Original article
Results of laser surgery in the treatment of Zenker’s diverticulum
Resultados de cirugía láser en el tratamiento del divertículo de Zenker
Marta Menéndez del Castro
, Raquel Fernández Morais, Patricia Martínez, Marta Fernández Pello, Marcos Carreño, Juan Carlos Álvarez
Corresponding author
Servicio de Otorrinolaringología, Hospital Universitario de Cabueñes, Gijón, Spain
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(A) Placement of the diverticuloscope with exposure of the septum. (B) Progressive section of the septum using CO2 laser. (C) Check of complete section of the diverticular septum, observing the distal oesophageal lumen.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Zenker’s diverticulum is a herniation of mucosa and submucosa in the posterior wall of Killian’s triangle, an area of potential weakness between the cricopharyngeal muscle and the inferior constrictor muscle of the pharynx.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> It was first described in 1769 by the English surgeon Abraham Ludlow, and later in 1877 by the German pathologist von Zenker.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although it is the most common oesophageal diverticulum,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> it is a rare condition with an estimated prevalence of .01%–.11%, and predominantly affects men aged 55–65 years, with another peak incidence between the ages of 70 and 80 years, and is more frequent in women at this second age peak.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although its origin is not clear, it is thought to be due to a combination of increased hypopharyngeal pressure during swallowing and cricopharyngeal muscle dysfunction.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The most usual form of presentation is impaired swallowing, typically presenting with regurgitation of undigested food, which may lead to aspiration or coughing fits. These symptoms can worsen and lead to weight loss and recurrent pneumonia due to aspiration, which can be life-threatening.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Treatment of this condition depends on the severity of the symptoms. In milder cases, conservative treatment, or less invasive techniques such as botulinum toxin infiltration into the constrictor muscle can be used, although the result is neither curative nor permanent.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,7</span></a> The only curative treatment is surgery. Open surgery or endoscopy are the currently available surgical techniques, the latter have advanced most in recent decades. Endoscopy is less invasive and requires less anaesthetic time, which are advantages to be considered given the generally advanced age at diagnosis and potential associated comorbidities.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Method</span><p id="par0025" class="elsevierStylePara elsevierViewall">We conducted a retrospective descriptive study of all patients diagnosed with Zenker’s diverticulum who underwent surgery in the ENT Department of the Hospital Universitario de Cabueñes between 2007 and 2019.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The following variables were collected: demographic data of the patients, preoperative clinical and medical history of interest, size of the diverticulum, time elapsed from surgery to start of oral intake, hospital stay, intra- and postoperative complications, recurrence of symptoms after surgery, and need for a second surgical procedure.</p><p id="par0035" class="elsevierStylePara elsevierViewall">To diagnose the condition, all the patients underwent fibrolaryngoscopy and pharyngo-oesophageal transit with barium (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), except for 3 patients, who were diagnosed by gastroscopy performed by the GI department.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">All patients in the series underwent endoscopic diverticulotomy with CO2 laser, and conversion to an open technique was not necessary in any case. The technique has been previously described in the literature.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> It is performed under general anaesthesia, and consists of placement of a Weerda bivalve diverticuloscope between the oesophagus and the diverticulum to expose the common wall, sectioning the common wall, and dissecting the mucosa and the underlying cricopharyngeal muscle under microscopic vision (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The procedure was performed in all cases with CO2 laser, and a nasogastric tube was placed under direct vision for enteral feeding during the postoperative period. All procedures were performed by the same surgeon.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The hospital stay was prolonged until safe oral tolerance was confirmed in all patients. A control pharyngo-oesophagogram was not routinely performed prior to oral tolerance.</p><p id="par0050" class="elsevierStylePara elsevierViewall">After hospital discharge, outpatient follow-up was performed for a minimum of one year, and resolution of the diverticulum was verified by pharyngo-oesophagogram in all the patients before the end of follow-up, including patients with complete clinical resolution.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the patient characteristics. Of the 27 patients included in the series, 19 (70.4%) were male and 8 (29.6%) were female, with a male: female ratio of 2.4:1. The mean age was 67 years, with a median age of 71, ranging from 30 to 91 years. Maximum incidence was in the seventh decade, at 40.7% of the patients (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">All the patients had some clinical symptoms at the time of diagnosis. The most frequent symptom was dysphagia, present in 92.6% of cases, followed by regurgitation in 40.7%. Less frequent was the presentation with complete dysphagia or aphagia (14.8%), aspiration during ingestion (11.1%), or sensation of a pharyngeal foreign body (7.4%).