Endoscopic stapling versus laser for Zenker diverticulum: a retrospective cohort study

Understanding Zenker's Diverticulum Treatment: Transoral CO2 Laser Microsurgery

The authors present a case of a 36-year-old woman with a recurrent throat foreign body sensation and persistent dysphagia. On physical examination, a polypoid mass was visible at the postcricoid region, mobile with swallowing. A barium swallowing test confirmed the diagnosis of Zenker's diverticulum. The patient underwent transoral CO2 laser microsurgery for excision of the pharyngeal pouch. At the four-month evaluation, the patient was remarkably asymptomatic and without evidence of recurrence. This clinical case illustrates in detail the endoscopic view of the pre and postoperative aspects of the pharyngeal pouch, showing a step-by-step transoral CO2 laser microsurgery technique, with video.

Endoluminal treatment for Zenker's diverticulum - a population-based observational study

BACKGROUND

Zenker's diverticulum is a false diverticulum arising in the oesophago-pharyngeal junction. It may cause symptoms like dysphagia and regurgitation. In Central Norway, treatment is centralized to St. Olavs hospital, either as an endoscopic stapled oesophago-diverticulostomy procedure at the Department of Gastrointestinal Surgery or as laser diverticulostomy at the Department of Ear, Nose and Throat Surgery, depending on diverticulum size.

METHODS

Retrospective, population-based, study from 2001-2020 on patients treated for Zenker's diverticulum, at the time with a rigid endoscopic approach. Patients were identified through the in-hospital register for operations. The two treatment groups were compared on relevant pre-, intra-, and postoperative variables by review of the individual patient records.

RESULTS

78 consecutive patients, 36 at Dept. of Ear, Nose and Throat Surgery and 42 at Dept. of Gastrointestinal Surgery, were treated with a total of 104 interventions. Crude incidence for a surgery-demanding Zenker's diverticulum was 0.57 per 100 000 per year. The Dept. of Ear, Nose and Throat Surgery administered significantly less often prophylactic antibiotics than the Dept. of Gastrointestinal Surgery (p < 0.001), administered more frequently intraoperative dexamethasone (p < 0.001), and had significantly more postoperative infections (19.6% vs 3.4%, p = 0.01). No procedure-related mortality was registered. Although no standardized follow-up took place, at a median of 119 months elapsed, observed clinical recurrence was 35% for the endostapler treatment and 51% for the laser treatment procedure.

CONCLUSION

Both rigid endoscopic stapled oesophago-diverticulostomy and laser diverticulostomy are safe treatments for Zenker's diverticulum, however with a substantial risk of recurrence.

Diagnosis and Open Surgical Management of Laimer's Diverticulum: Case Series and Review of the Literature

Objectives: Laimer's diverticulum (LD) is a very rare clinical entity originating between the cricopharyngeus muscle (CPM) and circular muscular fibers of the esophagus. Its diagnosis and management remain to be elucidated. This article summarizes our experience in its diagnosis and open surgical management.Methods: A retrospective review of LD cases treated at our tertiary medical institution was conducted between July 2018 and May 2023. The clinical and demographic data were retrieved from case notes.Results: Three cases were included in this review. There were 2 male patients and 1 female patient. The average and median ages were 47.3 and 54 years, respectively. Presenting symptoms included hoarseness, pharyngeal foreign body sensation, and neck mass. All 3 diverticula were on the left side, with the first 2 cases discovered accidentally on gastric endoscopic or cervical MRI examinations. After evaluating esophageal swallowing with barium sulfate or urografin contrast media, all the patients consented to undergo an open surgical procedure. During surgical exploration, the diverticula were found to be on the posterior part of the cervical esophagus, below CPM, and away from the recurrent laryngeal nerve, and only then, could the diagnosis of LD be established. Then, diverticulectomy and manual suturing of the esophagus was performed. Recovery of all 3 patients was uneventful. Nasogastric tube feeding lasted 7 to 12 days until esophageal examinations demonstrated no leak, and then, oral liquid feeding resumed. The median duration of follow-up was 50 months. No recurrence of symptoms or diverticulum was observed, and the swallowing function of all 3 patients was excellent.Conclusions: An open surgical approach is not only important for the diagnosis of LD, but can also be utilized as a safe and effective treatment.

