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Holland AM, Lorenz WR, Ricker AB, Mead BS, Scarola GT, Colavita PD. Cricopharyngomyotomy: Outcomes of flexible endoscopic management of small and medium sized Zenker's diverticulum. Am J Surg 2024:115823. [PMID: 38981838 DOI: 10.1016/j.amjsurg.2024.115823] [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: 04/12/2024] [Revised: 06/19/2024] [Accepted: 07/01/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Zenker's diverticulum (ZD) was historically treated with an open transcervical myotomy with diverticulectomy, but endoscopic approaches have gained popularity, though with little recent data. This study aimed to report flexible endoscopic cricopharyngomyotomy (FEC) outcomes, particularly in smaller diverticula. METHODS Patients with ZD treated with FEC at a tertiary center were reviewed. Patients were grouped by diverticulum size: small (sZD)≤1.5 cm; medium (mZD) > 1.5 cm. RESULTS Of 30 patients, median age, BMI, sex, and comorbidities were similar between sZD (n = 18) and mZD (n = 12). Overall, 80.0 % had the procedure performed with a needle knife. Median number of clips for mucosotomy closure (5.0[5.0,6.0]vs.7.0[5.0,7.0]clips;p = 0.051), operative time (59.5[51.0,75.0]vs.74.5[51.0,93.5]minutes;p = 0.498), length-of-stay (1.0[1.0,1.0]vs.1.0[1.0,1.0]days;p = 0.397), and follow-up (20.8[1.1,33.4]vs.15.6[5.4,50.4]months;p = 0.641) were comparable. There were no postoperative leaks; incomplete myotomy occurred in one sZD, yielding a clinical success rate of 96.7 %. CONCLUSIONS FEC has a high success rate for ZD and an advantage in small diverticula, difficult to treat with stapling or open technique.
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Affiliation(s)
- Alexis M Holland
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
| | - William R Lorenz
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
| | - Ansley B Ricker
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
| | - Brittany S Mead
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
| | - Gregory T Scarola
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
| | - Paul D Colavita
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, USA.
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Bencini L, Moraldi L, Bartolini I, Coratti A. Esophageal surgery in minimally invasive era. World J Gastrointest Surg 2016; 8:52-64. [PMID: 26843913 PMCID: PMC4724588 DOI: 10.4240/wjgs.v8.i1.52] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 09/18/2015] [Accepted: 12/08/2015] [Indexed: 02/06/2023] Open
Abstract
The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.
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Nielsen HUK, Trolle W, Rubek N, Homøe P. New technique using LigaSure for endoscopic mucomyotomy of Zenker's diverticulum: Diverticulotomy made easier. Laryngoscope 2014; 124:2039-42. [DOI: 10.1002/lary.24558] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 11/01/2013] [Accepted: 11/08/2013] [Indexed: 11/08/2022]
Affiliation(s)
- Hans Ulrik Kjaerem Nielsen
- Department of Otolaryngology-Head and Neck Surgery, Rigshospitalet; University Hospital of Copenhagen; Copenhagen Denmark
| | - Waldemar Trolle
- Department of Otolaryngology-Head and Neck Surgery, Rigshospitalet; University Hospital of Copenhagen; Copenhagen Denmark
| | - Niclas Rubek
- Department of Otolaryngology-Head and Neck Surgery, Rigshospitalet; University Hospital of Copenhagen; Copenhagen Denmark
| | - Preben Homøe
- Department of Otolaryngology-Head and Neck Surgery, Rigshospitalet; University Hospital of Copenhagen; Copenhagen Denmark
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Fama AF, Moore EJ, Kasperbauer JL. Harmonic scalpel in the treatment of Zenker's diverticulum. Laryngoscope 2009; 119:1265-9. [DOI: 10.1002/lary.20247] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Tang SJ, Tang L, Chen E, Myers LL. Flexible endoscopic Killian-Jamieson diverticulotomy and literature review (with video). Gastrointest Endosc 2008; 68:790-3. [PMID: 18402951 DOI: 10.1016/j.gie.2008.01.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2007] [Accepted: 01/01/2008] [Indexed: 12/10/2022]