</p><p id="par0065" class="elsevierStylePara elsevierViewall">Of the patients, 63% had no relevant history. Of the remainder, 2 patients (7.4%) had undergone previous cervical surgery (thyroid surgery in both cases), and 29.4% had some associated oesophageal disease: 6 patients had hiatus hernia (22.2%), 1 had oesophageal achalasia (3.7%), and 1 had Barrett’s oesophagus (3.7%). One of the patients with hiatal hernia associated with Zenker’s diverticulum was also diagnosed with upper oesophageal membranes and, after surgery, pancreatic carcinoma.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The size of the diverticula was calculated based on imaging tests. The mean size was 33.42 mm, with a range between 10 mm and 75 mm. In 8 of the cases the size could not be calculated because imaging tests were not available.</p><p id="par0075" class="elsevierStylePara elsevierViewall">There were no intraoperative complications in any case. No postoperative complications were recorded in 25 of the 27 patients who underwent the surgery (92.6%). Of the remaining two, one presented with an episode of self-limited febrile illness, and the other was diagnosed with an oesophageal perforation that debuted after an episode of emesis and cervicothoracic emphysema 24 h after surgery. The patient underwent emergency surgery and cervicotomy. He required admission to the intensive care unit, and was hospitalised for 100 days and oral intake was delayed until day 97 after the first surgery (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The mean time to starting oral intake was 7.19 days, with a median of 4 days, and the mean hospital stay was 8.81 days, with a median of 5 days. Excluding the patient with prolonged admission due to oesophageal perforation, the mean time to intake was 3.6 days (median 4 days), and the hospital stay was 5.16 days (median 5 days). Two of the patients developed complications unrelated to the surgery: diabetic decompensation and acute urinary retention, which lengthened their hospital stay to 11 and 6 days, respectively.</p><p id="par0085" class="elsevierStylePara elsevierViewall">All the patients received antibiotic treatment after surgery, 81.8% with amoxicillin-clavulanic acid, 13.6% with ciprofloxacin, and the remaining 4.5% with clindamycin. No relationship was seen between the treatment administered and the occurrence of complications or subsequent recurrence. After the patient with oesophageal perforation, all patients were routinely given antiemetics during the postoperative period.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The diverticulum recurred in 22.2% of the patients during follow-up and was verified by pharyngo-oesophagogram. The mean time from surgery to diagnosis of recurrence was 9.1 months. Only four of the patients (14.8%) were reoperated for symptomatic recurrence using the same endoscopic technique, while the other two remained asymptomatic and a conservative approach was chosen. Recurrence was more frequent in men (31.6%) than in women (0%), however this difference was not statistically significant (p = .072). There was also no association with patient history, symptoms at diagnosis, or age. A statistically significant relationship was observed between the size of the diverticulum and its recurrence (p = .003).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">Zenker’s diverticulum is a very rare condition with a non-specific clinical presentation, and therefore available series are limited in number. In symptomatic cases, the treatment of choice is surgery, which has evolved from open (diverticulotomy and upper oesophageal sphincter myotomy) to endoscopic techniques.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In 1917 Mosher published the first description of endoscopic treatment,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> although he abandoned this technique due to high rates of mediastinitis. In 1960 Dohlman and Mattson published the first large series of patients undergoing endoscopy and diathermic coagulation with acceptable results, and morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In 1981, van Overbeek began to use the CO2 laser in the endoscopic approach,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> and in the 1990s mechanical suture-type devices were added to the endoscopic technique.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In previous reviews comparing open and endoscopic techniques, it was observed that the percentage of clinical resolution was similar or slightly higher with open surgery, although at the cost of a higher morbidity and mortality rate, because there were more postoperative complications, such as cervical fistulas, recurrent laryngeal nerve injury, oesophageal stenosis, and even death. Moreover, the time to starting oral intake and hospital stay were shorter with the endoscopic techniques.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,15,16</span></a> Therefore, endoscopic surgery is now widely accepted in the treatment of this disorder, although open surgery is still performed when endoscopic diverticulotomy is not possible. In this regard, it is important to achieve correct exposure during surgery, and if due to the anatomical characteristics of the patient this is insufficient, a therapeutic alternative should be considered.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Our series shows similar characteristics to those previously published in the literature, with a predominance of males and people of advanced ages.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,6,8</span></a> The most frequent symptom at diagnosis was dysphagia in 92.6%, and the second most frequent symptom was regurgitation of food in 40.7%. These results are similar to those previously published,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,17,18</span></a> however, in other publications regurgitation predominated over dysphagia.