Occult Early Squamous Cell Carcinoma in Zenker's Diverticulum Treated With Diverticulectomy Followed by Additional Esophagectomy With Free Jejunal Reconstruction: A Case Report

Abstract

A 63-year-old man was evaluated for a 20-year history of dysphagia and vomiting. Barium-swallow esophagography showed a Zenker's diverticulum at the upper end of the esophagus. Esophagogastroduodenoscopy revealed the diverticulum about 20 cm from the incisors. There was no mucosal inflammation or irregularity in the diverticulum. Computed tomography showed that the diverticulum was about 8 cm in size. There was no lymphadenopathy around the esophagus. Because the patient's symptoms were worsening, we performed diverticulectomy using a linear stapling device and cricopharyngeal myotomy. The mucosa of the resected specimen had no macroscopically abnormal lesions. However, an area unstained by iodine that widely involved the surgical margin was recognized at pathologic examination. Pathologic findings revealed squamous cell carcinoma invading the lamina propria mucosa with inflammatory cell infiltration. In addition, the pathologic surgical margin was widely positive. However, a remnant tumor lesion was not detected by postoperative esophagogastroduodenoscopy. Biopsies near the staple line were negative. After obtaining informed consent, we performed resection of the cervical esophagus including the proximal stump of the diverticulum and cervical lymphadenectomy approximately 4 months after the primary operation as an additional surgery. Reconstruction was performed by free jejunal transplantation with microvascular anastomosis. The patient was discharged on postoperative day 45. Pathologic examination revealed no malignant lesion in the resected specimen, and radical cure was confirmed.