Pharyngeal pouch endoscopic stapling--are post-operative barium swallow radiographs of any value?

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.

Assessing the Clinical Utility of the Early Postoperative Pharyngogram in Hypopharyngeal Surgery for Dysphagia

OBJECTIVES/HYPOTHESIS

To evaluate the clinical utility of postoperative contrast x-ray pharyngograms (XRP) for detecting pharyngoesophageal leaks following hypopharyngeal dysphagia surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

Medical records were reviewed of patients undergoing endoscopic (E-) or open (O-) Zenker's diverticulectomy (-ZD) with cricopharyngeal myotomy (-CPM) and CPM alone from 2008 to 2020 at one academic institution. Exclusion criteria were patients who were fed enterally or underwent repair of epiphrenic diverticula or O-CPM during laryngectomy. XRP clinical indication, impact on clinical care, and factors associated with use patterns were examined using descriptive statistics and logistic regression (LR).

RESULTS

Of 152 subjects, 52% underwent O-ZD, 30% O-CPM, 15% E-ZD, and 3% E-CPM. An XRP was ordered for 65% of subjects, mostly routinely (94%). Among the four clinically apparent leaks observed in this cohort, early postoperative XRP confirmed one. It did not identify any clinically silent leaks. In univariate LR, undergoing XRP was associated with increasing day of diet advancement (odds ratio [OR] 4.7, 95% confidence interval [CI] 2.5-10.5) and hospital stay duration (OR 3.2, 95% CI 2.1-5.2), as well as surgeon specialty of otolaryngology compared to general surgery (OR 12.8, 95% CI 4.8-40.8) and procedure sub-type (O-CPM: OR 0.03, 95% CI 0.002-0.16). In multivariate LR, the following variables were significantly associated with XRP use: hospital stay (OR 1.7; 95% CI 1.1-3.0), otolaryngology (OR 105; 95% CI 15.4-2193), O-CPM (OR 0.03; 95% CI 0.002-0.16), and E-CPM (OR 0.04, 95% CI 0.002-0.60).

CONCLUSIONS

Prospective, multi-institutional studies are needed to confirm the low clinical utility we observed of early, postoperative XRP following hypopharyngeal surgery for dysphagia.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Zenker's Diverticulum: Can Protocolised Measurements with Barium SWALLOW Predict Severity and Treatment Outcomes? The "Zen-Rad" Study

Although barium swallow imaging is established in the investigation of Zenker's diverticulum (ZD), no agreed measurement protocol exists. We developed a protocol for measuring ZD dimensions and aimed to correlate measurements with symptoms and post-operative outcomes. This prospective study included patients with confirmed ZD who underwent flexible endoscopic septal division (FESD) between 2014 and 2018. ZD was confirmed on barium radiology with measurements reviewed by two consultant radiologists. Symptom severity pre- and post-FESD was measured using the Dysphagia, Regurgitation, Complications (DRC) scale. Regression analyses were conducted to identify dimensions associated with therapeutic success, defined as remission (DRC score ≤ 1) 6 months after index FESD. In total, 67 patients (mean age 74.3) were included. Interobserver reliability (intraclass correlation coefficients-ICCs) was greatest for pouch width (0.981) and pouch depth (0.934), but not oesophageal depth (0.018). Male gender (60.9%) was associated with larger pouch height (P = 0.008) and width (P = 0.004). A positive correlation was identified between baseline DRC score and pouch depth (ρ 0.326, P = 0.011), particularly the regurgitation subset score (ρ 0.330, P = 0.020). The index pouch depth was associated with FESD procedure time (rho 0.358, P = 0.041). Therapeutic success was achieved in 64.2% and was associated with shorter pouch height (median 14.5 mm vs. 19.0 mm, P = 0.030), pouch width (median 19.9 mm vs. 28.8 mm, P = 0.34) and cricopharyngeal length (median 20.2 mm vs. 26.3 mm, P = 0.036). ZD dimensions may be feasible and were evaluated using Barium radiology. Specific parameters appear to correlate with severity and post-FESD outcomes, which aid with pre-procedural planning.