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Endoscopic laser surgery has proven to be a safe technique. Dental trauma, post-surgical fever, subcutaneous emphysema, recurrent paralysis, haemorrhage, oesophageal fistula or mediastinitis have been described as potential complications.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,19</span></a> In our study, two patients (7.4%) developed complications related to the surgery. Compared with previous series, this percentage varies between 4.7% and 18.5%,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,8,17,18</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20,21</span></a> and Howell et al. published a rate of 11% in a systematic review.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> We had a postoperative fever rate of 4.7% (one patient), and rates of up to 11% have been described.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> The rate of oesophageal perforation was 4.7%, which is high compared to previous series and meta-analyses, with published rates of between 0% and 3.5%.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18,19,21</span></a> We observed no cases of the other complications described by previous authors.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The median time to oral tolerance in our case was 4 days, which is similar to previous publications, ranging from 4 to 7 days.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,17,18</span></a> The same applies for hospital stay: the mean was 5.16 days with a median of 5, although in this case the previously published data is more variable, as in certain series patients were discharged home before starting oral intake, so the range varies between 1 and 8 days.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4,6,8</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The administration of antibiotic prophylaxis or post-surgical antibiotic treatment has been widely described in previous series.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,17,18</span></a> However, systematic reviews do not recommend the administration of antibiotic treatment after this procedure, because although considered clean-contaminated surgery, there is no opening of the viscera and lower complication rates have not been seen after administration. However, there are no randomised studies on this subject.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> In our case, we observed no differences between the treatments administered. However, infectious complications in the retropharynx in this age group can be alarming, and therefore it may be wise to take a proactive approach.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Of our patients, 22.2% had recurrence after the surgery, a high percentage compared to previous publications, although of these only 14.8% presented symptoms and required surgical treatment. Recurrence rates after this technique of between 4.5% and 18% have been reported,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,18,21,22</span></a> although rates of up to 30% have been reported.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The inclusion of asymptomatic recurrence may explain our high recurrence rate compared to previous publications, because only cases of symptomatic recurrence are usually included. In our case, all patients underwent reintervention using the same endoscopic laser technique, with satisfactory results, which confirms that published by previous authors and upholds the safety and efficacy of this technique in the treatment of recurrence.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">In the present review, we observed a directly proportional and significant relationship between the size of the diverticulum and subsequent recurrence, in contrast to previous publications in which a higher recurrence rate was observed in small diverticula,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> or no relationship was observed,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> although most studies do not specify whether there is a relationship between size and recurrence. There are authors such as Dissard et al. who have questioned whether open surgery would be indicated more for smaller diverticula,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> but other authors, such as Hoffman et al. argue that the size of the diverticulum should not change the surgical indication. In our case, we obtained satisfactory results in small diverticula, and given the safety and reduced morbidity and mortality of the laser technique compared to the open technique, we recommend laser surgery irrespective of the size of the diverticulum.</p><p id="par0135" class="elsevierStylePara elsevierViewall">In terms of the different endoscopic surgical options, some studies have related laser endoscopic techniques with a higher incidence of postoperative complications, but with greater resolution of symptoms, and a lower rate of recurrence and need for revision surgery compared to endoscopy with mechanical suturing.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,20,22,24</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> However, it has been shown that laser exposure is better for small diverticula,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,20</span></a> as the mechanical suture technique does not allow resection of the bottom of the neck.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> On the other hand, the use of mechanical sutures increases the surgical cost per procedure. Mechanical sutures could be indicated in large diverticula, although further studies are required to corroborate this. Given all this data, we believe that CO2 laser diverticulotomy may be the surgical method of choice.