to compression of the esophagus and hence to the characteristic symptom of "delayed dysphagia" or "dysphagia of the 3rd bite". These physiopathological considerations underpin the rationale for surgical treatment, namely upper esophageal sphincter myotomy and diverticulectomy, which is the standard approach used in the 44 cases presented here. A diverticulopexy was performed only once due to the patient's advanced age. Myotomy alone was performed in only one case, given the small size of the diverticulum. In two patients the standard procedure was carried out following emergency therapy for iatrogenic perforation of the diverticulum. The patient with cancer underwent chemo-radiotherapy after futile surgical attempts. Complications included transitory salivary leakage (1 case), and a transitory laryngeal nerve deficit (1 case). Gastroesophageal reflux disease was present in two-thirds of the patients. A Nissen-Rossetti fundoplication was performed one year after treatment of the diverticulum in 5 patients. The following important aspects emerged: i) the incidence of neoplasia on the diverticulum; ii) the association and possible pathogenetic relationship with gastro-esophageal reflux disease iii) the validity of myotomy plus diverticulectomy as a treatment option in view of the negligible complications and the absence of relapse and/or persistence of dysphagia.