KJD is an uncommon esophageal type of hypopharyngeal pulsion diverticulum;
it appears through the Killian’s dehiscence,
resulting from herniation of mucosa and submucosa below the cricopharyngeal muscle wall (proximal lateral side of the cervical esophagus,
Killian-Jamieson space),
often unrecognized and misdiagnosed as a Zenker disease,
diverticulum originates on the posterior wall of the pharyngoesophageal segment in a midline area of weakness just above the cricopharyngeus1,3,4 and 5.
Zenker’s diverticulum is nearly four times as common as Killian-Jamieson diverticulum,
and in literature,
the two diseases have been observed simultaneously1.
KJDa are usually unilateral,
only 25% are bilateral; furthermore,
75% of the Killian-Jamieson diverticula were left sided (like in our patient) and 25% were bilateral1.
The two diseases have similar symptoms (dysphagia,
coughing and chest pain) but differ in location/mechanism and,
according to previous studies,
KJD has more non-specific symptoms than ZD; patients with a Zenker’s diverticula are more likely to have symptoms (particularly suprasternal dysphagia) attributable to the underlying diverticulum than patients with Killian- Jamieson diverticula1,
who usually are asymptomatic or have symptoms attributable to abnormal pharyngeal motility; in this publication we describe a symptomatic KJD.
Another feature that distinguish patient with a Zenker’s diverticulum from patient with KJD is the greater risk of overflow aspiration or aspiration pneumonia,
due the closure of the cricopharyngeus above the diverticulum1,3 and 5; our patient described,
during the anamnestic examination,
to have had episodes of overflow aspiration.
We also report that Zenker’s diverticulum is more likely associate with gastroesophageal reflux than is Killian-Jamieson diverticulum1,
3 and 4; this high prevalence is not applicable in our case report,
because our patient was for this condition,
actually under treatment.
The pathogenesis of KJD is unclear and is an established fact the advanced age distribution of patients3 and 5.
Our studies,
combining otolaryngological and general surgery experience,
allow us to conclude that KJdiverticulum is the result of a functional outflow obstruction in the esophagus in much the same way that a Zenker’s diverticulum,
result from a functional outflow obstruction in the pharynx.
The circular muscle fibres of the proximal esophagus are believed to inappropriately constrict during the act of swallowing; this may create high intraluminal pressure,
which is then transmitted to the weakened area within the Killian-Jamieson triangle1.
The pressure may be accentuated by the simultaneous closure of the cricopharyngeus muscle above the diverticulum.
The diagnosis of either Zenker's diverticulum or KJdiverticulum is based primarily on the radiographic findings,
rather than on endoscopy.
Radiologists should be aware of the findings of Killian-Jamieson diverticulum on pharyngo- esophagography,
so they are not mistaken for Zenker's diverticulum.
A left-sided Killian-Jamieson diverticulum can always be differentiated from a Zenker's diverticulum extending to the left of the midline on the basis of the radiographic anatomy; a Killian- Jamieson diverticulum is seen on the lateral wall of the pharyngoesophageal junction on anteroposterior view and below the cricopharyngeal muscle (methodic with RX-contrast may be useful).
A Zenker's diverticulum is seen in the posterior wall of the pharynx on lateral view,
often with contrast retained within the diverticulum.
Whereas that endoscopist may visualize the opening of a Zenker's or Killian-Jamieson diverticulum,
the location of the opening of the diverticulum in relation to the cricopharyngeus muscle is best shown on pharyngography when passage of the barium bolus outlines the protruding cricopharyngeal bar.
The size of the sac and its relationship with cervical esophagus are also best shown on barium studies.
At times,
it may be difficult to distinguish between a Zenker's diverticulum and a Killian-Jamieson diverticulum with a barium esophagram.
This occur especially when the diverticulum is large and extends inferiorly.
In such cases,
an axial CT scan may be used to locate the origin of the diverticulum more precisely.
The Authors believe in the surgical therapy as only recommended treatment for a symptomatic KJD,
especially if giant,
due to its close proximity to the recurrent laryngeal nerve and the concern of possible nerve injury.
Only two reports regarding the treatment of Killian-Jamieson diverticula have been cited in the literature3.
The first was by Rogers et al.,
who approached the Killian-Jamieson diverticulum through a horizontal left neck incision and performing a diverticulotomy.
The diverticulum was then mobilized and transected with a surgical stapling device.
No esophagomyotomy was performed.
The second introduced by Tang et al.
for the treatment of a symptomatic KJD,
is primarily based upon a needle-knife incision of the esophageal circular muscle,
who performed a distal vertical diverticulotomy with a flexible endoscope.
In our patient,
we performed an esophagomyotomy (along and near the diverticular neck) in addition to a diverticulopexy to relieve the potential functional obstruction in the circular esophageal muscle inferior to the diverticulum,
that may contribute to or cause its formation.
Our surgery treatment of the KJD was successful with resolving the patient symptoms.
Furthermore,
myotomy should be adopted as a treatment for KJD,
since its treatment is closely related to the prevention of the recurrence from the perspective of the features of diverticular disease.
In summary,
Palermo University Hospital experience indicates that Killian-Jamieson diverticulum is less common and considerably smaller than Zenker’s diverticulum and appear on pharyngo- esophagography as persistent left-sided or,
less frequently,
bilateral outpouchings from the proximal cervical esophagus below the cricopharyngeus.
Killian- Jamieson diverticulum also is less likely to cause symptoms and is less likely to be associated with overflow aspiration or gastroesophageal reflux than is Zenker’s diverticulum despite our case report,
to be considered as isolated case of rare giant KJD in old patient.