SURGICAL TREATMENT OF THE ZENKER DIVERTICLE SERIES OF 5 CASES GENERAL SURGERY DEPARTEMENT I HMIMV

The diverticulum of the cervical oesophagus, developed on the posterior surface of the pharyngo- oesophageal junction, is the most frequent of the diverticula of the oesophagus. It is an acquired anomaly of the old subject which would be caused by a spasm of the crico-pharyngeal muscle whose pathophysiology is not yet elucidated. Therapeutic options remain subject to debate and controversy. From diverticulectomy to diverticulopexy, with or without myotomy of the cricopharyngeal muscle, from cervicotomy to endoscopy, the choice remains difficult. The objective of our work is to report the results of the study of a series of 5 cases operated in the service of CHVI of the military hospital of Rabat ABSTRACT

The diverticulum of the cervical oesophagus, commonly called the Zencker's diverticulum, is the most common of the oesophageal diverticula, an acquired hernia of the posterior pharyngeal mucosa developed at the pharyngo-oesophageal junction between the fibers of the lower constrictor muscle and the crico-pharyngeal muscle. INTRODUCTION

We report the experience of CHVI service of HMIMV in Rabat; through a retrospective study of 5 patients operated on a Zenker diverticulum between January 2000 and December 2006. MATERIALS AND METHODS

This series consists of 3 men and 2 women This series consists of 3 men and 2 women. The median age of operated patients is 54 years with extremes between 49 and 58 years. The main symptom encountered was dysphagia, present in all patients, it was isolated in 3 cases and extreme (aphagia) in 1 case, 2 patients had regurgitations. 3 patients had a complication such as slimming. In 1 case, aphagia led to a chaotic state with anemia. Zenker's diverticulum diagnosis was made by the achievement of TOGD in 4 cases. Fibroscopy was performed in all cases. A CT scan was done in a patient. All our patients underwent surgical treatment with diverticulectomy combined with a separate suture. The suites were simple. The pathological examination did not find any carcinoma in our series. RESULTS

The pathogenesis of Zenker's diverticulum involves the pharyngeal and crico-pharyngeal muscles, which by their inadequate response during swallowing lead to abnormally high pressions in the hypopharynx, responsible for mucosal hernia through a weakness pharyngo-oesophageal area . Depending on the importance of the diverticulum, there are 3 stages: A: mucous protrusion B: horizontal development C: parallel development to the oesophagus which is gradually pushed back forward We have collected 5 cases over a period of 7 years, which testifies to the rarity of this pathology which mainly affects the elderly subject DISCUSSION

Dysphagia is the main symptom and may be associated with other signs such as regurgitation, coughing, breath smear, hypersialorrhea, false roads, dysphonia with hoarseness of the voice and sometimes left lateral cervical palpation of a mass. gurgling. At the end of its evolution, dysphagia leads to weight loss and sometimes to a cachectic state, which is a frequent complication of Zenker's diverticulum. While the risk of cancerization seems very low. The oesophageal transit is the key examination that allows to make the diagnosis. Endoscopy is useful for verifying the state of the diverticulum and removing suspected oesophageal cancer.

The surgical treatment can be diverticulectomy, diverticulopexy, associated or not with a myotomy of the cricopharyngeal muscle. These techniques require an approach by cervicotomy. Endoscopic treatment produces an endoscopic esophagodiverticulostomy with transmucosal myotomy of the cricopharyngeal. Only symptomatic and / or complicated diverticula should be treated. The chosen technique should take into account the age of the patient and the size of the diverticulum: If the size of the diverticulum is ≤ 2 cm, surgery is preferable with myotomy of the cricopharyngeal muscle (± diverticulectomy) If the size of the diverticulum is ≥ 5 cm and the young subject, the surgery is still preferable, by diverticulectomy rather than diverticulopexy, associated in all cases with the myotomy of the cricopharyngeal muscle. - If the size of the diverticulum is included