</p><p id="par0140" class="elsevierStylePara elsevierViewall">This study has limitations in that it is a retrospective and descriptive study, and the number of patients included (because it is a rare condition).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">Endoscopic CO2 laser surgery of Zenker’s diverticulum is a safe and effective therapeutic option. Although the recurrence rate may be high, especially for large diverticula, it is a technique that involves a shorter hospital stay and a shorter time to oral intake, and the procedure can be repeated in cases of recurrence without increasing the risk of postoperative complications. However, prospective, multicentre studies with a larger number of patients are needed to clarify and add to the currently available literature.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interests</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1616834" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion and conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1444987" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1616835" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Discusión y conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1444988" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-09-16" "fechaAceptado" => "2020-11-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1444987" "palabras" => array:4 [ 0 => "Zenker’s diverticulum" 1 => "Upper oesophageal sphincter" 2 => "CO2 laser surgery" 3 => "Complications" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1444988" "palabras" => array:4 [ 0 => "Divertículo de Zenker" 1 => "Esfínter esofágico superior" 2 => "Cirugía láser CO2" 3 => "Complicaciones cirugía laser" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Zenker’s diverticulum is an uncommon pathology of the upper oesophageal sphincter whose most frequent symptoms are the association of dysphagia and regurgitation. It is more frequent in advanced ages, and its treatment of choice is surgery in symptomatic cases.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A retrospective descriptive study was performed of 27 patients operated in the Otorhinolaryngology service of the Hospital Universitario de Cabueñes between 2007 and 2019 using laser endoscopic surgery.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">27 patients were operated, 70.4% male and 29.6% female, with a mean age of 67 years (range between 30 and 91). The most frequent symptom at diagnosis was dysphagia. No intraoperative complications were observed. One patient (3.7%) presented post-surgical fever, and another patient (3.7%) had a serious complication due to oesophageal perforation secondary to postsurgical emesis. The median hospital stay was 5 days, and the median oral intake was 4 days. Recurrence was observed in 6 patients (22.2%), 4 (14.8%) requiring a second intervention, which was performed using the same technique.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion and conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The surgical treatment of Zenker’s diverticulum has advanced in recent decades, with endoscopic treatment currently being the choice. Among the surgical options, endoscopic CO2 laser surgery is an effective and safe alternative, although possible complications must be considered. It is also an effective alternative for the treatment of recurrences.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion and conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El divertículo de Zenker es una patología infrecuente del esfínter esofágico superior cuya clínica típica es la asociación de disfagia y regurgitación alimentaria. Es más frecuente en edades avanzadas, y su tratamiento de elección es quirúrgico en casos sintomáticos, existiendo diversas técnicas quirúrgicas.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Método</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Se realiza un estudio descriptivo retrospectivo de 27 pacientes intervenidos en el servicio de Otorrinolaringología del Hospital Universitario de Cabueñes entre los años 2007 y 2019 mediante cirugía endoscópica láser.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se intervinieron 27 pacientes, un 70,4% varones y un 29,6% mujeres, con una edad media de 67 años (rango entre 30 y 91). El síntoma más frecuente al momento del diagnóstico fue la disfagia. No se observaron complicaciones intraoperatorias. Un paciente (3,7%) presentó fiebre postquirúrgica, y otra paciente (3,7%) una complicación grave por perforación esofágica secundaria a émesis postquirúrgica. La mediana de estancia hospitalaria fue de 5 días, y la del inicio de ingesta oral fue 4 días. Se observó recidiva en 6 pacientes (22,2%), requiriendo una segunda intervención cuatro de ellos (14,8%), que se realizó mediante la misma técnica.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discusión y conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">El tratamiento quirúrgico del divertículo de Zenker ha avanzado en las últimas décadas, siendo actualmente de elección el tratamiento endoscópico. Dentro de las opciones quirúrgicas, la cirugía endoscópica con láser CO2 es una alternativa eficaz y segura, aunque se deben tener en cuenta las posibles complicaciones, en ocasiones de gravedad. Supone también una alternativa eficaz para el tratamiento de las recidivas.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Discusión y conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Menéndez del Castro M, Fernández Morais R, Martínez P, Fernández Pello M, Carreño M, Carlos Álvarez J. Resultados de cirugía láser en el tratamiento del divertículo de Zenker. Acta Otorrinolaringol Esp. 2021;72:381–386.</p>" ] ] "multimedia" => array:5 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1287 "Ancho" => 1007 "Tamanyo" => 61945 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pharyngo-oesophageal transit performed with barium swallow showing the diverticulum in the posterior wall of the upper oesophageal sphincter.