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Minerva Urology and Nephrology Aug 2022Colovesical fistulas (CVFs) account for approximately 95% enterovesical fistulas (EVFs). About 2/3 CVF cases are diverticular in origin. It mainly presents with...
INTRODUCTION
Colovesical fistulas (CVFs) account for approximately 95% enterovesical fistulas (EVFs). About 2/3 CVF cases are diverticular in origin. It mainly presents with urological signs such as pneumaturia and fecaluria. Diagnostic investigations aim at confirming the presence of a fistula. Although conservative management can be chosen for selected individuals, most patients are mainly treated through surgical interventions. CVF represents a challenging condition, which records high rates of morbidity and mortality. Our systematic review aimed at achieving deeper knowledge of both indications, in addition to short- and long-term outcomes related to CVF management.
EVIDENCE ACQUISITION
We performed a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. Pubmed/MEDLINE, Embase, Scopus, Cochrane Library and Web of Science databases were used to search all related literature.
EVIDENCE SYNTHESIS
The 22 included articles covered an approximately 37 years-study period (1982-2019), with a total 1365 patient population. CVF etiology was colonic diverticulitis in most cases (87.9%). Pneumaturia (50.1%), fecaluria (40.9%) and urinary tract infections (46.6%) were the most common symptoms. Abdomen computed tomography (CT) scan (80.5%), colonoscopy (74.5%) and cystoscopy (55.9%) were the most frequently performed diagnostic methods. Most CVF patients underwent surgery (97.1%) with open approach (63.3%). Almost all patients had colorectal resection with primary anastomosis with or without ostomy and 53.2% patients underwent primary repair or partial/total cystectomy. Four percent anastomotic leak, 1.8% bladder leak and 3.1% reoperations rates were identified. In an average 5-68-month follow-up, overall morbidity, overall mortality and recurrences rates recorded were 8-49%, 0-63% and 1.2%, respectively.
CONCLUSIONS
CVF mainly affects males and has diverticular origin in almost all cases. Pneumaturia, fecaluria and urinary tract infections are the most characteristic symptoms. Endoscopic tests and imaging are critical tools for diagnostic completion. Management of CVFs depends on the underlying disease. Surgical treatment represents the final approach and consists of resection and reanastomosis of offending intestinal segment, with or without bladder closure. In many cases, a single-stage surgical strategy is selected. Perioperative and long-term outcomes prove good.
Topics: Colon, Sigmoid; Colonoscopy; Diverticulitis, Colonic; Diverticulum; Humans; Intestinal Fistula; Male; Urinary Bladder Fistula
PubMed: 34791866
DOI: 10.23736/S2724-6051.21.04750-9 -
The Cochrane Database of Systematic... Mar 2020Ulcerative colitis is an inflammatory condition affecting the colon, with an annual incidence of approximately 10 to 20 per 100,000 people. The majority of people with... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Ulcerative colitis is an inflammatory condition affecting the colon, with an annual incidence of approximately 10 to 20 per 100,000 people. The majority of people with ulcerative colitis can be put into remission, leaving a group who do not respond to first- or second-line therapies. There is a significant proportion of people who experience adverse effects with current therapies. Consequently, new alternatives for the treatment of ulcerative colitis are constantly being sought. Probiotics are live microbial feed supplements that may beneficially affect the host by improving intestinal microbial balance, enhancing gut barrier function and improving local immune response.
OBJECTIVES
To assess the efficacy of probiotics compared with placebo or standard medical treatment (5-aminosalicylates, sulphasalazine or corticosteroids) for the induction of remission in people with active ulcerative colitis.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, and two other databases on 31 October 2019. We contacted authors of relevant studies and manufacturers of probiotics regarding ongoing or unpublished trials that may be relevant to the review, and we searched ClinicalTrials.gov. We also searched references of trials for any additional trials.
SELECTION CRITERIA
Randomised controlled trials (RCTs) investigating the effectiveness of probiotics compared to standard treatments or placebo in the induction of remission of active ulcerative colitis. We considered both adults and children, with studies reporting outcomes of clinical, endoscopic, histologic or surgical remission as defined by study authors DATA COLLECTION AND ANALYSIS: Two review authors independently conducted data extraction and 'Risk of bias' assessment of included studies. We analysed data using Review Manager 5. We expressed dichotomous and continuous outcomes as risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the GRADE methodology.
