A preventable medical error: Successful management of iatrogenic Zenker's diverticulum perforation

Abstract

Introduction and significance

Zenker's diverticulum is a rare condition characterized by a false diverticulum, as a true diverticulum involves herniation of all wall layers outward. Dysphagia, difficulty in swallowing, is the most common symptom. Diagnosis is primarily made through X-ray studies using contrast material during swallowing. Treatment options include open surgery or endoscopy.

Case presentation

We present the case of an adult male who experienced progressive dysphagia for approximately two years. A diagnosis of Zenker's diverticulum was confirmed by radiography following unsuccessful endoscopic treatment and a subsequent perforation of the diverticulum. The patient underwent successful open surgery after adequate preoperative preparation.

Clinical discussion

Zenker's diverticulum is an uncommon cause of pharyngeal dysphagia, but it should be considered in the differential diagnosis due to the importance of early intervention and prevention of malignancy. The endoscopic approach carries a significant risk of perforation, necessitating careful treatment and close monitoring during and after the procedure.

Conclusion

The endoscopic approach is considered the best treatment method for Zenker's diverticulum and should be used with caution to avoid complications, especially perforation, which makes open surgery the most appropriate treatment in this case.

Highlights

• •Zenker's diverticulum is a rare esophageal diverticulum.
• •It is the most common esophageal deverticulum and that it is a false diverticulum.
• •Zenker's diverticulum is a rare cause of pharyngeal dysphagia, but it is the most common manifestation of pharyngeal dysphagia.
• •It may mask cancer in rare cases, so endoscopy should be used to detect cancer.
• •Surgical removal of the diverticulum is the most appropriate treatment for diverticular perforation.

1. Introduction

Zenker's diverticulum, also known as the esophageal diverticulum, is a herniation of the mucous and submucosal layers through the muscular layer at a level below the thyropharyngeal muscle and above the cricopharyngeal muscle. This area is anatomically known as Killian's dehiscence. This diverticulum is considered a false diverticulum [1]. The incidence and prevalence of Zenker's diverticulum is estimated to be approximately 1–11 per 100,000 individuals [2]. Most cases of Zenker's diverticulum occur on the left side of the neck, more frequently than on the right side, and predominantly affect males [3]. A variety of symptoms may manifest from this diverticulum, including cough, bad breath, a sensation of a neck mass, regurgitation of undigested food, and dysphagia (difficulty swallowing). Diagnostic methods include gastrointestinal endoscopy and X-rays of the esophagus using oral contrast medium. Treatment options encompass open surgery and rigid endoscopic procedures. We present a case where the initial treatment of Zenker's diverticulum using a rigid endoscope was unsuccessful, necessitating a subsequent successful open surgical intervention.

This case is described in accordance with the criteria of SCARE [4].

2. Presentation of case

2.1. Patient information

We present a case of a 62-year-old male who had been experiencing pharyngeal dysphagia for approximately 2 years. The symptoms initially involved solid foods, gradually progressing to liquid foods. However, in the past 2 weeks, the dysphagia became continuous, affecting all food types. Additionally, the patient reported reflux of undigested food, pain, and hoarseness over the past 2 months. The patient's medical history includes a 30-year smoking history. No allergies, drug reactions, or tumor history were reported.

3. Clinical findings

Upon presentation to the emergency department, the patient's general condition was good, and vital signs were within normal limits. No neck vessel swelling was observed. The patient was admitted to the digestive department for further evaluation of the dysphagia.

4. Diagnostic assessment

Laboratory investigations revealed a hemoglobin level of 16.8 g/dL, a white blood cell count of 10,000/mm³, and a platelet count of 433,000/mm³.

A contrast swallow X-ray demonstrated a large, clear diverticulum on the left side of the neck (Fig. 1).

Fig. 1.

X-ray image with contrast material swallow clearly shows a diverticulum in the cervical esophagus (green arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

An upper gastrointestinal endoscopy revealed a cecal pouch on the posterior surface of the esophagus, measuring approximately 2 cm in diameter, without any abnormal tissue growth.

