Evolving Management of Zenker's Diverticulum in the Endoscopic Era: A North American Experience

The robot can break bars with the best of them: a novel approach to treating cricopharyngeal bars with myotomy

INTRODUCTION

Failure of the cricopharyngeus to relax results in oropharyngeal dysphagia, which over time results in hypertrophy and increased risk for aspiration. Open myotomy is one definitive treatment option, however there are several drawbacks attributable to the long neck incision, ± drain placement, and invasiveness of the procedure. We aim to share our experience using the DaVinci robotic platform to perform a minimally invasive cricopharyngeal myotomy, which has never been described before in the literature.

METHODS

All robotic cricopharyngeal myotomies performed in adult patients by a single surgeon from 2021 to 2022 were retrospectively reviewed. No patients were excluded. Outcomes of interest included length of procedure, time to diet resumption, hospital length of stay, complications, symptom improvement at follow-up, and symptom recurrence.

RESULTS

Eight robotic cricopharyngeal myotomies were performed. The median age was 65 years old (62-91) and mostly female (n = 5, 56%) with a median BMI of 28.9 kg/m2 (21.7-39.5). The median procedure length was 113 min (94-141) and there were no intraoperative complications. All patients underwent a post-procedural esophagram with no leaks were identified. All patients were started on clear liquids in recovery and transitioned to full liquids prior to discharge. All but one patient was subsequently discharged home on the same day as procedure. All patients had routine 2-week post-operative follow-up in addition to phone follow-up at a later date (6-11 months post-operative). All patients reported resolution of symptoms. There were no complications or readmissions. No instances of recurrence were reported. On cost analysis, the minimally invasive robotic approach allows for an outpatient procedure with similar cost to an open approach with a one-night stay.

CONCLUSION

Our experience with the novel technique of minimally invasive robotic cricopharyngeal myotomy for cricopharyngeal bars with cervical dysphagia is safe, efficacious, less invasive, and cost saving, with excellent patient outcomes.

Postoperative Complications and Reoperative Surgery in the Treatment of Patients With Zenker Diverticulum

Importance

The association of the surgical approach, surgical specialty, and other factors with the outcomes of surgical treatment of Zenker diverticulum (ZD) have been debated in the literature.

Objectives

To explore the outcomes of 3 different surgical methods used in the management of ZD and determine the associations between patient characteristics, such as preoperative comorbidities and treatment outcomes.

Design, Setting, and Participants

This retrospective, population-based cohort study examined patient records of patients who underwent surgical treatment for ZD from the Care Register for Healthcare database in Finland between January 1996 and December 2015. Data review and analysis were completed in 2021.

Exposure

Surgical treatment for ZD.

Main Outcome and Measures

Complications of surgical procedures used in the management of ZD.

Results

In this study, 1044 patients (median [IQR] age, 70.0 [22.0-98.0] years; 416 female individuals [39.8%]) surgically treated for ZD were identified. Most patients (606 [58.0%]) had no preoperative comorbidities. A total of 67 (6.4%) complications were recorded, with a mortality rate of 0.9%. The likelihood of complications was associated with patient age (t [1042] = 2.28; Cohen d, 0.29; 95%, CI 0.04, 0.54), surgical approach (Cramer V = 0.14 [95% CI 0.07-0.21]), and surgical specialty (Cramer V, 0.16; 95% CI, 0.06-0.28). The median (IQR) length of stay in association with the primary surgical intervention was 3.0 (0-85.0) days. Length of stay was associated with patient age (Cramer V, 0.14; 95% CI, 0.06-0.25), especially in patients older than 90 years, surgical approach (F [2, 466.2] = 26.9; ηp2 = 0.08; 95% CI, 0.05-0.11), and surgical specialty (F [4, 22.1] = 11.0; ηp2 = 0.07; 95% CI, 0.04-0.10). Reoperation was associated with the initial surgical approach (Cramer V, 0.18; 95% CI, 0.12-0.23) and surgical specialty (Cramer V, 0.14; 95% CI, 0.09-0.21).

Conclusions and Relevance

The results of this cohort study suggest that the outcomes of surgical management depended on the surgical approach, surgical specialty, and patient age. Overall, surgical treatment may be considered safe and may be considered for all patients with symptomatic ZD.

Peroral cricopharyngeal myotomy for the management of Zenker's diverticulum in the hands of a general surgeon

BACKGROUND

The treatment of Zenker's diverticulum has been shifted from open cricopharyngeal myotomy and rigid endoscopy to the use of flexible endoscopy. Few studies evaluate general surgeon's performance of flexible endoscopic management of Zenker's diverticulum as the majority are performed by gastroenterologists. The objective of our case series is to show that general surgeons trained in surgical endoscopy can perform this procedure with favorable outcomes.

METHODS

A retrospective review of peroral cricopharyngeal myotomies performed at Spectrum Health hospital in Grand Rapids, Michigan by a single surgical endoscopist between the 2018 and 2021 was conducted. The primary outcome was the improvement of dysphagia. Intra-procedural complications, post-procedural complications, hospital length of stay, time to oral intake, and recurrence were also evaluated. Age, sex, body mass index, diverticulum size, and procedure time were abstracted. Median (ranges) and frequencies (percentages) are used to describe the patient population and outcomes.

