Long-Term Outcome of the Treatment of Zenker’s Diverticulum

C-reactive protein as an early marker of postoperative leakage in patients after endoscopic laser assisted Zenker's diverticulotomy

BACKGROUND AND AIM

Minimally invasive endoscopic techniques are the treatment of choice for Zenker's diverticulum (ZD). Our objective was to evaluate the results and efficacy of endoscopic and open approaches, to determine whether postoperative C-reactive protein (CRP) serum levels can be used as a marker to exclude the presence of esophageal leakage, and to identify risk factors for development of postoperative leakage and complications.

MATERIALS AND METHODS

Patients who underwent transcervical myotomy and diverticulotomy (TMD) or endoscopic cricopharyngeal myotomy (ECM) with CO₂ laser for ZD in years 2008-2021 at our department were included in this retrospective study.

RESULTS

Of the 101 patients enrolled, 83 patients underwent ECM and 18 TMD. The procedure time of the endoscopic technique was significantly shorter compared to that of transcervical method (p < 0.001). The median time to oral intake was 6 days for ECM and 10.5 days in the TMD group (p < 0.001). There was a 13% (n = 11) and 16.7% (n = 3) symptomatic recurrence rate and 3.6% (n = 3) and 16.7% (n = 3) major complications rate for ECM and TMD groups, respectively. The incidence of contrast leak (CL) evaluated by postoperative swallow study was 8.9% (9 from 83 patients in the ECM group only). In patients with CL, a significant increase in CRP levels on postoperative day (POD) 2 and 3 was detected when compared to patients without CL.

CONCLUSIONS

Endoscopic diverticulotomy with CO₂ laser represents a safe and efficient treatment of ZD. Elevation of postoperative CRP serum levels over 123.8 mg/L on POD2 and 98.8 mg/L on POD3 may indicate presence of an esophageal leakage.

Zenker Diverticulum: Does Size Correlate With Preoperative Symptoms?

Introduction Zenker diverticulum (ZD) usually affects adults after the 7th decade of life. Treatment for ZD is indicated for all symptomatic patients, but some patients prefer to defer surgical treatment until symptoms get worse and decrease their quality of life.

Objective To evaluate the association of the preoperative symptoms in ZD patients with the size of the ZD.

Methods A retrospective study design. Electronic medical records were used to identify patients diagnosed with ZD and treated over 11 years. Data collection included the chief complaints and symptoms, medical history, and findings on radiologic swallow evaluations of the patients. The diverticulum size was stratified into 3 groups: small (< 1 cm), moderate (1–3 cm), and large (> 3 cm).

Results A total of 165 patients were enrolled and stratified by diverticulum size (48 small, 67 medium, and 50 large). Dysphagia, cough, and regurgitation were the most prevalent symptoms. Dysphonia was more frequent among patients with a small pouch. Logistic regression analysis showed that dysphagia and choking were associated with large and medium diverticulum size (p < 0.05). Additionally, dysphonia was significantly associated with the presence of a small-sized ZD (p < 0.04).

Conclusion Upper gastrointestinal symptoms such as dysphagia and choking may be associated with a ZD > 1 cm and should always be evaluated. Additionally, the presence of dysphonia was found to be correlated with a ZD < 1 cm, suggesting that a prompt and appropriate fluoroscopic evaluation must be considered in those patients in whom no other clear cause of dysphonia is evident.

Cap-Assisted Endoscopic Septotomy of Zenker's Diverticulum: Early and Long-Term Outcomes

INTRODUCTION

Multiple therapeutic modalities including surgery and rigid and flexible endoscopy have been adopted to manage Zenker's diverticulum (ZD). Minimally invasive flexible endoscopic septotomy (FES) techniques have been increasingly favored over the past 20 years; however, long-term data are still scanty. The aim of this study is to evaluate early and long-term outcomes of FES for naive ZD in a single-center setting.