Affiliation(s)
- Shou-jiang Tang
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9151, USA
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Flexible endoscopic clip-assisted Zenker's diverticulotomy: the first case series (with videos). Laryngoscope 2008; 118:1199-205. [PMID: 18401278 DOI: 10.1097/mlg.0b013e31816e2eee] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In treating Zenker's diverticulum (ZD), there are potential risks associated with performing flexible endoscopic diverticulotomy without suturing or stapling. We recently introduced flexible endoscopic clip-assisted diverticulotomy (ECD) in treating ZD by securing the septum prior to dissection. OBJECTIVE To evaluate the feasibility and safety of ECD for complete septum dissection. STUDY DESIGN Case series at an academic center. Seven consecutive patients (mean age 71 y; range 48-91 y) with symptomatic ZD of various craniocaudal sizes based on radiographic measurements (mean 2.6 cm; range 0.8 cm-4.5 cm) were included. The mean depth of the septum was 1.73 cm (range 0.3 cm-3.1 cm). The mean duration of symptoms was 4.8 years (range 0.5-10 y). METHODS After endoclips were placed on either side of the cricopharyngeal bar, the septum was dissected between these two clips down to the inferior end of the diverticulum with a needle-knife. Procedures including "one-step ECD" (n = 1), "stepwise ECD" (n = 3), and "bottom ECD" (n = 2) were performed based on the septum depth of the ZD during endoscopy. ECD was not performed on one patient due to severe mucosal fragility of the esophageal inlet. Iatrogenic blunt dissection of the septum by the endoscopic hood occurred secondary to patient retching during the procedure. Main outcome measurements were symptom resolution and complications. RESULTS All patients (n = 6) who underwent ECD had complete resolution of esophageal symptoms at a minimum 6-month follow-up. There were no procedural complications. The patient who did not undergo ECD developed an esophageal perforation. She was managed conservatively without surgical intervention. On follow-up, her dysphagia was completely resolved. CONCLUSIONS ECD is feasible, safe, and effective for complete septum dissection. ECD and endoscopic stapler-assisted diverticulotomy are complimentary rather than competing strategies in approaching ZD. Study limitations include the case series design and limited follow-up period.
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Tang SJ, Lara LF. Flexible endoscopic clip-assisted Zenker's diverticulotomy (with videos). Gastrointest Endosc 2008; 67:704-8. [PMID: 18308312 DOI: 10.1016/j.gie.2007.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2007] [Accepted: 11/06/2007] [Indexed: 12/10/2022]
Abstract
BACKGROUND In treating Zenker's diverticulum (ZD), there are potential risks associated with flexible endoscopic diverticulotomy without suturing or stapling. Rigid endoscopic stapler-assisted diverticulotomy has limitations. The septum is usually not completely dissected with either technique. OBJECTIVE Our purpose was to evaluate the feasibility of flexible endoscopic clip-assisted diverticulotomy (ECD) for complete septum dissection. DESIGN Case report. SETTING Academic center. PATIENT An elderly male with symptomatic residual ZD. INTERVENTIONS After 1 endoclip (InScope multiclip applier, Ethicon Endo-Surgery) was placed on each side of the cricopharyngeal bar, the septum was easily and completely dissected between these 2 clips down to the bottom of the diverticulum into the esophageal mucosa with a needle-knife. MAIN OUTCOME MEASUREMENT Symptom resolution and complications. RESULTS Complete esophageal symptom resolution without complications. LIMITATION Case report. CONCLUSIONS ECD is feasible, easy, safe, and effective for complete septum dissection. This is the first reported case of ECD. ECD provides another option in managing ZD with flexible endoscopy.
