Endoscopic staple-assisted esophagodiverticulostomy for Zenker's diverticulum

Results of laser surgery in the treatment of Zenker's diverticulum

INTRODUCTION

Zenker's diverticulum is an uncommon pathology of the upper oesophageal sphincter whose most frequent symptoms are the association of dysphagia and regurgitation. It is more frequent in advanced ages, and its treatment of choice is surgery in symptomatic cases.

METHOD

A retrospective descriptive study was performed of 27 patients operated in the Otorhinolaryngology service of the Hospital Universitario de Cabueñes between 2007 and 2019 using laser endoscopic surgery.

RESULTS

27 patients were operated, 70.4% male and 29.6% female, with a mean age of 67 years (range between 30 and 91). The most frequent symptom at diagnosis was dysphagia. No intraoperative complications were observed. One patient (3.7%) presented post-surgical fever, and another patient (3.7%) had a serious complication due to oesophageal perforation secondary to postsurgical emesis. The median hospital stay was 5 days, and the median oral intake was 4 days. Recurrence was observed in 6 patients (22.2%), 4 (14.8%) requiring a second intervention, which was performed using the same technique.

DISCUSSION AND CONCLUSIONS

The surgical treatment of Zenker's diverticulum has advanced in recent decades, with endoscopic treatment currently being the choice. Among the surgical options, endoscopic CO2 laser surgery is an effective and safe alternative, although possible complications must be considered. It is also an effective alternative for the treatment of recurrences.

Results of laser surgery in the treatment of Zenker's diverticulum

INTRODUCTION

Zenker's diverticulum is an uncommon pathology of the upper oesophageal sphincter whose most frequent symptoms are the association of dysphagia and regurgitation. It is more frequent in advanced ages, and its treatment of choice is surgery in symptomatic cases.

METHOD

A retrospective descriptive study was performed of 27 patients operated in the Otorhinolaryngology service of the Hospital Universitario de Cabueñes between 2007 and 2019 using laser endoscopic surgery.

RESULTS

27 patients were operated, 70.4% male and 29.6% female, with a mean age of 67 years (range between 30 and 91). The most frequent symptom at diagnosis was dysphagia. No intraoperative complications were observed. One patient (3.7%) presented post-surgical fever, and another patient (3.7%) had a serious complication due to oesophageal perforation secondary to postsurgical emesis. The median hospital stay was 5 days, and the median oral intake was 4 days. Recurrence was observed in 6 patients (22.2%), 4 (14.8%) requiring a second intervention, which was performed using the same technique.

DISCUSSION AND CONCLUSIONS

The surgical treatment of Zenker's diverticulum has advanced in recent decades, with endoscopic treatment currently being the choice. Among the surgical options, endoscopic CO2 laser surgery is an effective and safe alternative, although possible complications must be considered. It is also an effective alternative for the treatment of recurrences.

Fiberoptic Endoscopic–Assisted Diverticulotomy: A Novel Technique for the Management of Zenker's Diverticulum

Endoscopic diverticulotomy is rapidly becoming the procedure of choice for treatment of Zenker's diverticulum. The endoscopic approach has resulted in significant decreases in patient morbidity, time to resumption of oral intake, and overall cost as compared with open treatment. However, a small but significant patient population is unable to accommodate the rigid laryngoscope and therefore requires open treatment. We present a novel technique, flexible fiberoptic endoscopic–assisted diverticulotomy, for the management of patients who are unable to undergo rigid endoscopy.

Pharyngeal pouch management: an historical review

BACKGROUND

Management of the pharyngeal pouch has evolved enormously since the first description by Ludlow in 1764 and the first case series by Zenker and Von Ziemssen in 1877. With the introduction of antibiotics, and the advancement of surgical technique with the advent of endoscopic surgery and lasers, current management is vastly different to that in the nineteenth century.

OBJECTIVES

This paper traces the history of pharyngeal pouch management, and discusses the various treatment options and opinions recorded during the nineteenth and twentieth centuries, comparing these with techniques popular today.

RESULTS AND CONCLUSION

Pharyngeal pouch surgery has been associated with significant morbidity, both because of the elderly age of patients typically affected by the condition and because of the surgery itself and potential post-operative complications encountered. The historical development of pharyngeal pouch management and the understanding of pharyngeal pouch pathophysiology are discussed.

Endoscopic staple diverticulostomy for Zenker's diverticulum: review of experience in 337 cases

OBJECTIVE

Surgical treatment of Zenker's diverticulum (ZD) has evolved over the previous 2 decades to a predominantly endoscopic approach. In this study, we review our experience with endoscopic staple-assisted diverticulostomy (ESD) for treatment of ZD from 2002 to 2011.