Zenker diverticulum: Experience in surgical treatment of large diverticula

The purpose of this retrospective study is to show that transcervical diverticulectomy (TD) in treatment of Zenker diverticulum (ZD) can still be a first choice procedure in selected patients and in experienced hands its safety might be compared to the minimally invasive endoscopic diverticulostomy.The study cohort consisted of 44 patients (18 male, 26 female) operated for (ZD). All the patients underwent open diverticulectomy. The decision to choose open surgical repair depended on surgical risk, age of the patient, size of the diverticular septum (the distance between the top of the diverticulum and its bottom on barium study), and patient's preference.Mean age of patients was 64.6 ± 11.9 years; range: 26 to 88 years. A total of 36.4% out of them finished 70 years. Postoperative mortality was nil. Two major complications (4.5%) requiring surgical intervention occurred: leak and hematoma.Data were analyzed by t test for independent samples using Statistica 12.5 software. P value <0.05 was considered statistically significant.Surgical treatment of patients with ZD should be individualized. Large Zenker diverticula with the septum longer than 6 cm should preferably be resected through an open approach because it is not possible to remove the septum completely during one-step endoscopic procedure and diverticulostomy creates a weak and large common cavity in the esophagus. Surgical repair is effective for all sizes of diverticula, but its most serious complications such as leakage or laryngeal nerve injury should be considered, especially in elderly patients with comorbidities. However, age alone should not be the main criterion if choosing the treatment option.

Correlation of Radiologic Findings and Clinical Outcome in Pharyngeal Pouch Stapling

Objectives:

We undertook to identify any correlation between radiologic findings and clinical outcome in pharyngeal pouch surgery.

Methods:

We performed a retrospective case control study in a teaching hospital in Dundee, Scotland. The subjects were 21 patients who underwent pharyngeal pouch stapling. We used a novel method to measure the characteristics of each pouch by focusing on a triangular area in the neck of the pouch.

Results:

A correlation was found between the radiologic preoperative findings and the clinical outcome. A short triangle was more likely to result in postoperative complications, whereas a long one was more likely to require revision surgery.

Conclusions:

It is possible to predict the surgical outcome from the radiologic characteristics of the diverticulum. We believe that our findings may have important clinical implications.

Endoscopic Stapling Diverticulotomy: An Audit of Difficulties, Outcome, and Patient Satisfaction

OBJECTIVE: To evaluate the procedure in terms of technical difficulties, patient satisfaction, symptom relief, recurrence, and further management.

STUDY DESIGN: Retrospective study including 41 patients who underwent endoscopic stapling diverticulotomy. Clinical notes were reviewed, and patients were sent a patient satisfaction questionnaire. Statistical analysis was done using the χ2 square test.

SETTING: Teaching hospital.

RESULTS: Larger pouches had the best results; 81.578% were satisfied with the surgery, and 86.84% had improved swallowing. Complications presented in 6 patients (15%), including a perforated pouch and an esophageal perforation. Complications were more frequent in small pouches.

CONCLUSIONS AND SIGNIFICANCE: Endoscopic stapling diverticulotomy offers rapid recovery in most patients, with early oral intake and short hospital stay. There is a high degree of symptoms relief, and the patient's satisfaction rate is high. The assessment of the pharyngeal pouch size is an important factor when deciding the best management for a patient with a pharyngeal pouch.

EBM rating: C-4

Prognostic variables for the clinical success of flexible endoscopic septotomy of Zenker's diverticulum

BACKGROUND AND AIMS

Flexible endoscopy septotomy for Zenker's diverticulum (ZD) is an alternative to endostapling; however, long-term data are sparse and studies are heterogeneous. The aim of this study was to assess the clinical success of flexible endoscopy diverticuloscope-assisted septotomy according to all ZD-related symptoms and to identify potential prognostic variables.

METHODS

A prospective database of all patients with ZD undergoing septotomy and followed up for 24 months or longer was analyzed. Septotomy was conducted by using a diverticuloscope-assisted technique. Dysphagia, regurgitation, and respiratory symptoms (during the day and at night) were scored by their weekly frequency from 0 to 3 when on a solid food diet. Clinical success (asymptomatic state) was defined as a maximum of 2 symptoms with a score of 1 (once per week). Prognostic variables of clinical success included age, sex, pretreatment total symptom score, pre- and posttreatment ZD size, and septotomy length. The Kaplan-Meier method and Cox proportional hazards model were used to calculate the crude and adjusted hazard ratio (HR).