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Affiliation(s)
- Shou-jiang Tang
- Division of Digestive Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas 75390-8887, USA
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Abstract
INTRODUCTION Patients with Zenker's diverticulum often present with a hiatal hernia. Theoretically, the gastric acid fluid could rise up to the hypopharynx producing an injury to the mucosa of Killian's triangle and hypertrophy of the cricopharyngeal muscle. We performed dual-channel pH monitoring in healthy people as a control group and in patients with a Zenker's diverticulum to elucidate the relationship between Zenker's diverticulum and gastroesophageal reflux disease (GERD) as well as extraesophageal reflux (EER). METHODS Patients with Zenker's diverticulum underwent dual-channel 24-h pH monitoring to exclude the possibility of an EER or a GERD. The measurements were performed in 4 patients preoperatively and postoperatively as well as in 14 patients only postoperatively. The control group consisted of healthy volunteers who did not suffer from a reflux disease (n=20). In each group we determined the number of refluxes, the fraction time, the RAI (reflux area index), and the DeMeester Score Index. In addition we classified the severity of the EER with a grading system which was developed in an earlier study in our department. RESULTS Patients with a Zenker's diverticulum suffered significantly from EER (p<0.01). The difference between the patients measured preoperatively and the patients postoperatively was minor. More than 72% of the patients suffered from a severe EER. CONCLUSIONS Patients with a Zenker's diverticulum have a high possibility of suffering from EER and GERD. The pathophysiology of this relationship can only be speculated. In addition to a cricopharyngeal myotomy, long-term therapy with a PPI (proton pump inhibitor) seems indicated.
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Affiliation(s)
- C Morales-Divo
- Klinik für Hals-Nasen-Ohrenheilkunde, Johannes-Gutenberg-Universität, Mainz, Germany.
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Seaman DL, de la Mora Levy J, Gostout CJ, Rajan E, Herman L, Knipschield M. An animal training model for endoscopic treatment of Zenker's diverticulum. Gastrointest Endosc 2007; 65:1050-3. [PMID: 17531640 DOI: 10.1016/j.gie.2006.10.052] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Accepted: 10/23/2006] [Indexed: 12/10/2022]
Abstract
BACKGROUND Zenker's diverticulum (ZD) is an uncommon disease, which is typically treated surgically. The alternative to surgery is a diverticulotomy, performed endoscopically. Given the rarity of this condition, it is not possible to obtain training. There has been no animal model identified that resembles the disease in human beings. OBJECTIVE To present an animal model of ZD that resembles the disease in human beings. DESIGN We prospectively characterized the endoscopy, the radiography, and the histologic anatomy of the pharyngeal diverticulum in the pig. SETTINGS Domestic pigs scheduled for euthanasia underwent radiography and endoscopy and, after euthanasia, neck dissection of the pharyngeal diverticulum. INTERVENTIONS AND METHODS Thirteen consecutive animals were studied. Pictures were taken for the endoscopic view, as well as radiographies during barium swallow in 1 pig. The neck region was dissected, and the pharynx and the upper esophagus were extracted. The size of the diverticulum was measured, and the block was fixed in formalin. Fixed specimens were cut in the transverse and coronal axis, and pictures were taken. The septum between the diverticulum and the esophagus was reviewed microscopically. RESULTS The pharyngeal diverticulum measured an average of 2.7 cm (1.3-5 cm), depending on the size of the pig. From an endoscopic and radiologic perspective, the pig pharyngeal diverticulum is identical to a ZD. The septum contains muscle as well as fibrous tissue and fat. These anatomical characteristics closely resemble the anatomy in human beings. CONCLUSIONS We believe that we established an animal training model for the endoscopic treatment of ZD.