MAIN RESULTS
In this review, we included 14 studies (865 randomised participants) that met the inclusion criteria. Twelve of the studies looked at adult participants and two studies looked at paediatric participants with mild to moderate ulcerative colitis, the average age was between 12.5 and 47.7 years. The studies compared probiotics to placebo, probiotics to 5-ASA and a combination of probiotics plus 5-ASA compared to 5-ASA alone. Seven studies used a single probiotic strain and seven used a mixture of strains. The studies ranged from two weeks to 52 weeks. The risk of bias was high for all except two studies due to allocation concealment, blinding of participants, incomplete reports of outcome data and selective reporting. This led to GRADE ratings of the evidence ranging from moderate to very low. Probiotics versus placebo Probiotics may induce clinical remission when compared to placebo (RR 1.73, 95% CI 1.19 to 2.54; 9 studies, 594 participants; low-certainty evidence; downgraded due to imprecision and risk of bias, number needed to treat for an additional beneficial outcome (NNTB) 5). Probiotics may lead to an improvement in clinical disease scores (RR 2.29, 95% CI 1.13 to 4.63; 2 studies, 54 participants; downgraded due to risk of bias and imprecision). There may be little or no difference in minor adverse events, but the evidence is of very low certainty (RR 1.04, 95% CI 0.42 to 2.59; 7 studies, 520 participants). Reported adverse events included abdominal bloating and discomfort. Probiotics did not lead to any serious adverse events in any of the seven studies that reported on it, however five adverse events were reported in the placebo arm of one study (RR 0.09, CI 0.01 to 1.66; 1 study, 526 participants; very low-certainty evidence; downgraded due to high risk of bias and imprecision). Probiotics may make little or no difference to withdrawals due to adverse events (RR 0.85, 95% CI 0.42 to 1.72; 4 studies, 401 participants; low-certainty evidence). Probiotics versus 5-ASA There may be little or no difference in the induction of remission with probiotics when compared to 5-ASA (RR 0.92, 95% CI 0.73 to 1.16; 1 study, 116 participants; low-certainty evidence; downgraded due to risk of bias and imprecision). There may be little or no difference in minor adverse events, but the evidence is of very low certainty (RR 1.33, 95% CI 0.53 to 3.33; 1 study, 116 participants). Reported adverse events included abdominal pain, nausea, headache and mouth ulcers. There were no serious adverse events with probiotics, however perforated sigmoid diverticulum and respiratory failure in a patient with severe emphysema were reported in the 5-ASA arm (RR 0.21, 95% CI 0.01 to 4.22; 1 study, 116 participants; very low-certainty evidence). Probiotics combined with 5-ASA versus 5-ASA alone Low-certainty evidence from a single study shows that when combined with 5-ASA, probiotics may slightly improve the induction of remission (based on the Sunderland disease activity index) compared to 5-ASA alone (RR 1.22 CI 1.01 to 1.47; 1 study, 84 participants; low-certainty evidence; downgraded due to unclear risk of bias and imprecision). No information about adverse events was reported. Time to remission, histological and biochemical outcomes were sparsely reported in the studies. None of the other secondary outcomes (progression to surgery, need for additional therapy, quality of life scores, or steroid withdrawal) were reported in any of the studies.
AUTHORS' CONCLUSIONS
Low-certainty evidence suggests that probiotics may induce clinical remission in active ulcerative colitis when compared to placebo. There may be little or no difference in clinical remission with probiotics alone compared to 5-ASA. There is limited evidence from a single study which failed to provide a definition of remission, that probiotics may slightly improve the induction of remission when used in combination with 5-ASA. There was no evidence to assess whether probiotics are effective in people with severe and more extensive disease, or if specific preparations are superior to others. Further targeted and appropriately designed RCTs are needed to address the gaps in the evidence base. In particular, appropriate powering of studies and the use of standardised participant groups and outcome measures in line with the wider field are needed, as well as reporting to minimise risk of bias.
