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Maquet C, Evrard M, Laffouilhere TP, Lacassin M, Nokovitch L, Marie JP, Slama NB, Crampon F, Deneuve S. Comparative analysis of CO2 laser and ultracision harmonic scalpel for endoscopic treatment of Zenker's diverticulum using a propensity score: A retrospective observational study. Am J Otolaryngol 2024; 45:104435. [PMID: 39226772 DOI: 10.1016/j.amjoto.2024.104435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 07/21/2024] [Indexed: 09/05/2024]
Abstract
OBJECTIVES Zenker's diverticulum (ZD) is a progressive condition that can cause dysphagia and aspiration. Endoscopic cricopharyngeal myotomy (ECPM) is the gold standard treatment for ZD, but there are various techniques available. We aimed to compare the efficacy and safety of the ultrasonic harmonic scalpel (UHS) versus the CO2 laser (CO2L) for ECPM in ZD. DESIGN We led an observational study. The main composite outcome consisted in persistence of postoperative dysphagia OR recurrence/reoperation of symptomatic ZD within two years postoperatively. Surgery was considered effective when no dysphagia within two years postoperatively. The secondary outcome was the occurrence of acute mediastinitis within 72 h postoperatively. A propensity score was built to adjust for differences observed between non-randomized groups. Additional sensitivity analyses were performed. SETTING All patients with ECPM surgery for ZD were included from 2011 to 2018 in a single tertiary center. Patients with failure of endoscopic exposition were excluded. PARTICIPANTS The study included 86 patients who underwent ECPM with either the CO2L (n = 53) or UHS (n = 33) technique. ZD size and other demographic variables were comparable between the groups. MAIN OUTCOME MEASURES UHS had superior efficacy compared to CO2L (relative risk of failure = 0.29; 95 % confidence interval: 0.05-1.0; p = 0.05), but there was a higher incidence of mediastinitis in the UHS group (12 % vs. 4 %), although this was not statistically significant. RESULTS AND CONCLUSION The UHS technique appears to be an effective technique for ECPM in ZD patients but its safety remains to explore by further larger studies.
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Affiliation(s)
- Charles Maquet
- CHU Rouen, Department of Otorhinolaryngology and Head and Neck Surgery, F-76000 Rouen, France.
| | - Mathieu Evrard
- CHU Rouen, Department of Otorhinolaryngology and Head and Neck Surgery, F-76000 Rouen, France
| | - Thibaut Pressat Laffouilhere
- Clinique Ambroise Paré, Groupe ELSAN, Department of Medical Information, 387 Rte de Saint-Simon, F-31100 Toulouse, France.
| | - Marion Lacassin
- CHU Rouen, Department of Biostatistics, F-76000 Rouen, France.
| | - Lara Nokovitch
- CHU Rouen, Department of Otorhinolaryngology and Head and Neck Surgery, F-76000 Rouen, France
| | - Jean-Paul Marie
- CHU Rouen, Department of Otorhinolaryngology and Head and Neck Surgery, F-76000 Rouen, France.
| | - Neil Ben Slama
- CHU Rouen, Department of Otorhinolaryngology and Head and Neck Surgery, F-76000 Rouen, France.
| | - Frederic Crampon
- CHU Rouen, Department of Otorhinolaryngology and Head and Neck Surgery, F-76000 Rouen, France.
| | - Sophie Deneuve
- CHU Rouen, Department of Otorhinolaryngology and Head and Neck Surgery, F-76000 Rouen, France.
