Endoscopic stapling technique of esophagodiverticulostomy for Zenker's diverticulum

Pharyngeal pouch endoscopic stapling--are post-operative barium swallow radiographs of any value?

Posterior pharyngeal pouch endoscopic stapling has gained increasing popularity among otolaryngologists especially in elderly patients. Post-operative barium swallow appearances can create confusion with the appearance of persistent pouches. We describe our experience in 10 patients, three of whom had external excision with cricopharyngeal myotomy and the remaining seven had endoscopic stapling approach. All three patients who had external excision showed no residual pouch whereas all seven patients who had endoscopic techniques performed showed some residual pouch. We were unsuccessful in our attempt to correlate post-operative symptoms with radiological appearance. Attempts by other radiologists at identifying pre- and post-operative barium swallow radiographs in patients who had endoscopic stapling of pharyngeal pouch were unsuccessful. We conclude that post-operative barium swallow radiography plays no role in determining the success of endoscopic stapling of pharyngeal pouch.

Endoscopic treatment of Zenker's diverticulum

BACKGROUND

The most important aspect of the surgical management of Zenker's diverticulum is probably the cricopharyngeal myotomy. Endoscopic diverticulotomy can be performed with a needle-knife papillotome, which allows simultaneous myotomy of the upper esophageal sphincter.

METHODS

Since 1978, 47 patients (28 men and 19 women 51 to 81 years of age) underwent endoscopic diverticulotomy. Most patients underwent more than one treatment session (mean value 2.2). The procedure was performed with sedation. Tubes were not used, and oral intake of food was begun the first day after the operation.

RESULTS

Forty-five (95.74%) patients had no dysphagia or only occasional, mild dysphagia during the postoperative course. No fistula, no recurrent laryngeal paralysis, and no deaths occurred.

CONCLUSION

Endoscopic diverticulotomy seems to be a good choice of therapy at least for patients with associated diseases that increase surgical risk.

Esophageal rings, webs, and diverticula

Rings, webs, and diverticula are among the most common anatomic anomalies of the esophagus. Although these structural lesions are often asymptomatic, patients can develop significant problems with dysphagia, regurgitation, and aspiration. This article discusses the epidemiology, pathogenesis, diagnosis, and therapy of esophageal rings, webs, and diverticula with emphasis on the clinical, diagnostic, and therapeutic strategies involved in caring for patients with these conditions.

The role of endoscopic stapling diverticulotomy in recurrent pharyngeal pouch

Endoscopic stapling diverticulotomy is an increasingly popular treatment option for pharyngeal pouch. It has been our treatment of choice for the condition for over three years. Of the over 50 cases treated using the technique, three were performed for recurrent pouches--two following previous endoscopic stapling diverticulotomy and one following previous external excision. We describe these three cases to highlight the advantages and effectiveness of the technique in recurrence cases.

Endoscopic stapling treatment of pharyngeal pouch

BACKGROUND

We describe our experience of a recently reported endoscopic stapling technique for the treatment of pharyngeal pouch.

METHODS

In contrast to other endoscopic procedures, which only divide the common wall between oesophagus and diverticulum, the linear cutting stapler also tightly seals the divided edges of mucosa and muscle.

RESULTS

The procedure was performed without complications in three patients with complete resolution of pre-treatment symptoms.

CONCLUSIONS

To our knowledge this is the first report of the use of this procedure in Australia. This endoscopic stapling operation appears to be safe, simple and cost-effective and offers advantages over previously used techniques.

Terminalized semimechanical side-to-side suture technique for cervical esophagogastrostomy

BACKGROUND

The classic manual end-to-side technique of esophagogastrostomy after gastric pull-up to the neck carries a rather high risk of fistula and stricture.

METHODS

A terminalized semimechanical side-to-side technique of cervical esophagogastrostomy was performed in 16 patients by the application of an Endo-GIA stapler across the gastric and esophageal walls placed side by side, so as to create a V-shaped posterior opening between the two lumina. The anterior aspect of the anastomosis was hand-sewn using a classic running suture. The cross-sectional area of the semimechanical anastomoses was estimated by barium swallow study 2 months after operation and compared with that of 24 manual end-to-side esophagogastrostomies.

RESULTS

The cross-sectional area was 225 +/- 15.7 mm2 (mean +/- standard error of the mean) for the 16 semimechanical anastomoses versus 136 +/- 15 mm2 for the 24 manual anastomoses (p = 0.0001). The anastomotic area decreased from 206.6 +/- 13.5 mm2 in 29 patients without dysphagia to 107.5 +/- 4.7 mm2 in 7 patients with moderate dysphagia for solids that did not require endoscopic dilation and to 55.7 +/- 16 mm2 in 4 patients with severe dysphagia that required dilation (p = 0). The anastomotic area in 6 of the 7 patients with initial moderate dysphagia for solids increased spontaneously with time from 107.3 +/- 5.5 mm2 to 174.6 +/- 8.1 mm2, with concomitant symptomatic relief (p = 0.0277).

CONCLUSIONS

The terminalized semimechanical side-to-side suture technique produces a larger anastomosis than the classic end-to-side esophagogastrostomy technique. Inflammatory changes related to the operation may cause transient narrowing of a cervical esophagogastrostomy.