Topics: Adolescent; Adult; Anti-Inflammatory Agents, Non-Steroidal; Bias; Child; Colitis, Ulcerative; Combined Modality Therapy; Humans; Mesalamine; Middle Aged; Numbers Needed To Treat; Probiotics; Randomized Controlled Trials as Topic; Remission Induction; Sample Size; Sulfasalazine
PubMed: 32128795
DOI: 10.1002/14651858.CD005573.pub3 -
ANZ Journal of Surgery Oct 2020Diverticula of the appendix (DA) are infrequent and their clinical implications are often overlooked. Several studies have found a significantly increased prevalence of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Diverticula of the appendix (DA) are infrequent and their clinical implications are often overlooked. Several studies have found a significantly increased prevalence of neoplasms in appendiceal specimens with diverticula. Despite the potential clinical implications, there is a paucity of literature. A systematic review and meta-analysis was performed to evaluate the prevalence of DA and its association with neoplasia.
METHODS
A systematic search of literature (Cochrane, EMBASE, PubMed and Medline) reporting the prevalence of DA and association with neoplasia was performed in November 2019. Relevant articles were assessed in accordance with the PRISMA guidelines. Risk of bias assessment was carried out using modified Newcastle-Ottawa scale. Meta-analysis with risk ratio and random-effects model was performed using RevMan.
RESULTS
The initial search identified 1122 potential articles of which 11 were appropriate for quantitative analysis. The prevalence rate of DA was 1.74%. The mean age of patients with DA and those without DA was 41.2 and 33.9 years, respectively. The ratio of male to female was 1.8:1. The prevalence of neoplasia in specimens without DA versus those with DA was 1.28% and 26.94%, respectively. Only four studies addressed the prevalence of locoregional neoplasia in the setting of DA compared to control. Meta-analysis with random-effects model demonstrated that pooled risk ratio was 25.46 (95% confidence interval 12.77-50.75, P < 0.00001).
CONCLUSION
The strong association with neoplasia in this meta-analysis reinforces the clinical significance of DA. Surgeons, pathologists and radiologists should be mindful of this uncommon pathology and consider individualized patient management, until further evidence can direct clinical guidelines for the management of patients with DA.
Topics: Appendiceal Neoplasms; Appendix; Cecal Diseases; Diverticulum; Female; Humans; Male; Neoplasms; Prevalence
PubMed: 32207873
DOI: 10.1111/ans.15811 -
ANZ Journal of Surgery May 2023Duodenal diverticulum occurs in approximately 20% of the population and can lead to life-threatening complications such as perforation. Most perforations are secondary...
BACKGROUND
Duodenal diverticulum occurs in approximately 20% of the population and can lead to life-threatening complications such as perforation. Most perforations are secondary to diverticulitis, with iatrogenic causes being exceptionally rare. This systematic review explores the aetiology, prevention and outcomes of iatrogenic perforation of duodenal diverticulum.
METHODS
A systematic review was performed according to the PRISMA guidelines. Four databases were searched, including Pubmed, Medline, Scopus and Embase. The primary data extracted were clinical findings, type of procedure, prevention and management of perforation and outcomes.
RESULTS
Forty-six studies were identified, of which 14 articles met inclusion criteria and comprised 19 cases of iatrogenic duodenal diverticulum perforation. Four cases identified duodenal diverticulum pre-intervention, nine were identified peri-intervention, and the remainder were identified post-intervention. Perforation secondary to endoscopic retrograde cholangiopancreatography (n = 8) was most common, followed by open and laparoscopic surgery (n = 5), gastroduodenoscopy (n = 4) and other (n = 2). Operative management with diverticulectomy was the most frequent treatment (63%). Iatrogenic perforation was associated with 50% morbidity and 10% mortality.
CONCLUSION
Iatrogenic perforation of duodenal diverticulum is exceptionally rare and associated with high morbidity and mortality. There are limited guidelines surrounding standard perioperative steps to prevent iatrogenic perforations. A review of preoperative imaging helps identify potential aberrant anatomy, such as a duodenal diverticulum, to allow for recognition and prompt management initiation in the event of perforation. Intraoperative recognition and immediate surgical repair are safe options for this complication.