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Affiliation(s)
- Diahann L Seaman
- Developmental Endoscopy Unit, Mayo Clinic, Rochester, Minnesota 55905, USA
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Richtsmeier WJ. Myotomy length determinants in endoscopic staple-assisted esophagodiverticulostomy for small Zenker's diverticula. Ann Otol Rhinol Laryngol 2005; 114:341-6. [PMID: 15966519 DOI: 10.1177/000348940511400502] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A small Zenker's pouch is a major challenge for endoscopic staple-assisted esophagodiverticulostomy (ESED). This study tested the stapler dimensions so as to identify limitations they impose on ESED. Combining ESED with additional endoscopic suturing could extend the incision and consequently the myotomy. Zenker's diverticulum residual pouch measurements were performed with a previously reported latex glove model and in patients undergoing surgery. Two stapler designs were compared by measuring the residual pouch length for both the stock and modified staplers. One other stapler model cannot be modified without damaging the mechanism. The Endostitch was used to place an additional suture at the apex of the staple line, allowing cutting between the staples while leaving a closed distal incision. All three staplers suitable for ESED leave a residual pouch of 1.5 cm when unmodified. The modified anvil staplers gave a smaller residual pouch by 4 to 5 mm. An additional septal reduction can be accomplished by suturing the area distal to the staple line and incising the party wall beyond the stapler cut. The absolute amount of residual pouch with an additional myotomy is 3 mm. The combined staple-suture technique has proven relatively safe thus far. To provide a maximally efficient myotomy in a patient with a short pouch, the surgeon needs to be aware of the stapler differences. Modifications of the staplers may decrease the depth of the residual pouch, but may carry an added liability. A minimum residual pouch can be achieved with a combination of stapler and suture techniques, but is more technically demanding than the original ESED description.
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Affiliation(s)
- William J Richtsmeier
- Department of Otolaryngology-Head and Neck Surgery, Bassett Healthcare, Cooperstown, New York 13326, USA
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Abstract
Due to rising life expectancy of the population, the proportion of elderly patients requiring surgery is rising as well. Present aspects of selected, typical, nononcologic diseases of elderly people are discussed. The key to success in their treatment is not to consider primarily the patient's calendrical age but to assess the individual profile of risk factors on the basis of comorbidities. The kind, extent, and timing of an operation has to be based on this assessment. For the treatment of acute diseases (e.g., complicated ulcera, cholecystitis, appendicitis, mesenteric ischemia, and diverticulitis), a rapid and efficacious diagnostic algorithm is essential that takes into account the reduced functional reserve of old people. Constructive interdisciplinary cooperation and minimally invasive techniques play dominant roles in both diagnosis and therapy. Given these prerequisites, there is no reason to withhold surgical intervention from elderly patients.
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Affiliation(s)
- H-J Gassel
- Zentrum Operative Medizin, Chirurgische Klinik und Poliklinik, Universität Würzburg
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Abstract
Esophageal diverticula are classified by location-phrenoesophageal (Zenker's diverticulum-70%), thoracic and mediastinal (10%), and epiphrenic (20%). Almost all esophageal diverticula are acquired pulsion diverticula. The most common symptoms are dysphagia, regurgitation, thoracic pain, and pulmonary manifestations related to aspiration. Barium swallow and upper endoscopy will help to establish the diagnosis while esophageal manometry may reveal underlying dysmotility. Diverticula should not be treated unless they are symptomatic. The treatment of Zenker's diverticulum is surgical and consists of either diverticulectomy or diverticular suspension with a myotomy of the cricopharyngeus muscle via cervical approach. Transoral endoscopic stapled diverticulostomy is a new and simple approach which may become the treatment of choice, particularly in elderly and high-risk patients. Treatment of diverticula of the mid and low esophagus must take into account any motor anomalies or associated lesions. Diverticulectomy with esophageal myotomy and an anti-reflux procedure through a left thoracotomy is the standard approach, but endoscopic approaches seem feasible, particularly for epiphrenic diverticula, and may become the norm in years to come.
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Affiliation(s)
- N Carrère
- Service de Chirurgie Générale et Digestive, CHU Toulouse-Purpan - Toulouse
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