A new device to simplify flexible endoscopic treatment of Zenker's diverticulum

Flexible endoscopic treatment for Zenker's diverticulum: a systematic review and meta-analysis

BACKGROUND AND AIMS

Flexible endoscopic septum division (FESD) is a rapidly evolving technique for the treatment of Zenker's diverticulum (ZD). The aim was to perform a systematic review and meta-analysis of the literature focusing on FESD for ZD, including an in-depth evaluation of its efficacy, safety, and limitations.

METHODS

A comprehensive literature search was completed to identify papers that examined the efficacy and safety of FESD for ZD. Demographic, clinical, and technical information was retrieved. Main outcomes were extracted, pooled, and analyzed. Heterogeneity among studies was assessed using the I(2) statistic. A random effect model was used as the pooling method in cases of high heterogeneity; otherwise the fixed effect model was applied. Meta-regression was also performed. Main outcomes such as rates of success, adverse events, and recurrences were evaluated.

RESULTS

Twenty studies with a total of 813 patients were selected. The pooled success, adverse events, and recurrence rates were 91% (95% confidence interval [CI], 86%-95%; I(2) = 69.5%), 11.3% (95% CI, 8%-16%; I(2) = 64%), and 11% (95% CI, 8%-15%; I(2) = 38.4%), respectively. Substantial heterogeneity across studies was found. However, for success rates, excluding 3 studies reduced heterogeneity to non-significant rates [I(2) = 25.6%; P = .154]. Adverse event rates decreased with larger samples (coefficient, -0.0123; 95% CI, -0.03 to -0.003; P = .017), whereas recurrence rates increased (coefficient, 0.006; 95% CI, -0.0010 to 0.0125; P = .093). Year of publication was negatively associated with success rate, whereas the opposite pattern was found for recurrence rates.

CONCLUSIONS

FESD is a feasible, safe, and effective treatment for symptomatic ZD, with low adverse event and recurrence rates.

Flexible endosopic management of Zenker's diverticulum: characteristics and outcomes of 52 cases at a tertiary referral center

Zenker's diverticulum causes substantial morbidity among affected elderly patients. In the United States, rigid endoscopic cricopharyngeal myotomy is the mainstay of management and the flexible endoscopic technique is reserved for those not deemed candidates for rigid endoscopy due to an inability to extend the neck and/or medical comorbidities. Short- and long-term outcomes following flexible endoscopic cricopharyngeal myotomy in the United States are limited. We reviewed the patient characteristics and outcomes of 58 consecutive flexible endoscopic cricopharyngeal myotomies performed at Mayo Clinic, Rochester, between March 2006 and November 2013. There were 58 procedures performed on 52 unique patients. The median age was 77 years, and 48% of patients were female. More than one third of patients had either failed previous rigid therapy or were deemed inoperable by the referring surgeon. Size of the diverticulum ranged from 1 cm to 5 cm with a mean of 2.8 cm. Most procedures (67%) were performed under general anesthesia. Initial procedural success was achieved in all patients. Of the patients, 77% reported complete symptom resolution at mean follow-up time of 26 months. Of the procedures, 71% were not associated with any adverse event, but esophageal microperforation occurred during 11 procedures (19%). Of these, nine resolved with conservative management, one required an endoscopic stent, and one developed a neck abscess that required drainage. Our data show in a group of elderly patients with preexisting comorbidities flexible endoscopy therapy for Zenker's diverticulum is feasible. Initial symptomatic improvement was universal, and long-term response appears durable. The most common adverse event was esophageal microperforation, and the majority (82%) of these resolved with conservative management. Direct comparison with outcomes of rigid endoscopic or open surgical techniques has not been performed, but these data suggest that a randomized trial is warranted to assess the efficacy and safety of a flexible endoscopic technique.

Comparison of electrical current and ultrasonic device for incision of the septum of the pharyngoesophageal diverticulum in a pig model

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.

Flexible endoscopic management of Zenker diverticulum: the Mayo Clinic experience

OBJECTIVE

To describe the outcome of patients undergoing flexible endoscopic therapy for symptomatic Zenker diverticulum.

PATIENTS AND METHODS

We retrospectively evaluated the outcome of 22 consecutive patients who underwent flexible endoscopic cricopharyngeal myotomy using needle-knife electrocautery performed by a single endoscopist from March 2006 through January 2010.

RESULTS

Of the 22 patients with symptomatic Zenker diverticulum, 13 were men and 9 were women (median age, 84.5 years). Moderate sedation was used in all but 3 (14%) of the patients. Postprocedural free air occurred in 6 patients (27%) and resolved uneventfully in all. Another patient developed a neck abscess 1 week after endoscopic treatment, which was surgically drained. All procedures were performed on an outpatient basis, although 8 patients (36%) required subsequent hospitalization. The mean (SD) length of stay in the hospital was 2.9 (1.64) days. All patients had initial symptomatic improvement, and 18 (82%) maintained improvement at a mean (SD) follow-up of 12.7 (9.2) months.

CONCLUSION

Flexible endoscopic cricopharyngeal myotomy is an effective treatment of symptomatic Zenker diverticulum, with low recurrence rates and with the benefit of no general anesthesia and hospitalization in most cases. Esophageal perforation is the most common procedural complication.

Endoscopic Carbon Dioxide Laser Zenker's Diverticulotomy Revisited

Objectives:

We assessed the efficacy of endoscopic Zenker's diverticulotomy with the carbon dioxide (CO2) laser and Acuspot and compared it with the historical results of using a CO2 laser without Acuspot and electrocautery diverticulotomy.

Methods:

Between 1976 and 2005, a total of 229 endoscopic Zenker's diverticulotomies in 189 patients were performed in our institution. Since 1995, micro-endoscopic diverticulotomy with the CO2 laser and Acuspot (MEDCO2A) has been performed in 61 cases. Between 1984 and 1995, micro-endoscopic diverticulotomy with the CO2 laser (MEDCO2) was performed in 113 cases. Before 1984, endoscopic diverticulotomy with electrocautery (EDE) was performed in 55 cases. All patients had radiologically proven Zenker's diverticula. We recorded preoperative and postoperative complaints of dysphagia, the frequency of recurrence in long-term follow-up, postoperative tube feeding, non-oral intake, days of admission, and complications.

Results:

After operation, dysphagia was absent in 84.6% of MEDCO2A cases, 78.4% of MEDCO2 cases, and 72.0% of EDE cases. Repeat surgery was required in 13.0% of MEDCO2A cases, 19.6% of MEDCO2 cases, and 24.3% of EDE cases. Five patients developed mediastinitis (2 MEDCO2 cases and 3 EDE cases); none died as a consequence. In 1 patient, squamous cell carcinoma was found in the diverticulum.

Conclusions:

The technological improvement of the CO2 laser with Acuspot has further increased the efficacy of its use over that of methods previously used in our institution. The results and complications rate are comparable to those reported for endoscopic stapler diverticulotomy in the literature.