METHODS

From 2010 to 2017, ZD patients treated with FES were included in a prospectively maintained database (NCT03948438). Those who had already been treated surgically or endoscopically were excluded from the analysis. The Dakkak and Bennett dysphagia scale was used to rate the dysphagia. Persistent complete or near-complete resolution of symptoms (Dakkak and Bennett 0 or 1) was defined as clinical success. Postprocedural adverse events were reported according to ASGE lexicon.

RESULTS

Overall, 256 consecutive patients were treated. Mean pouch size was 29.8 ± 11.3 mm. The procedure was successfully completed in all scheduled patients, with an early clinical success of 96.1%. Adverse events occurred in 3.5% (9/256) of patients. Eight of them were mild/moderate with no fatal events, whereas one patient required surgery. Recurrences occurred in 31.3% (80/256) of treated patients after a mean time of 9 ± 3 months and 95% of recurrences were treated by a second FES. At an average follow-up of 5.5 years, 95.3% of patients were asymptomatic after a mean number of 1.3 procedures.

DISCUSSION

FES is a safe and effective treatment modality for patients with ZD. Recurrence rate is significant; however, endoscopic reintervention is associated with long-term relief of dysphagia.

Foregut Diverticula

Diverticular disease can present anywhere along the gastrointestinal (GI) tract. It can result from various pathologies such as abnormal contraction within the GI tract or inflammation causing scar tissue and the resulting forces surrounding the GI tract. Its clinical presentation can vary from asymptomatic to severe symptoms, with significant decrease in quality of life. The treatment for various diverticula along the GI tract can also vary, depending on the severity of symptoms. This article describes diverticular disease occurring within the foregut, with emphasis on pathophysiology, clinical presentation, and treatment.

Transoral endoscopic repair of Zenker diverticulum by a thoracic surgical service

OBJECTIVE

Zenker diverticulum (ZD), a pulsion diverticulum of the esophagus, has been traditionally managed with an open surgical approach, but endoscopic transoral stapling has been reported with increasing frequency. The objective of this study was to evaluate the results of endoscopic repair of ZD by a thoracic surgery service.

METHODS

We conducted a retrospective review of patients who underwent transoral stapling repair of ZD at our institution by the thoracic surgery service. We evaluated perioperative outcomes including dysphagia (1, no dysphagia to 5, unable to swallow saliva) and failure of repair requiring surgical intervention.

RESULTS

A total of 151 patients (median age, 78 years; 75 men, 76 women) underwent evaluation for endoscopic repair of ZD. Endoscopic stapled repair of the ZD was completed in 135. Sixteen patients underwent conversion to open repair. The perioperative mortality was 0.6% (1 patient). The median hospital stay was 2 days (range, 0-18 days). Complications occurred in 5 patients who underwent endoscopic repair. The mean preoperative dysphagia score was 2.8 and improved to 1.2 during follow-up (median, 16 months; P < .001). During further follow-up (median, 52 months), 8 patients (5.3%) had failure of the endoscopic repair requiring open surgery (n = 5) or redo transoral stapling (n = 3).

CONCLUSIONS

Endoscopic stapling repair of ZD can be performed safely with good results in experienced centers by thoracic surgeons with significant esophageal experience. Long-term follow-up is required to evaluate the durability of endoscopic repair of ZD.

30-Day Postoperative Outcomes Following Transcervical Zenker's Diverticulectomy in the Elderly: Analysis of the NSQIP Database

OBJECTIVE

To compare the effect of patient factors, including age, on 30-day postoperative outcomes and complications for patients undergoing transcervical Zenker's diverticulectomy.

STUDY DESIGN

Retrospective cross-sectional analysis.

SETTING

American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database.

METHODS

Patients who underwent open Zenker's diverticulectomy (Current Procedural Terminology code 43130) were queried via the NSQIP (2006-2018). Outcomes analyzed include patient demographics, medical comorbidities, admission type, operative characteristics, length of admission, postoperative complication, readmission, and reoperation.