RESULTS

Septotomy was attempted and achieved in a single session in 89 patients. Clinical success at the intention-to-treat analysis was 69%, 64%, and 46% at 6, 24, and 48 months, respectively. Adverse events occurred in 3 patients: perforation in 2 (2%) and postprocedural bleeding in 1 (1%). Independent variables for failure at 6 months were a septotomy length ≤25 mm (HR 6.34) and pretreatment ZD size ≥50 mm (HR 11.08), whereas at 48 months, they were septotomy length ≤25 (HR 2.20) and posttreatment ZD size ≥10 mm (HR 2.03). Success rates for ZD ranging in size from 30 mm to 49 mm with a septotomy >25 mm were 100% and 71% at 6 months and 48 months, respectively.

CONCLUSION

Flexible endoscopic septotomy for ZD is feasible and safe. Treatment success correlates with the length of the septotomy and the size of ZD, which should ultimately determine the appropriate approach.

Revision Zenker diverticulum: laser versus stapler outcomes following initial endoscopic failure

OBJECTIVES

We used a retrospective chart review to analyze revision endoscopic carbon dioxide (CO2) laser and staple repairs of recurrent Zenker diverticulum (ZD).

METHODS

The medical records of patients with recurrent ZD after primary endoscopic repair were selected. The chart data included method of repair (CO2 laser or stapler), demographics (age and sex), defect size (in centimeters), preoperative and postoperative symptoms, and complications. Patients' dysphagia was graded on a modified Functional Oral Intake Scale from 1 to 4 (1 being normal intake and 4 being severely limited intake or gastrostomy tube dependence). Regurgitation was also graded on a 1-to-4 scale (1 being no regurgitation and 4 being aspiration).

RESULTS

A total of 148 consecutive patients with ZD were treated with endoscopic repair between 2000 and 2010. Twelve of these patients had revisions after failed primary endoscopic management procedures, all done with the stapler. Eight revision surgeries were performed by CO2 laser, and 4 by stapler repair. No difference was noted in patient age or defect size (laser, 3.06-cm defects; stapler, 2.75-cm defects). The length of hospital stay and the time to oral intake for the patients who had a revision stapler procedure were significantly greater (p values of 0.029 and 0.009) than those for the patients in the primary stapler procedure group. Better postoperative regurgitation scores were noted for patients who had a CO2 laser procedure.

CONCLUSIONS

Secondary endoscopic repair for ZD recurrence is an effective treatment method. Better symptom outcomes were observed with secondary CO2 laser repair than with stapler revision. Patients with revision stapling had longer hospital stays and a longer time to oral intake than did patients with primary staple repairs.

Impact of endoscopic stapling of Zenker's diverticulum on patient health status as assessed by the Glasgow Benefit Inventory

OBJECTIVES

The aim of this study was to measure the effect of endoscopic stapling of Zenker's diverticulum on the health status of patients.

METHODS

We used the Glasgow Benefit Inventory (GBI) tool to ascertain patients' perceived experience.

RESULTS

The study demonstrated a positive health impact following endoscopic stapling of the Zenker's diverticulum. The mean total GBI score was +18.9 (95% confidence interval, +/- 11.2). The impact of endoscopic stapling was positive for all three subsets of the GBI. The GBI scores were comparable to those obtained after other common otorhinolaryngological procedures such as tonsillectomy, rhinoplasty, and middle ear surgery.

CONCLUSIONS

These data should improve our ability to counsel patients regarding important therapeutic decisions and expectations of surgical outcome.

Laser versus stapler: outcomes in endoscopic repair of Zenker diverticulum

OBJECTIVES/HYPOTHESIS

To analyze a single surgeon's experience with endoscopic CO(2) laser and stapler repair of Zenker diverticulum (ZD) by comparing dysphagia and regurgitation outcomes.

STUDY DESIGN

Retrospective chart review of 148 patient charts.