Long-term experience with endoscopic staple-assisted esophagodiverticulostomy for Zenker's diverticulum

The authors have previously described the endoscopic staple-assisted esophagodiverticulostomy (ESED) technique for treatment of Zenker's diverticulum. In the initial series of six patients, ESED was shown to be safe and effective in the short term, with a significant reduction in hospital stay and convalescence as compared with other surgical techniques. This report documents the authors' long-term experience with ESED (average follow-up, 9.3 months; range, 1.5 to 25 months) and discusses the long-term results of this therapy, technical issues, and variations they have utilized, as well as the advantages and limitations of this approach. Thirty-six patients with Zenker's diverticula have been treated from March 1995 to March 1997. In 34 of the patients, ESED was accomplished, resulting in successful resolution of preoperative symptoms in 32 (94%). Two patients had persistent dysphagia after initial ESED; a revision ESED was successfully performed without complication in both. Two patients were unable to be treated with ESED because of inability to expose the diverticulum with the Weerda laryngoscope. Oral liquid diet has been resumed, on average, 0.8 days after surgery (range, 0 to 4 days), with solid diet resumed by day 5 (range, 1 to 14 days). The average hospital stay has been 1.3 days (range, 1 to 4 days). There have been no postoperative deaths, infections, or airway difficulties. Perioperative morbidity to date has included one case of iatrogenic pharyngeal perforation, one postoperative fever, one transient true vocal fold paralysis, and two dental injuries, with no long-term sequelae. The results support the use of ESED as the initial treatment of choice for patients with Zenker's diverticula.

Endoscopic laser myotomy in the treatment of pharyngeal diverticula

The endoscopic approach is a simple and cost-effective option in the treatment of hypopharyngeal diverticula. Whereas almost a third of all endoscopic myotomies performed by UK otolaryngologists are carried out with the stapling technique, CO2 laser diverticulotomy has not been given as much consideration (Koay et al., in press). We report on the first British series of 15 patients treated between 1985 and 1993 with microscopic laser diverticulotomy. The follow-up period was four to 11 years. Complications occurred in three patients, two patients required a repeat myotomy and 11 patients have been satisfied with their swallow since the operation. Our results are similar to those of larger studies. The laser technique is more established than the stapling gun myotomy and it has the advantage of superior visualization. It may also be used in small pouches which do not admit the insertion of a stapling gun.

Endoscopic Zenker's Diverticulotomy (Dohlman Procedure): Forty Cases Reviewed

Pharyngoesophageal diverticula, first described in 1769, occur in an area of natural weakness between the inferior pharyngeal constrictor muscles of the pharynx and the cricopharyngeus muscle. The cause of these acquired diverticula is controversial, although most likely it is related to cricopharyngeus muscle dysfunction. Treatment is directed toward correcting the underlying sphincter dysfunction and managing the diverticulum. Endoscopic diverticulotomy requires division of the cricopharyngeus and the common wall between the esophagus and diverticulum, a technique popularized by Dohlman. We reviewed the results of 40 endoscopic diverticulotomy patients, ranging in age from 46 to 88 years, many of whom had significant existing comorbidities. The mean size of the diverticula was 4.1 cm, mean surgery time was 41 minutes, and mean hospital stay was 4.5 days. Thirty-seven of 40 patients, including 3 whose previous external procedure was not successful, returned to a regular diet, reported no regurgitation and were satisfied with the procedure. Complications in order of occurrence were pneumomediastinum (4 patients), urinary tract infection (2), upper respiratory tract infection (2), and lip laceration (1). Our results compare favorably with those of external approaches. The technique should be considered safe, expedient, and effective, particularly in patients with existing comorbidities.

Endoscopic staple-assisted esophagodiverticulostomy for Zenker's diverticulum

We have used a new technique, endoscopic staple-assisted esophagodiverticulostomy (ESED), for the treatment of Zenker's diverticulum. This technique is a modification of the endoscopic approach first described by Mosher in 1917 and popularized by Dohlman and Mattsson in which the common wall between the esophagus and diverticulum was divided without mucosal closure. ESED differs in that an endosurgical stapler is used to create an esophagodiverticulostomy by dividing the common wall between the esophagus and diverticulum, with the mucosal and muscular edges sealed by the staples. We have performed this procedure in six patients, with no perioperative morbidity in any patient. All patients resumed oral intake on either the first or second postoperative day, with no evidence of fistula formation or mediastinitis. Hospital stay has averaged 2 days (range, 1 to 3 days). Patient follow-up after ESED averages 6 months and is available for five of the six patients treated. There has been complete resolution of pretreatment symptoms in these five patients, with resumption of regular diet between postoperative day 3 and day 14 (average, day 9). Our results demonstrate that ESED is a safe and effective treatment for Zenker's diverticulum. This endoscopic approach offers a number of advantages over previously used treatments for Zenker's diverticulum, including reduced morbidity, rapid convalescence, short hospitalization, brief operative time, and predictable resolution of symptoms.

Zenker's diverticulum--a historical review and trends in therapy

More than 200 years have passed since the pulsion diverticulum of hypopharynx was first described. This paper reviews different opinions on its etiology over the centuries. The German pathologist F.A. von Zenker, who successfully pursued research on a variety of topics, is often associated with this diverticulum through his classical work from 1867 "Krankheiten des Oesophagus", which deals with the pathogenesis and clinical presentations of this herniation of the posterior mucosal wall. Numerous surgical techniques, which have been practised mainly during this century, are also reviewed. Different options of endoscopic surgery, which is presently the preferred approach at many medical centers, are described and discussed. Our own experience of endoscopic surgery in patients with Zenker's diverticulum is also presented.