5. Therapeutic intervention

Based on the findings, an endoscopic intervention was planned to repair Zenker's diverticulum. During the procedure, a rigid endoscope was inserted into the diverticulum, and an attempt was made to resect the muscular septum through a submucosal tunnel. However, the procedure was unsuccessful due to incomplete resection.

Several hours later, the patient developed subcutaneous emphysema in the right and left neck and right chest wall. The patient was placed on absolute diet, and broad-spectrum antibiotics were administered.

A contrast swallow CT scan was ordered, which revealed a contrast leak at the cervical esophageal level and bilateral pneumothorax with air in the neck and chest wall (Fig. 2A, Fig. 2B).

Fig. 2A.

Axial CT scan with contrast ingestion showing leakage of contrast from the cervical esophagus (green arrow) and trachea (blue arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2B.

Axial CT scan showing bilateral pneumothorax resulting from cervical esophageal perforation.

A bilateral chest tube was inserted (Fig. 2C), and the patient was prepared for open surgery. Under general anesthesia, a longitudinal incision was made along the medial border of the sternocleidomastoid muscle, extending from the cricoid cartilage to the notch above the sternum. The dissection proceeded medially to the carotid sheath, exposing a large, perforated Zenker's diverticulum (Fig. 3A). The diverticulum edges were identified and completely excised, with separate closure of the mucosa and muscle layers. It is very important that myectomy of the cricopharyngeal muscle is performed during the surgical. A muscle flap from the sternothyroid and thyrohyoid muscles was placed over the repaired diverticulum (Fig. 3B), and the wound was closed in layers with a drain.

Fig. 2C.

Chest X-ray after bilateral chest decompression, demonstrating good lung diffusion.

Fig. 3A.

Intraoperative image showing Zenker's diverticulum (blue arrow) and the area of perforation (green arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 3B.

Intraoperative image showing the cervical esophagus after diverticulectomy and suturing of the perforation area using flaps (green arrow). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

The patient was monitored postoperatively for a week without complications and was discharged in good condition.

6. Discussion

The incidence of esophageal diverticula is generally considered rare, accounting for approximately 0.06–4 % based on endoscopic and radiological reports [5]. Zenker's diverticulum is the most common type of esophageal diverticulum, comprising approximately 75 % of cases [6].

Zenker's diverticulum is a false diverticulum, meaning it involves a herniation of the mucosal and submucosal layers through the muscular layer in a small anatomical area known as Killian's dehiscence, located between the oblique and transverse fibers of the inferior pharyngeal sphincter muscle [7]. The majority of cases occur posteriorly on the left side due to the thicker muscle layer on the right side. Most cases are diagnosed in individuals in their seventh or eighth decade of life, with rare occurrences before the age of forty [8]. The exact physiological mechanism causing Zenker's diverticulum is not fully understood but is believed to be related to esophageal motor abnormalities, esophageal strictures, and potential defects in the upper or lower esophageal sphincter. The primary causative factor is likely increased pressure in the lower pharynx [9].

Clinical symptoms of Zenker's diverticulum vary, with dysphagia being the most common manifestation. Other symptoms may include belching, severe pneumonia, and abscess formation, which can result from aspiration of diverticular contents into the lungs, especially during sleep [10]. Symptom duration can range from several weeks to years. As the diverticulum enlarges and dysphagia worsens, symptoms become more severe and distressing. Ulceration or bleeding may occur within the diverticulum, which is lined with stratified squamous epithelium. Malignancy can develop in Zenker's diverticulum at a rate of approximately 0.3–7 % [10].