METHODS

Medical records of all patients receiving endoscopic repair of ZD with either CO(2) laser (61 patients) or stapler (67 patients) were reviewed. Additional data included demographics (age and sex), size (cm), preoperative and postoperative symptoms, need for revision, and complications. Symptoms of dysphagia were graded based on a modified Functional Oral Intake Scale 1 to 4 scale (1 = normal intake; 4 = severely limited/G-tube dependent). Regurgitation was also graded on a 1 to 4 scale (1 = no regurgitation; 4 = aspiration events).

RESULTS

We noted no difference in patient age or defect size (laser, 3.26 cm; stapler, 3.53 cm; P .135). Significant differences were noted in return trips to the operating room for failed procedures (laser, 0; stapler, 7; P = .009), length of stay (laser, 3.19 days; stapler, 1.29 days; P < .001), time to oral intake (laser, 3.01 days; stapler, 1.22 days; P < .001). Significant improvement occurred in laser and staple patient symptom scales following surgery (P < .001). Laser dysphagia and regurgitation scores showed greater improvement when compared to stapler scores (P < .001).

CONCLUSIONS

Endoscopic CO(2) laser and staple methods are effective in treating ZD. The laser can have greater efficacy and result in lower recurrence rates. Both methods are analyzed and compared.

Endoscopic carbon dioxide laser diverticulostomy versus endoscopic staple-assisted diverticulostomy to treat Zenker's diverticulum

BACKGROUND

The 2 most frequently used endoscopic methods to treat Zenker's diverticulum are staple-assisted and CO(2) laser esophagodiverticulostomy.

METHODS

The study centered around a retrospective evaluation of 107 patients with Zenker's diverticulum who were treated endoscopically by CO(2) laser (n = 72) or staple-assisted diverticulostomy (n = 35).

RESULTS

Patients in the staple-assisted group had a shorter duration of postoperative hospitalization, attributed to earlier oral intake, than patients in the CO(2) laser group. There were no serious postoperative complications in either group. Postoperative fever and emphysema in the neck or mediastinum occurred more frequently in the CO(2) laser group, but this did not lead to any complications. Most patients reported partial or complete relief of their symptoms and there was no significant difference in the number of reoperations between the 2 treatment groups.

CONCLUSIONS

Zenker's diverticulum was treated safely and effectively by the 2 endoscopic techniques, but the staple-assisted method seemed to be the most favorable.

Dysphagia After Endoscopic Repair of Zenker's Diverticulum

OBJECTIVES/HYPOTHESIS

To determine whether patient outcomes after endoscopic staple-assisted diverticulectomy(ESD) were correlated with demographic or disease-specific patient characteristics.

STUDY DESIGN

Retrospective chart review with followup.

METHODS

A survey was sent to all eligible subjects who had undergone ESD from February 1995 to June 2004 to gather information about their postoperative weight, diet, dysphagia symptoms, distress, and overall satisfaction.

RESULTS

Thirty-five individuals responded(49% response rate) at a mean of 29 (range,3-83) months postoperative. There was a significant reduction in the following symptoms: food avoidance,regurgitation, dysphagia for pills, choking, coughing,difficulty finishing a meal, heartburn/reflux, and halitosis. There was no significant difference for dysphonia.Swallow-related distress had decreased from a preoperative level of 7.86 to 2.23 at follow-up (P <.001). Overall satisfaction with the surgery was high. There were no significant differences in outcome by any demographic characteristic, duration of preoperative symptoms, presence of gastroesophageal reflux disease, Zenker's diverticulum size, time since surgery,or number of surgeries. Ninety-one percent of subjects reported improvement in their swallowing after surgery, but 22% reported some decline since that time. Symptomatic subjects reported significantly higher swallow-related distress and lower satisfaction(P < .01). Preoperative variables were not correlated with a return of symptoms. Individuals who underwent multiple procedures had similar levels of benefit and satisfaction as those who underwent a single ESD procedure.

CONCLUSION

ESD results in high levels of patient satisfaction, significant reduction in postoperative symptoms, low levels of complications,and the opportunity to safely and successfully repeat the procedure if necessary.

Evolution of surgical treatment for pharyngeal pouch

BACKGROUND

The development of endoscopic techniques, particularly endoscopic stapling, has led to a re-evaluation of the treatment of pharyngeal pouch. The pathophysiology and treatment of the condition is reviewed.