Topics: Humans; Duodenal Ulcer; Cholangiopancreatography, Endoscopic Retrograde; Gastroscopy; Diverticulum; Iatrogenic Disease; Intestinal Perforation
PubMed: 36881513
DOI: 10.1111/ans.18376 -
Jornal de Pediatria 2023Meckel diverticulum (MD) is a common malformation of the digestive tract, often accompanied by serious complications. It is important to find safe and effective... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Meckel diverticulum (MD) is a common malformation of the digestive tract, often accompanied by serious complications. It is important to find safe and effective diagnostic methods for screening MD. The aim of this study was to evaluate the effectiveness of a technetium-99m (Tc-99m) scan for pediatric bleeding MD.
METHODS
The authors conducted a systematic review of studies published in PubMed, Embase, and Web of Science before 1 January 2023. Studies based on PICOS were included in this systematic review. The flow chart was made by PRISMA software. The quality of included studies was assessed by RevMan5 software (QUADAS-2: Quality Assessment of Diagnostic Accuracy Studies-2). The sensitivity, specificity, and other measurements of accuracy were pooled using Stata/SE 12.0 software.
RESULTS
Sixteen studies with 1115 children were included in this systematic review. A randomized-effects model was used for the meta-analysis because of significant heterogeneity. The combined sensitivity and specificity were 0.80 [Confidence Interval (95% CI, 0.73-0.86) and 0.95 (95% CI, 0.86-0.98)], respectively. The area under the curve (AUC) was 0.88 (95% CI, 0.85-0.90). Publication bias (Begg's test p = 0.053) was observed.
CONCLUSION
Tc-99m scan has high specificity, but moderate sensitivity, which is always influenced by some factors. Hence, the Tc-99m scan has some limitations in the diagnosis of pediatric bleeding MD.
Topics: Child; Humans; Technetium; Meckel Diverticulum; Radionuclide Imaging; Gastrointestinal Hemorrhage; Sensitivity and Specificity
PubMed: 37277097
DOI: 10.1016/j.jped.2023.03.009 -
International Journal of Colorectal... Sep 2023There is a hypothesis of an association between diverticulosis and metabolic syndrome (MS) or its components, but data on this topic are inconsistent, and a systematic... (Review)
Review
BACKGROUND
There is a hypothesis of an association between diverticulosis and metabolic syndrome (MS) or its components, but data on this topic are inconsistent, and a systematic review has not been performed. We conducted a systematic review to investigate the possible association between cardiometabolic risk factors and diverticulosis.
METHODS
A systematic literature search was conducted via PubMed, Cochrane Library, and Web of Science in December 2022 to collect the necessary data. Studies that examined the association between MS or individual metabolic factors and asymptomatic diverticulosis were included in the review.
RESULTS
Of the potentially relevant articles identified via PubMed (477), Cochrane Library (224), and Web of Science (296), 29 articles met the inclusion criteria and were used for this work. These studies were assessed for study quality using GRADE. Overall, 6 studies were rated as "very low," 19 studies as "low," and 4 studies as "moderate." The data suggest an association between arterial hypertension, obesity, and fatty liver disease in younger patients and diverticulosis. Patient age appears to play an important role in diverticular formation. Data on diabetes mellitus is inconclusive and may require further investigation depending on the location of the diverticula.
CONCLUSION
Based on the synthesized data, there is an association between arterial hypertension, obesity, and fatty liver disease in younger patients. The formation of diverticula seems to be influenced by age and genetic factors. The study suggests a connection with cardiometabolic risk factors. To gain a better understanding of the role of metabolic risk factors in asymptomatic diverticulosis, targeted studies are necessary based on these findings.
Topics: Humans; Diverticulum; Hypertension; Obesity; Risk Factors; Liver Diseases
PubMed: 37725283
DOI: 10.1007/s00384-023-04532-4 -
Expert Review of Gastroenterology &... 2023Common bile duct stones (CBDS) have a reported recurrence rate of 4%-24% after stone extraction. The most commonly applied stone extraction method is endoscopic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Common bile duct stones (CBDS) have a reported recurrence rate of 4%-24% after stone extraction. The most commonly applied stone extraction method is endoscopic cholangiopancreatography (ERCP). We conducted a systematic review and meta-analysis to identify all available risk factors for recurrent CBDS following stone retraction.