RESULTS

A total of 614 patients were identified. Mean age at time of surgery was 71.1 years, with 13.4% older than 85 years. Outpatient procedures were performed in 29.8%. Postoperative complications occurred in 6.7%, with reoperation and readmission rates of 6.4% and 7.2%, respectively. A mortality rate of 0.3% was observed. Only smoking status (odds ratio, 2.94; P = .008) and history of congestive heart failure (odds ratio, 10.00; P = .014) were shown to have a significant effect on postoperative complications.

CONCLUSION

Smoking status confers a high risk for postoperative complication. Age was not an independent risk factor associated with adverse outcomes following open diverticulectomy, suggesting this procedure can be safely performed in patients with advanced age.

Interdisciplinary Comparison of Endoscopic Laser-Assisted Diverticulotomy vs. Transcervical Myotomy as a Treatment for Zenker's Diverticulum

BACKGROUND

Currently, there are different competing techniques for the treatment of Zenker's diverticulum (ZD). To improve patient selection, we compared endoscopic laser-assisted diverticulotomy (ELAD) with transcervical myotomy (TCM) with regard to possible risk factors for treatment failure.

METHODS

Data of ZD patients (n = 104) treated between 2004 and 2016 with either TCM (38%) or ELAD (62%) were analyzed retrospectively. Univariate and multivariate analyses were performed.

RESULTS

TCM is associated with a higher morbidity (27.8% vs. 10.2%; p = 0.095) but lower recurrence rate (7.3% vs. 19.3%; p = 0.095). Preoperative reflux disease (OR 8.755; p = 0.021) was identified as an independent risk factor for complications.

CONCLUSIONS

Although short-term outcome and symptom relief are similar, TCM tends to have a higher complication rate but better long-term results. Preoperative reflux disease is an independent risk factor for postoperative complications.

Is Myotomy Plus Diverticulopexy Suitable for Symptomatic Zenker's Diverticula?

The aim of the study was to prospectively evaluate the outcome of myotomy plus diverticulopexy over short and long-terms. A prospectively collected consecutive series (2007-2017) of 37 patients undergoing myotomy plus diverticulopexy was analyzed for clinical condition, operative information, peri-operative events, and follow-up by means of interview and physical examination. Diverticulopexy was scheduled regardless of the diverticulum's features and patient condition, other than operability. There was no choice or selection between possible treatment options. Patients were evaluated pre-operatively, at post-operative day 30 and after 1 year. Follow-up aimed at assessing the subjective condition following treatment. During the interview, patients were asked to self-assess their ability to swallow before and after surgery. No patient had peri-operative events, complications associated with the procedure, wound infection or impaired swallowing. All patients could start drinking the day after operation, could return to solid diet on post-operative day 2 and be discharged on post-operative days 3-4. Barium swallowing was not necessary before discharge. Full solid diet was resumed according to patient's compliance from post-operative day 2 (some patients refused solid diet soon after the operation even if asymptomatic). Follow-up ranged between 1 and 8 years. No patient was lost at follow-up. No disease recurrence was observed. Finally, no patient needed or sought for a clinical examination between the follow-up calls. Patients reported at least 50% improvement of symptomatology after 1 year. Diverticulopexy appears to be clinically safe, methodologically reproducible, and an effective procedure; it avoids suturing and offers good outcome results along with high patient satisfaction.

Cricopharyngeal function or dysfunction: what's the deal?

PURPOSE OF REVIEW

The purpose of the review is to examine current research focused on upper oesophageal sphincter (UES) and cricopharyngeus muscle function, and how better understanding UES physiology will translate to improved management.

RECENT FINDINGS

Although much is known about UES function, new information describing the dynamics of the UES and cricopharyngeus is being identified through manometry, combined fluoromanometry, and anatomic study. Response of the UES to injury, reflux, and surgical interventions is reported. Direct surgical treatment of cricopharyngeus noncompliance with or without diverticuli continues to show benefit and long-term results support a sustained improvement in three-quarters of patients.

SUMMARY

UES and cricopharyngeus function is complex and dynamic. It is affected by internal signals such as posture and constitution of refluxate, aging, and interventions particularly radiation and surgery. Clear understanding of the triggers and responses of the UES will enable clinicians to choose the correct therapy for their dysphagic patients.