METHODS

An electronic literature search was undertaken on the pathophysiology, history and surgery of pharyngeal pouch (Zenker's diverticulum). These last two terms were used to the search the Cochrane, Medline and Embase databases (from 1966 to date) and the bibliographies of extracted articles.

RESULTS AND CONCLUSION

With recognition of the central role of the cricopharyngeus muscle in the pathogenesis of pouch formation, the emphasis on treatment has shifted from diverticulectomy to cricopharyngeal myotomy. Minimally invasive techniques have become established since the advent of endoscopic stapling devices. Although randomized controlled data are lacking, the endoscopic approach appears to offer advantages in terms of a shorter duration of anaesthesia, more rapid resumption of oral intake, shorter hospital stay and quicker recovery. It is associated with excellent success rates and minimal morbidity.

Carbon Dioxide Laser Endoscopic Diverticulotomy Versus Open Diverticulectomy for Zenker???s Diverticulum

OBJECTIVES/HYPOTHESIS

To compare open and CO2 laser-assisted endoscopic surgical management of Zenker's diverticulum.

STUDY DESIGN

A retrospective review of 49 consecutive surgically treated patients with Zenker's diverticulum was conducted.

METHODS

Patients' records were reviewed and analyzed for patient age and sex, size of diverticulum, incision time (time recorded from start of incision to surgical completion of case), length of hospital stay, complications, and follow-up management. A postoperative questionnaire inquiring about swallow function was conducted by mail or telephone. Swallow function was assessed on a four-point scale.

RESULTS

Various procedures performed included endoscopic CO2 laser-assisted diverticulotomy (n = 24) and open diverticulectomy with cricopharyngeal myotomy (n = 28). The average incision time of laser endoscopic cases (47 min) was significantly shorter (P <.001) than that of open diverticulectomy cases (170 min). Length of hospital stay did not significantly vary between the two groups. Five patients (21%) initially treated with laser endoscopic diverticulotomy demonstrated symptomatic persistent Zenker's diverticulum; three underwent repeat operation. No open cases required repeat operation. One endoscopic case was aborted secondary to esophageal injury from placement of the endoscope. Postoperative fever was seen in two (8%) endoscopic cases and four (14%) open approach cases. No major complications (recurrent laryngeal nerve paralysis, mediastinitis, or death) were encountered. More than 90% of respondents in each treatment group reported normal or near-normal swallow function.

CONCLUSION

Laser endoscopic management is a reasonable and safe method for surgical treatment of Zenker's diverticulum in comparison with the open technique. Employment of the endoscopic approach reduces operative time and the complexity of postoperative care. Practitioners should be aware that the endoscopic approach may result in a higher failure rate.

Endoscopic stapling for pharyngeal pouch: does it make the cut?

BACKGROUND

Endoscopic stapling to treat pharyngeal pouch is a relatively new technique with the potential to reduce the morbidity associated with the open approach for pharyngeal pouch. Despite enthusiasm for the endoscopic approach there have been no series reported in Australia, and descriptions of outcomes and benefits are currently anecdotal. The aim of the present study was to determine the outcome associated with endoscopic stapling of pharyngeal pouch in an Australian setting.

METHODS

All patients admitted for endoscopic stapling for a pharyngeal pouch between 1998 and 2002 by surgeons from the Adelaide and Flinders Universities were identified, and their medical records were reviewed for clinical and operative details. All patients were interviewed by telephone using a structured questionnaire to determine symptom resolution and patient satisfaction. The Likert scale was used to assess the impact of preoperative and postoperative symptoms upon quality of life.

RESULTS

A total of 31 patients were identified. The mean age of the group was 75 years (range: 35-91 years) and half the patients had an American Society of Anesthesiologists physical status score of 3 or greater. In four patients the procedure was abandoned; (for three because of inability to pass the diverticuloscope and for one because the pouch was too small). Standard open surgery was undertaken in these patients. Of the 27 procedures completed endoscopically, interview follow up was obtained in 23, at a mean follow up of 17 months (range: 2-68 months). Outcome was very good or excellent in 21 (91%), with significant symptom resolution, reduction in Likert scores and high patient satisfaction. Three patients had previously had pouch surgery and endoscopic stapling was straightforward in these patients. Recurrence of a symptomatic pouch occurred in three patients. There was no significant morbidity related to the procedure.