RESEARCH DESIGN AND METHODS
A literature search of studies with case-control design was performed to identify potential risk factors for recurrent CBDS. The impact of different risk factors on stone recurrence was analyzed. Pooled odds ratios (ORs) with 95% CIs and heterogeneity were calculated. Identified risk factors were graded as 'strong,' 'moderate,' or 'weak' after quality assessment.
RESULTS
A total of 46 studies discussing stone recurrence following ERCP treatment were included. CBD diameter1.5 cm, sharp CBD angulation, multiple ERCP sessions, postoperative pneumobilia, history of CBD incision, and biliary stent placement were identified as strong risk factors; larger CBD diameter, periampullary diverticulum, mechanical lithotripsy, and history of cholecystectomy were identified as moderate. Other weak risk factors were also listed.
CONCLUSIONS
In this comprehensive study, we identified 14 risk/protective factors for recurrent CBDS following ERCP. Pooled odds ratios were calculated and evaluated the quality of evidence. These findings may shed light on the assessment and management of CBDS.
Topics: Humans; Cholangiopancreatography, Endoscopic Retrograde; Sphincterotomy, Endoscopic; Gallstones; Risk Factors; Common Bile Duct; Choledocholithiasis; Retrospective Studies; Treatment Outcome
PubMed: 37531090
DOI: 10.1080/17474124.2023.2242784 -
ANZ Journal of Surgery Sep 2021Meckel's diverticulum (MD) is the most common congenital malformation in the gastrointestinal tract. Limited up-to-date evidence is available regarding MD in pregnancy....
INTRODUCTION
Meckel's diverticulum (MD) is the most common congenital malformation in the gastrointestinal tract. Limited up-to-date evidence is available regarding MD in pregnancy. We aim to review the available pertinent literature to help support clinical decision making and patient management in the future.
MATERIALS AND METHODS
The search term 'Meckel's diverticulum' was combined with 'pregnant' or 'pregnancy'. Database searches of EMBASE, Medline and PubMed were conducted. All papers published in English from 01/01/1990 to 01/01/2021 were included. Simple statistical analysis (t-test) was performed.
RESULTS
Twenty-seven cases were included. Average age = 26.9 years. Average gestation = 25.1 weeks. Occurrence: first trimester = 3.7%; second trimester = 48.1% and third trimester = 48.1%. Presenting symptoms: abdominal pain 88.9%; nausea/vomiting 59.3%; fever 18.5%; abdominal distension 18.5%; haematochezia 11.1%; constipation 11.1%; haematemesis 3.7%, diarrhoea 3.7% and asymptomatic 3.7%. Mean duration of preceding symptoms = 3.4 days. Diagnostic imaging modalities utilised: ultrasound = 40.7%; CT = 25.9%; MRI = 14.8%; abdominal X-ray = 11.1% and endoscopy = 7.4%. All cases required definite surgical management: laparotomy = 65.4%; laparoscopy = 15.4%; C-section = 19.2% and unreported = 3.8%. Main intra-operative findings: perforated MD = 40.7%; intussusception with MD as a lead point = 11.1%; bleeding MD = 11.1%, inflamed MD = 11.1%; small bowel obstruction = 11.1%; gangrenous MD = 3.7%; volvulus = 3.7% and unspecified = 7.4%. Mean length from ileocolic junction = 51.7 cm. Average length of stay was 7.1 days. T-test (p-value = 0.12) when comparing management strategy. Three maternal complications and two foetal mortalities.
CONCLUSION
MD and associated pathology are difficult to diagnose in the pregnant cohort. Current imaging demonstrates low diagnostic accuracy and a deviation away from recognised nuclear medicine investigations. Surgery appears the definitive management with both open and laparoscopic approaches utilised. Significant maternal morbidity and foetal mortality are associated with this condition.