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2268 "Ancho" => 1001 "Tamanyo" => 220717 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Intraoperative images. (A) Placement of the diverticuloscope with exposure of the septum. (B) Progressive section of the septum using CO2 laser. (C) Check of complete section of the diverticular septum, observing the distal oesophageal lumen.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 881 "Ancho" => 1207 "Tamanyo" => 29671 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Distribution of patients by age range. We can see that the most frequent age at diagnosis is between 70 and 79 years (41% of the patients).</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 679 "Ancho" => 1007 "Tamanyo" => 65096 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Axial computed tomography (CT) showing oesophageal perforation associated with an upper mediastinal collection, hypodense, with contrast enhancement.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of patients (n) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Percentage \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Sex</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Males \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Females \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.6% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Symptoms on diagnosis</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dysphagia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92.6% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Regurgitation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Aphagia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.8% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Aspiration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Foreign body sensation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Size</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><30 mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.2% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>30–60 mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">44.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>>60 mm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29.6% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Complications</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Postoperative fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Oesophageal perforation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Recurrence</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No recurrence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">77.8% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Asymptomatic recurrence (conservative approach) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Symptomatic recurrence (surgical revision) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.8% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2756567.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Summary of patient characteristics.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Paryngeal (Zenker’s) diverticulum is a disorder of upper esophageal sphincter opening" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I.J. Cook" 1 => "M. Gabb" 2 => "V. Panagopoulos" 3 => "G.G. Jamieson" 4 => "W.J. Dodds" 5 => "J. Dent" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/0016-5085(92)91508-2" "Revista" => array:6 [ "tituloSerie" => "Gastroenterology" "fecha" => "1992" "volumen" => "103" "paginaInicial" => "1229" "paginaFinal" => "1235" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1397879" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diverticulotomía endoscópica utilizando Ligasure TM" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.A. Moreira da Silva" 1 => "A. Germade" 2 => "L. Pérez Citores" 3 => "S. Maestro Antolin" 4 => "F. Santos" 5 => "F. Sánchez Barranco" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.gastrohep.2016.04.001" "Revista" => array:6 [ "tituloSerie" => "Gastroenterol Hepatol" "fecha" => "2017" "volumen" => "40" "paginaInicial" => "80" "paginaFinal" => "84" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27184555" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Zenker’s diverticulum: Rotterdam experience" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "L.J. Visser" 1 => "J.A.U. Hardillo" 2 => "D.A. Monserez" 3 => "M.H. Wieringa" 4 => "R.J. Baatenburg de Jong" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00405-015-3825-0" "Revista" => array:6 [ "tituloSerie" => "Eur Arch Otorhinolaryngol" "fecha" => "2016" "volumen" => "273" "paginaInicial" => "2755" "paginaFinal" => "2763" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26576954" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Functional results in endoscopic Zenker’s diverticulum surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Dissard" 1 => "L. Gilain" 2 => "R. Pastourel" 3 => "T. Mom" 4 => "N. Saroul" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.anorl.2017.02.009" "Revista" => array:6 [ "tituloSerie" => "Eur Ann Otorhinolaryngol Head Neck Dis" "fecha" => "2017" "volumen" => "134" "paginaInicial" => "309" "paginaFinal" => "313" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28341539" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pharyngeal diverticula" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A.G.D. Maran" 1 => "J.A. Wilson" 2 => "A.H. Al Muhanna" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Otolaryngol Allied Sci" "fecha" => "1986" "volumen" => "11" "paginaInicial" => "219" "paginaFinal" => "225" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tratamiento del divertículo de Zenker: comparación de diferentes técnicas" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.H. Egea" 1 => "L.P. Delgado" 2 => "G.T. Galve" 3 => "M.G. Larpa" 4 => "C. Orte" 5 => "A. 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