CONCLUSIONS

The early experience of endoscopic stapling for pharyngeal pouch in Adelaide is encouraging. The procedure achieves excellent control of symptoms and can be undertaken with minimal morbidity. Recurrence may be a problem, although repeat endoscopic stapling can be undertaken without difficulty.

Radiographic findings and complications after surgical or endoscopic repair of Zenker's diverticulum in 16 patients

OBJECTIVE

The purpose of our study was to reassess the radiographic findings and complications associated with surgical or endoscopic repair of Zenker's diverticulum.

MATERIALS AND METHODS

Sixteen patients who underwent various procedures for repair of Zenker's diverticulum (diverticulectomy and cricopharyngeal myotomy in [n = 8], diverticulopexy and cricopharyngeal myotomy [n = 4], endoscopic stapling diverticulotomy [n = 3], and cricopharyngeal myotomy alone [n = 1]) had radiographic studies with water-soluble contrast material, barium, or both during the early postoperative period (n = 7), late postoperative period (n = 4), or both (n = 5). The radiologic reports and images were reviewed to determine the postoperative findings and complications associated with surgical or endoscopic repair of Zenker's diverticulum.

RESULTS

Radiographic studies revealed leaks during the early postoperative period in three (27%) of 11 patients after surgical repair of Zenker's diverticulum and in zero of three patients after endoscopic diverticulotomy. Pharyngeal dysfunction (pharyngeal paresis, decreased epiglottic tilt, laryngeal penetration, or tracheobronchial aspiration) was detected in seven (54%) of 13 patients after surgery and in one (33%) of three patients after endoscopic diverticulotomy; five of these eight patients had follow-up barium studies during the late postoperative period, and all five showed marked improvement in pharyngeal function. An extrinsic cricopharyngeal impression was detected in six (38%) of these 16 patients, a remnant diverticulum in four (25%), and mucosal beaking in three (19%). A suspended or inverted diverticulum was detected in one of the four patients who underwent surgical diverticulopexy.

CONCLUSION

Radiologists should be aware of the various postoperative findings and complications associated with surgical or endoscopic repair of Zenker's diverticulum so that appropriate interventions can be taken in patients with this condition.

Pharyngeal pouch (Zenker's diverticulum)

Pharyngeal pouches occur most commonly in elderly patients (over 70 years) and typical symptoms include dysphagia, regurgitation, chronic cough, aspiration, and weight loss. The aetiology remains unknown but theories centre upon a structural or physiological abnormality of the cricopharyngeus. A diagnosis is easily established on barium studies. Treatment is surgical via an endoscopic or external cervical approach and should include a cricopharyngeal myotomy. Unfortunately pharyngeal pouch surgery has long been associated with significant morbidity, partly due to the surgery itself and also to the fact that the majority of patients are elderly and often have general medical problems. External approaches are associated with higher complication rates than endoscopic procedures. Recently, treatment by endoscopic stapling diverticulotomy has becoming increasingly popular as it has distinct advantages, although long term results are not yet available. The small risk of developing carcinoma within a pouch that is not excised remains a contentious issue and is an argument for long term follow up or treating the condition by external excision, particularly in younger patients.

Pharyngeal pouch carcinoma: real or imaginary risks?

Pharyngeal pouch or Zenker's diverticulum presents to the otolaryngologist with symptoms of dysphagia. As supported by the published literature, the condition is more frequently seen in Northern Europe, especially the United Kingdom, than elsewhere in the world. The cause of the reported increased incidence in the United Kingdom is not known, but may be dietary. Surgical management is the treatment of choice and is directed at the cricopharyngeus muscle by either an external or an internal approach. There is a real risk of carcinoma or carcinoma in situ developing in a treated or untreated pharyngeal pouch. Excision of the pouch sac is recommended in younger patients, less than 65 years, and in patients who have a large pouch. If endoscopic diverticulotomy is performed, then long-term patient symptom follow-up is to be advocated.