Barium swallow X-ray is the most effective diagnostic tool for Zenker's diverticulum [11,12]. Diverticula are classified as small (less than 2 cm), medium (2–4 cm), or large (greater than 4 cm). If Zenker's diverticulum is suspected, a contrast-enhanced CT scan is recommended to rule out malignancy and other conditions. Endoscopy is used in preoperative evaluation to assess the diverticular cavity and wall. However, caution is advised during endoscopy as inadvertent perforation of the diverticulum may occur [13]. Neck ultrasound and esophageal manometry are less important diagnostic tests.

Zenker's diverticulum is treated surgically through open surgery or an endoscopic approach. The primary goals of treatment are to alleviate clinical symptoms, improve quality of life, and reduce the risk of associated malignancy, although this is rare. Treatment strategies include supportive and definitive approaches. Supportive treatment aims to address dehydration or malnutrition related to the diverticulum or complications such as recurrent pneumonia.

Definitive surgical treatment is indicated for diverticula larger than 1 cm that are symptomatic. Smaller, asymptomatic diverticula less than 1 cm in size generally do not require definitive treatment [14]. Zenker's diverticula larger than 1 cm with associated symptoms are treated surgically or through rigid endoscopy. Endoscopic approaches are preferred for smaller diverticula, while medium and large diverticula are typically treated surgically through an open left neck incision [15].

Both surgical and endoscopic methods have advantages and disadvantages. Open surgery is associated with potential complications such as bleeding, infection, and injury to surrounding nerves, particularly the recurrent laryngeal nerve, especially when the diverticulum is located on the right side. Fistula formation and diverticulum recurrence may also occur. Laparoscopic approaches carry risks such as esophageal perforation, mediastinitis, bleeding, leakage, stricture, neck abscess, and gum rupture [16]. While laparoscopic approaches have lower postoperative morbidity and mortality rates compared to open surgery, a significant disadvantage is the increased risk of malignancy at the margins of the diverticulectomy sac [13].

Surgical treatment is also considered the appropriate approach in cases of failed endoscopic treatment, which occurs in approximately 16–68 % of cases [16], as demonstrated in our case where perforation occurred during endoscopic treatment. Esophageal perforation is a serious complication that can lead to mediastinitis. The survival rate for esophageal perforation varies depending on the location: approximately 94 % for cervical esophageal perforation, 60 % for thoracic esophageal perforation, and 71 % for abdominal esophageal perforation [17].

For patients who decline surgical treatment or have contraindications, a conservative approach may be considered, involving the use of calcium channel blockers and nitrates to reduce esophageal tension. Some centers may also administer botulinum toxin injections into the upper esophageal sphincter [14].

7. Conclusion

Zenker's diverticulum is a rare esophageal diverticulum that sometimes hides the presence of cancer inside it. Therefore, it is preferable to perform an upper gastrointestinal endoscopy in the presence of ulceration, bleeding or pain, as in our case. This case provides a distinctive model for diagnosis and management, and explains the method of managing esophageal perforation and using flaps.

Ethical approval

Ethical approval for this study (Ethical Committee No. NAC 207) was provided by the Ethical Committee NAC of Damascus hospital, Damascus, Syria on 11 November 2024.

Guarantor

Ali Alrahil.

Sources of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Consent of patient

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Research registration

N/A.

Author contribution

Ali Alrahil: Conceptualization, resources, who wrote, original drafted,

edited, visualized, validated, literature reviewed the manuscript,

and the corresponding author who submitted the paper for publication.

Essam Moumena: Supervision, visualization, validation, resources, and review of the manuscript.

Mazen Aljanadi and Mhd Saeed Nassar: Visualization, validation, and review of the manuscript.

Tammam Hasan: PhD in thoracic surgery, Performed the surgical operation, followed up, coordinated and supervised the scientific research.

All authors read and approved the final manuscript.

Not commissioned, externally peer-reviewed.

Declaration of competing interest

The authors declare that they have no competing interests.

Data availability

The datasets generated during and/or analyzed during the current study are not publicly available because the Data were obtained from the hospital computer-based in-house system. Data are available from the corresponding author upon reasonable request.