RESULTS

Forty patients were included in the study. Median age was 74 years old (60-95) with a male predominance (n = 27, 67.5%). Median BMI was 28 kg/m2 (18-43), average procedure length of 64 min (41-119), diverticulum size of 28 mm (19-90), and average length of stay of 0.9 days (0-8). There were no intra-procedural complications. All patients had a post-procedural esophagram prior to initiation of diet. Esophageal leak was the only complication that occurred, which was found on post-procedural esophagram (n = 5). Only two patients had clinical sequelae. All leaks closed without additional surgical intervention. The majority of patients had their diet resumed and discharged the same day of the procedure. Frequency of recurrence was 17.5% (n = 7).

CONCLUSION

Our study demonstrates that general surgeons trained in endoscopy can perform endoscopic myotomies for Zenker's diverticula on a wide range of sizes, with favorable patient outcomes, and few complications.

A multi-centre analysis of a decade of endoscopic pharyngeal pouch surgery in Cheshire and Merseyside

BACKGROUND

There are sparse data on the outcomes of endoscopic stapling of pharyngeal pouches. The Mersey ENT Trainee Collaborative compared regional practice against published benchmarks.

METHODS

A 10-year retrospective analysis of endoscopic pharyngeal pouch surgery was conducted and practice was assessed against eight standards. Comparisons were made between results from the tertiary centre and other sites.

RESULTS

A total of 225 procedures were performed (range of 1.2-9.2 cases per centre per year). All centres achieved 90 per cent resumption of oral intake within 2 days. All centres achieved less than 2-day hospital stays. Primary success (84 per cent (i.e. abandonment of endoscopic stapling in 16 per cent)), symptom resolution (83 per cent) and recurrence rates (13 per cent) failed to meet the standard across the non-tertiary centres.

CONCLUSION

Endoscopic pharyngeal pouch stapling is a procedure with a low mortality and brief in-patient stay. There was significant variance in outcomes across the region. This raises the question of whether this service should become centralised and the preserve of either tertiary centres or sub-specialist practitioners.

Adverse Events after Rigid and Flexible Endoscopic Repair of Zenker’s Diverticula: A Systematic Review and Meta-analysis

Objective

To determine adverse events after endoscopic flexible vs endoscopic rigid cricopharyngeal myotomy for treatment of Zenker’s diverticulum (ZD).

Data Sources

Systematic review of MEDLINE, Web of Science, CINAHL, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials for all years according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional studies were identified from review citations and a by hand search of manuscripts referencing ZD.

Review Methods

A structured literature search was conducted to identify studies for this systematic review. Methodological Index for Non-randomized Studies (MINORS) criteria were applied to assess study quality. For inclusion, each study had to provide data for at least 10 adult patients who had undergone endoscopic ZD repair reporting clear association with the postprocedure course in each case. Data extracted included all reported adverse events, recurrences, follow-up, and operative times.

Results

In total, 115 studies were included. All but 8 were retrospective case series. Sixty-one reported series of patients after rigid endoscopic stapler repair, 31 after rigid laser repair, and 13 with other rigid endoscopic instruments. Twenty-nine flexible endoscopic studies were included. Mortality, infection, and perforation were not significantly more likely in either the rigid or the flexible group, but bleeding and recurrence were more likely after flexible endoscopic techniques (20% vs <10% and 4% vs 0%, respectively). Dental injury and vocal fold palsy were reported rarely in the rigid endoscopic groups.

Conclusions

Adverse events are rare after endoscopic Zenker’s repair. The flexible approach minimizes exposure limitations and can be completed in some patients without general anesthesia. Transoral rigid approaches result in fewer revision surgeries compared with flexible diverticulotomy.

Comparison of flexible endoscopic cricopharyngeal myectomy and myotomy approaches for Zenker diverticulum repair

BACKGROUND AND AIMS

Incision of the cricopharyngeal (CP) muscle with flexible endoscopy is an important approach for Zenker diverticulum (ZD) repair with symptomatic resolution in approximately 90% of cases, but recurrence has been reported in up to 20%. We report our experience with a new endoscopic myectomy of the CP muscle and compare the outcome with conventional myotomy of ZD.

METHODS

Our retrospective study included all patients with ZD who underwent endoscopic repair between August 1, 2014 and July 31, 2017. Conventional CP myotomy was defined as a vertical cut through the CP muscle. CP myectomy was defined as parallel excisions followed by snare resection at the CP resection base. Measurement of ZD size was based on barium esophagram and endoscopic estimation. Outcomes included ZD recurrence, improvement of dysphagia, and procedure adverse events.