Topics: Adult; Female; Humans; Intestinal Perforation; Intussusception; Laparoscopy; Laparotomy; Meckel Diverticulum; Pregnancy
PubMed: 34152674
DOI: 10.1111/ans.17014 -
ANZ Journal of Surgery Apr 2021Primary choledocholithiasis (PC) is a common disease in biliary surgery. The treatment is always challenging due to its high recurrence. A systemic review is undertaken... (Review)
Review
BACKGROUND
Primary choledocholithiasis (PC) is a common disease in biliary surgery. The treatment is always challenging due to its high recurrence. A systemic review is undertaken to determine the risk factors for recurrence and provide with the individualized management strategy.
METHODS
Electronic databases PubMed (Medline), Embase and Cochrane Central Register of Controlled Studies were searched for relevant articles on risk factors for PC recurrence. Its therapeutic intervention was also collected and analysed.
RESULTS
A total of 36 articles were eligible for inclusion. The recurrent risk factors include abnormalities of biliary anatomy (peripapillary diverticulum), dynamics (choledochal dilation, sharp angulation and stone number), metabolism (advanced age and hypothyroidism) and bacterial infection (Enterobacter and Helicobacter pylori). These factors eventually induce cholestasis and stone formation. At present, there is no guideline and expertise consensus for PC management. The treatment mainly consists of stone retrieval approaches and internal drainage surgeries. The former are minimally invasive methods: endoscopic sphincterotomy (EST), papillary balloon dilation (EPBD) and laparoscopic common bile duct exploration (LCBDE). The latter include choledochoduodenostomy (CDS) and choledochojejunostomy (CJS) with Roux-en-Y reconstruction. By far, the internal drainage surgeries have significantly lower recurrence than stone retrieval approaches.
CONCLUSION
Abnormal biliary anatomy, dynamics, metabolism and bacterial infection are the risk factors for PC. Both EST/EPBD and LCBDE can be performed as initial treatment. For recurrent PC, CDS is more suitable to the elderly, while Roux-en-Y CJS reserves for young patients or those in good conditions.
Topics: Aged; Cholangiopancreatography, Endoscopic Retrograde; Choledocholithiasis; Common Bile Duct; Dilatation; Humans; Risk Factors; Sphincterotomy, Endoscopic; Treatment Outcome
PubMed: 32815266
DOI: 10.1111/ans.16211 -
Cureus Aug 2023Zenker's diverticulum treatment options range from endoscopic rigid or flexible procedures to surgery. There are limited studies available comparing these techniques.... (Review)
Review
Zenker's diverticulum treatment options range from endoscopic rigid or flexible procedures to surgery. There are limited studies available comparing these techniques. Frequently, the choice of treatment depends on the physician's preference or experience, as well as the institution's resources and capacity. Therefore, this study aims to define the best approach based on the highest efficacy and the lowest severe adverse events. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search was performed. Only comparative studies were included, analyzing flexible endoscopy versus rigid endoscopy or surgery. The outcomes analyzed were clinical and technical success, severe adverse events, length of stay, and duration of the procedure. Analysis was performed using Review Manager 5.4.1 (RevMan 5.4, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Eight retrospective cohort studies met the inclusion criteria. A total of 1281 patients were identified, 492 underwent flexible endoscopy, 453 underwent rigid endoscopy, and 336 underwent surgery. There was no difference in clinical success [risk difference (RD), 0.07 (95% CI -0.05 to 0.19%); P = 0.26], technical success [RD, 0.07 (95% CI -0.03 to 0.16); P = 0.18], severe adverse events [RD, -0.03 (95% CI -0.13 to 0.07; P = 0.052), perforation [RD, 0.07 (95% CI -0.04 to 0.19); P = 0.22] or procedure time [mean difference (MD), - 10.03 (95% CI -26.93 to 6.88); P = 0.24). There was lower length of stay with flexible endoscopy compared to the other approaches [MD, -1.98 (95% CI -3.56 to -0.40); P = 0.001]. Based on the current evidence, the three main techniques are effective for the treatment of Zenker's diverticulum. Although there was no significant difference in the safety of each technique in this meta-analysis, this result should be interpreted cautiously due to the limited data and the risk of vies between the techniques, considering that the results tend to favor flexible endoscopy, mainly explained by the newer and safer devices. Length of stay is lower with flexible endoscopy versus the other techniques, which can be beneficial considering the geriatric populations where Zenker's diverticulum mainly occurs.
PubMed: 37680421
DOI: 10.7759/cureus.43021