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Wallerius KP, Bowen AJ, O'Byrne TJ, Aden AA, Peraza LR, Xie KZ, Richards BA, El-Badaoui J, Bayan SL, Wong Kee Song LM, Ekbom DC. Comparing Open Versus Rigid Endoscopic and Flexible Endoscopic Techniques for the Treatment of Zenker's Diverticulum. Otolaryngol Head Neck Surg 2023; 169:962-970. [PMID: 36906817 DOI: 10.1002/ohn.318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/16/2023] [Accepted: 01/27/2023] [Indexed: 03/13/2023]
Abstract
OBJECTIVE To describe the outcomes of patients undergoing open stapler versus transoral rigid and flexible endoscopic therapies for symptomatic Zenker's diverticulum. STUDY DESIGN Single institution retrospective review. SETTING Tertiary care academic hospital. METHODS We retrospectively evaluated the outcomes of 424 consecutive patients who underwent Zenker's diverticulotomy via an open stapler, rigid endoscopic CO2 laser, rigid endoscopic stapler, rigid endoscopic harmonic scalpel, or flexible endoscopic technique from January 2006 to December 2020. RESULTS A total of 424 patients (173 females, mean age 73.1 ± 11.2 years) from a single institution were included. A total of 142 patients (33%) underwent endoscopic laser treatment, 33 (8%) underwent endoscopic harmonic scalpel, 92 (22%) underwent endoscopic stapler, 70 (17%) underwent flexible endoscopic, and 87 (20%) underwent open stapler. All open and rigid endoscopic procedures and most of the flexible endoscopic procedures (65%) were performed under general anesthesia. The flexible endoscopic group had a higher percentage of procedure-related perforation, defined as subcutaneous emphysema or contrast leak on imaging (14.3%). The recurrence rates were higher in the harmonic stapler, flexible endoscopic, and endoscopic stapler groups at 18.2%, 17.1%, and 17.4%, respectively, and lower in the open group (1.1%). Length of hospital stay and return to oral intake were similar among groups. CONCLUSION The flexible endoscopic technique was associated with the highest rate of procedure-related perforation, while the endoscopic stapler had the lowest number of procedural complications. Recurrence rates were higher among the harmonic stapler, flexible endoscopic, and endoscopic stapler groups and lower in the endoscopic laser and open groups. Prospective comparative studies with long-term follow-up are needed.
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Affiliation(s)
- Katherine P Wallerius
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew J Bowen
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas J O'Byrne
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Aisha A Aden
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lazaro R Peraza
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Katherine Z Xie
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bradley A Richards
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph El-Badaoui
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Semirra L Bayan
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Dale C Ekbom
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Sapundzhiev NR, Davidov G, Platikanov V, Stoyanov GS, Ignatov V. Anesthesia-related Safety Profile of a High-energy Ultrasonic Scalpel in Oropharyngeal and Laryngeal Surgery: An Ex Vivo Model. Cureus 2019; 11:e5266. [PMID: 31576259 PMCID: PMC6764607 DOI: 10.7759/cureus.5266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction The aim of this study was to evaluate the fire risks associated with a harmonic scalpel, with an established avian model simulating oropharyngeal/laryngeal surgery. Methods A standard polyvinyl-chloride (PVC) endotracheal tube (ETT) was inserted into a degutted, whole raw chicken through which 100% oxygen was piped at 10 L/min. The inflated cuff of the tube was grasped and sectioned with the jaws of a standard high-power ultrasonic dissection system Ultracision (Ethicon Endosurgery, Cincinnati, Ohio, USA). Then, the whole ETT was grasped and cut, leaving the device in contact with the ETT for two more minutes. In a second step under the same conditions, an electrosurgical device was placed into the chicken cavity and activated at the chicken tissue near the ETT at a setting of 20 W. All trials were repeated to ensure accuracy. Results No ignition could be produced with the harmonic scalpel under any operation mode settings. In all cases, the ETT was cut through with some fumes and brown discoloration at the site of contact. The electrosurgical device easily caused flash ignition within seconds. Conclusion The harmonic scalpel appears to be a safer tool than electrosurgical devices in the setting of open cavity surgery in oxygen-enriched environments with respect to the presence of flammable medical PVC devices as ETT or catheters.
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Affiliation(s)
| | - Georgi Davidov
- Otolaryngology, St. Marina University Hospital, Varna, BGR
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Ishaq S, Sultan H, Siau K, Kuwai T, Mulder CJ, Neumann H. New and emerging techniques for endoscopic treatment of Zenker's diverticulum: State-of-the-art review. Dig Endosc 2018; 30:449-460. [PMID: 29423955 DOI: 10.1111/den.13035] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 02/04/2018] [Indexed: 02/06/2023]
Abstract
Zenker's diverticulum (ZD), or pharyngeal pouch, is an anatomical defect characterized by herniation of the posterior pharyngeal wall through Killian's dehiscence, and may result in dysphagia and regurgitation. Multiple therapeutic modalities including surgery, rigid and flexible endoscopy have been developed to manage ZD. Although surgical management with open and endoscopically assisted techniques have historically been the mainstay of ZD treatment, minimally invasive flexible endoscopic techniques, carried out under conscious sedation, are increasingly favored. Over the last two decades, the advent of new accessories and techniques have changed the landscape of endotherapy for ZD, with the current armamentarium including, but not limited to, endoscopic stapling, CO2 laser, argon plasma coagulation, needle knife, bipolar forceps, hook knife, clutch cutter, stag beetle knife, and submucosal tunneling endoscopic septum division. We hereby review the latest evidence to support the endoscopic management of ZD.
