Surgical treatment of a severe, massive, symptomatic Zenker's diverticulum in a very elderly patient.

Zenker's diverticula commonly occur in the elderly, and quality of life is often impaired by typical symptoms such as dysphagia, regurgitation, halitosis, cough and aspiration pneumonia, malnutrition and weight loss. The "gold standard" treatment for pharyngo-oesophageal diverticula is the resection of the sac via left lateral cervicotomy and cricopharingeal myotomy. In the last decade, with the fast development of minimally invasive techniques, an endoscopic stapled approach has been proposed. This procedure rapidly encountered the favour of gastroenterologists because patients with Zenker's diverticulum often present serious co-morbidities and seem to benefit from the minimally invasive technique; but the crucial point in the treatment of Zenker's diverticula, in addition to the sac resection, is the myotomy of the cricopharyngeal muscle fibres and this could not be safely and completely achieved in endoscopic stapling owing to the risk of vascular lesions and incomplete sectioning of the sac. Moreover, many studies have reported similar results between open and endoscopic procedures in terms of postoperative morbidity and mortality, showing better functional outcomes in surgical patients even if elderly and presenting co-morbidities. In this report, the case of a 95 year-old patient, one of the oldest operated on for this disease and reported in the literature, is described. He was affected by a massive 8 cm Zenker's diverticulum and an oesophageal motility disorder (dyskinesia), with significant co-morbidity. Surgical diverticulectomy combined with cricopharyngeal myotomy was performed with excellent early and late results.