RESULTS

Sixty-four patients underwent endoscopic repair for ZD, 44 with CP myotomy and 20 with CP myectomy. Mean (standard deviation) size of ZD was 3.3 cm (1.0) and 3.8 cm (1.2) in the myotomy and myectomy cohorts, respectively (P = .11), and median procedure time was 50 and 56 minutes, respectively (P = .73). In the CP myotomy cohort, 10 patients (22.7%) had recurrence of ZD at a median of 19.1 months, whereas no recurrence was documented in the CP myectomy cohort (P = .02). This trend was also shown in multivariate analysis but was not statistically significant (P = .07). There was no statistical difference in improvement of dysphagia and adverse events.

CONCLUSIONS

CP myectomy is a new endoscopic technique for ZD repair. In our experience, it was safe and well tolerated, with a high initial success rate and less ZD recurrence when compared with myotomy.

Management of Zenker's diverticulum using flexible endoscopy

Background and Aims

Zenker's diverticulum is a false diverticulum through Killian's dehiscence. Symptoms include halitosis, dysphagia, regurgitation, cough, and aspiration pneumonia. Treatment options include open transcervical cricopharyngeal myotomy, trans-oral rigid endoscopic stapling, and minimally invasive endoscopic myotomy. Although open surgical techniques have historically been the criterion standard for treatment, endoscopic options have become increasingly used. We propose the use of flexible endoscopy in the management of Zenker's diverticulum.

Methods

We present a retrospective case series of 9 patients undergoing endoscopic cricopharyngeal myotomy from 2014 to 2018 using our endoscopic technique.

Results

We demonstrate that endoscopic technique provided adequate symptomatic relief in 7 of 9 patients, with no operative adverse events.

Conclusions

Cricopharyngeal myotomy using flexible endoscopy is a safe and effective technique for the management of Zenker's diverticulum. Potential benefits of this approach include shorter operative times, shorter postoperative admissions, and earlier progression of diet. Initial treatment with endoscopic technique does not preclude future open repairs.

Esophageal obstruction due to a right-sided Zenker diverticulum

A Zenker's or pharyngoesophageal diverticulum may represent a rare cause of upper digestive obstruction, or more often, cervical dysphagia, regurgitations and cough. It develops most often on the posterior left side of cervical oesophagus in elderly patients, and depending on the severity of clinical symptoms may warrant surgical or endoscopic treatment. For large lesions with a difficult endoscopic access to the diverticular neck, surgery is recommended. In our case, we illustrate a giant right-sided Zenker's diverticulum responsible for complete aphagia in a 78-year-old male patient. Open surgery by right cervical approach, with diverticulopexy and cricopharyngeal myotomy was performed, with an uneventful recovery. This paper presents with preoperative and intraoperative illustrations of high educational value for this, often underdiagnosed, clinical entity.

[Pathophysiology, diagnosis and treatment of Zenker's diverticulum]

Zenker's diverticulum occurs at the dorsal pharyngoesophageal junction through Killian's dehiscence and is caused by increased intrabolus pressure. Symptomatic disease most frequently affects male elderly patients. Primary symptom is oropharyngeal dysphagia, as well as regurgitation of undigested food, halitosis, and chronic aspiration. A barium swallow study is performed to confirm diagnosis. Treatment options for symptomatic patients include open surgery, as well as transoral rigid or flexible endoscopic procedures. Transoral procedures have become the main treatment approach over the past year thanks to reduced intraoperative complication rates compared to open surgery. The septum dividing the diverticulum from the esophagus is most commonly divided by a stapler device, papillotome, or laser. For high-risk patients who are poor candidates for general anesthesia, the procedure can be performed via flexible endoscopy in awake patients, albeit at an increased risk of recurrence.

New flexible endoscopic controlled stapler technique for the treatment of Zenker's diverticulum: A case series

AIM

To report about the combination and advantages of a stapler-assisted diverticulotomy performed by flexible endoscopy.

METHODS

From November 2014 till December 2015 17 patients (8 female, 9 male, average age 69.8 years) with a symptomatic Zenker diverticulum (mean size 3.5 cm) were treated by inserting a new 5 mm fully rotatable surgical stapler (MicroCutter30 Xchange, Cardica Inc.) next to an ultrathin flexible endoscope through an overtube. The Patients were under conscious sedation with the head reclined in left position, the stapler placed centrally and pushed forward to the bottom of the diverticulum. The septum was divided by the staple rows under flexible endoscopic control.

RESULTS

In eleven patients (64.7%) the stapler successfully divided the septum completely. Mean procedure time was 21 min, medium size of the septum was 2.8 cm (range 1.5 cm to 4 cm). In four patients the septum was shorter than 3 cm, in seven longer than 3 cm. To divide the septum, averagely 1.3 stapler cartridges were used. Two minor bleedings occurred. Major adverse events like perforation or secondary haemorrhage did not occur. After an average time of two days patients were discharged from the hospital. In 6 patients (35.3%) the stapler failed due to a thick septum or insufficient reclination of the head. Follow up endoscopy was performed after an average of two months in 9 patients; 4 patients (44.4%) were free of symptoms, 5 patients (55.6%) stated an improvement. A relapse of symptoms did not occur.

CONCLUSION

Flexible endoscopic Zenker diverticulotomy by using a surgical stapler is a new, safe and efficient treatment modality. A simultaneously tissue opening and occlusion prevents major complications.