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Affiliation(s)
- Sauid Ishaq
- Department of Gastroenterology, Russell Hall Hospital, Dudley, UK.,Birmingham City University, Birmingham, UK.,St George's University, Grenada, West Indies
| | - Haleema Sultan
- Department of Gastroenterology, Russell Hall Hospital, Dudley, UK
| | - Keith Siau
- Department of Gastroenterology, Russell Hall Hospital, Dudley, UK.,Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
| | - Toshio Kuwai
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure, Japan
| | - Chris J Mulder
- Department of Gastroenterology and Hepatology, VU Medical Center, Amsterdam, Netherlands
| | - Helmut Neumann
- Department of Interdisciplinary Endoscopy, University Hospital Mainz, Mainz, Germany
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Comparison of electrical current and ultrasonic device for incision of the septum of the pharyngoesophageal diverticulum in a pig model. Surg Endosc 2015; 29:3409-13. [PMID: 25669640 DOI: 10.1007/s00464-015-4090-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 01/16/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Complications of endoscopic treatment of pharyngoesophageal diverticulum (PED) such as bleeding and perforation occur in up to 15 % of cases. Our objective was to compare incision of the PED septum using the ultrasonic device (group H) with incision using electrical current (group M) in a pig model. METHODS Twenty domestic pigs were divided into groups H and M. The incision of the PED septum was performed using the ultrasonic device or using electrical current, respectively. The procedural time, complication rate, length of the border of the incised septum, and thermal tissue damage were compared between groups. RESULTS Mean time to divide the septum and total procedure time were significantly shorter in group H. Mean length of the border of the incised septum was significantly higher in group H. The lateral thermal spread caused by electrical current (group M) was more intense. Hemorrhage was exclusively observed in group M. CONCLUSION Experimental endoscopic diverticulotomy using ultrasonic device was faster and caused less tissue damage when compared to electrical current.
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Whited C, Lee WT, Scher R. Evaluation of endoscopic harmonic diverticulostomy. Laryngoscope 2012; 122:1297-300. [PMID: 22447228 DOI: 10.1002/lary.23251] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 01/07/2012] [Accepted: 01/30/2012] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS The purpose of this study is to review a consecutive series of patients with Zenker's diverticulum who were treated with endoscopic diverticulostomy using either the endoscopic stapler (ENDO GIA 30 Autosuture; Covidien, Dublin, Ireland) or Harmonic Ultrasonic Surgical Instrumentation (Ethicon Endo-Surgery, Cincinnati, OH) to evaluate the safety and optimal application of Harmonic technology to the treatment of patients with Zenker's diverticulum. STUDY DESIGN This is a retrospective review at a tertiary academic hospital with institutional review board approval. METHODS All patients undergoing endoscopic repair of Zenker's diverticulum between April 1, 2009 and December 1, 2010 at a single institution were studied. RESULTS A total of 65 endoscopic diverticulostomies were performed: 24 Harmonic assisted, 41 stapler assisted. Average diverticulum size was 3.46 cm. There were two complications with staple-assisted (pharyngeal leak and recurrence) and six complications with Harmonic-assisted diverticulostomies (two pharyngeal leaks, two chest pains, one recurrence, and one subcutaneous emphysema). There was a statistically significant difference in the complication rates between the staple-assisted (4.88%) and Harmonic-assisted (25%) cohorts (P = .04). There were no complications with diverticula <2 cm. CONCLUSIONS Endoscopic Harmonic esophagodiverticulostomy has been reported for the treatment of Zenker's diverticula. However, our data demonstrate a significantly higher complication rate with use of the Harmonic technology compared to the staple-assisted method (P = .04). Additional evaluations are warranted to validate these findings and before Harmonic diverticulostomy can be recommended as treatment for the majority of cases.
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Affiliation(s)
- Chad Whited
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Duke University Hospital, Durham, North Carolina 27707, USA
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