Novel technique of flexible endoscopic therapy of Zenker’s diverticulum using a pulsed Holmium laser—a retrospective single-center analysis

Background

In recent years, flexible endoscopic therapy of Zenker’s diverticulum seems to become the standard approach. The aim of this study was to assess the safety, efficacy and short-term outcome of flexible endoscopic diverticulotomy of Zenker’s diverticulum with a pulsed Holmium laser (PHL).

Patients and methods

All patients treated with endoscopic laser-diverticulotomy using a PHL between February 2013 and November 2021 at the University Hospital Salzburg were extracted from our prospectively maintained endoscopic database. Demographic data, size of Zenker’s diverticulum, procedure duration, complications, short-term outcome and rate of recurrence were evaluated.

Results

In the study period, 45 procedures in 36 patients were performed. Mean depth of the Zenker diverticulum was 21 mm (10–60 mm), mean procedure time was 31 min (15–60 min), intraprocedural adverse events occurred in 2 out of 45 patients (5%) which were both managed endoscopically, post-procedural stenosis occurred in 1 patient (2%). In the follow-up examinations (mean follow-up after 6.4 months), 27 out of 36 patients (75%) were symptom-free, 6 patients (17%) reported an improvement of dysphagia. 3 patients (9%) suffered from persistent dysphagia. After initial symptom relief, a recurrent diverticulum occurred in 5 patients. Endoscopic re-intervention with PHL was done in these cases.

Conclusions

Flexible endoscopic treatment of primary and recurrent Zenker’s diverticulum using a PHL is a promising, safe and effective treatment with, in our opinion, technical advantages in comparison to the CO2 laser. Further controlled prospective trials are needed.

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Objectives and study aims  Recent pilot studies have assessed the feasibility of a novel 1.9-/1.5-μm dual emission endoscopic laser treatment ( _1.9-/1.5-μm DEELT) for endoscopic hemostasis, ablation and resection. In this study, we investigated the safety and efficacy of _1.9-/1.5-μm DEELT in patients with chronic anemia due to gastrointestinal vascular lesions in a real-life multicenter cohort setting.

Patients and methods  Consecutive patients with moderate/severe iron-deficiency anemia undergoing _1.9-/1.5-μm DEELT for upper and lower gastrointestinal bleeding due to vascular lesions were enrolled in three academic referral centers. Safety and successful ablation of vascular lesions were the primary outcomes. Long-term hemoglobin level, blood transfusion requirements, endoscopic severity scores of complex vascular disorders and technical lasing parameters were also assessed. Long-term hemoglobin variations have been further assessed, with repeated measure analysis of variance and univariate analyses.

Results  Fifty patients (median age 74; range 47 to 91 years) with gastric antral vascular ectasia (GAVE) (22), angioectasia (22) and radiation proctopathy (6) underwent 58 _1.9-/1.5-μm DEELT between 2016 and 2020. All procedures were technically feasible leading to successful ablation of the targeted lesion/s, with no incident or adverse event potentially related to the _1.9-/1.5-μm DEELT technique. Within a 6-month follow-up, hemoglobin values significantly rose (+ 1.77 at 1 month and + 1.70 g/dL at 6 months, P  < 0.01), the blood supply requirement decreased (at least one transfusion in 32 versus 13 patients, P  < 0.01), and GAVE lesions showed a clear endoscopic improvement (from 5 points to 1 points, P  < 0.01).

Conclusions  The 1.9-/1.5-μm laser system is a safe and effective endoscopic tool for haemostatic ablation of bleeding vascular lesions within the gastrointestinal tract in tertiary referral centers.