METHODS

Retrospective chart review of 359 primary and revision ESD procedures performed on 337 unique patients between September 2002 and December 2011. Data were tabulated for age, sex, size of diverticulum, time to symptom recurrence, complications, and relief of symptoms.

RESULTS

Of 337 attempted primary ESD procedures, 3.9% (N = 13) were aborted due to inadequate exposure. Of 324 patients who underwent primary ESD, 93.8% (N = 304) reported postoperative improvement of dysphagia symptoms. There was a 4.0% (N = 13) major complication rate. Patient-reported recurrence of symptoms occurred in 7.1% (N = 23) of primary ESD patients but was not significantly associated with diverticulum size (P = .9765). Twenty-one patients underwent revision ESD, with 95% (N = 20) of patients reporting improvement and 4.8% (N = 1) developing recurrent symptoms.

CONCLUSION

Primary and revision ESD were shown to have similar success at relieving the symptoms of ZD, with low procedure abandonment and perioperative complication rates. Further patient follow-up is needed to determine the durability of symptom improvement and ZD recurrence rate following ESD.

Comparison of Carbon Dioxide Laser—Assisted versus Stapler-Assisted Endoscopic Cricopharyngeal Myotomy

Objectives:

We directly compared endoscopic carbon dioxide (CO2) laser and stapler treatment methods for both cricopharyngeal hypertrophy (CPH) and Zenker's diverticulum (ZD).

Methods:

We performed a single-institution retrospective chart review of 153 patients who underwent either CO2 laser–assisted or stapler-assisted endoscopic cricopharyngeal myotomy (CPM).

Results:

Isolated CPH was more likely to be treated with the CO2 laser than by stapler techniques. The ZD pouch size decreased significantly after surgery in both laser (p = 0.04) and stapler (p = 0.008) groups. The average duration of the procedure for CPM was longer for the laser than for the stapler (p = 0.01). Both techniques were successful when used in revision procedures. The overall complication rates were not statistically significantly different. Laser surgery trended toward a higher rate of major complications (2.4% versus 0%). Symptomatic recurrence was more likely after stapler surgery (p = 0.002). The rates of revision surgery were similar in the two groups (3.3% for laser and 4.3% for stapler).

Conclusions:

In the treatment of isolated CPH or ZD, stapler-assisted endoscopic surgery results in a shorter operative time, whereas laser-assisted CPM results in a decreased incidence of symptomatic recurrence.

Role of the "rising tide sign" in the diagnosis and assessment of the results of surgery for Zenker's diverticulum

OBJECTIVE

To evaluate the role of the videoendoscopic "rising tide sign" (RTS) in the diagnosis and assessment of surgical repair of Zenker's diverticulum.

STUDY DESIGN

Retrospective.

SUBJECTS AND METHODS

A total of 148 patients with Zenker's diverticulum underwent surgery in our department. A videoendoscopic swallowing study (VESS) was performed pre- and postoperatively, and the two examinations compared for the presence of the RTS. VESS characteristics based on the time to RTS onset and the size of diverticulum, as seen on a barium swallow, were also compared in a subset of 38 patients.

RESULTS

All patients presented with the RTS on preoperative VESS. No correlation was observed between the time to onset of the sign and size of the diverticulum. Follow-up data were available for 121 patients (mean follow-up: 8 months): 111 patients were significantly improved during follow-up, with complete disappearance of the RTS. Recurrence of symptoms was observed at this time in 10 patients. Seven of these 10 patients had concomitant recurrence of the RTS and required repeat surgery after a mean follow-up of 37 months.

CONCLUSION

The RTS observed by videoendoscopy is a supplementary tool for the diagnosis of Zenker's diverticulum and for evaluation of the efficacy of surgery during the postoperative follow-up.

Flexible endoscopic and surgical management of Zenker's diverticulum

Zenker's diverticulum is an outpouching of the mucosa through the Killian's triangle. The etiology of Zenker's diverticulum is not well understood. It is thought to be due to the incoordination or incomplete relaxation of the cricopharyngeal muscle. Most patients are men who present with symptoms of dysphagia between the seventh and eighth decades of life. The diagnosis is made with a dynamic contrast swallowing study. Treatment options include open surgical diverticulectomy and diverticulopexy with myotomy or myotomy alone using flexible or rigid endoscopes. Rigid endoscopic treatment is currently the preferred initial choice for Zenker's diverticulum of any size. The flexible endoscopic technique is used when there is a high risk of general anesthesia, or neck extension is contraindicated. Some centers use flexible endoscopy as the initial treatment option. Due to a lack of prospective studies, the treatment choice should be tailored to the individual patient and local expertise.

Evaluation of endoscopic harmonic diverticulostomy

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.

Endoscopic repair of Zenker's diverticulum by harmonic scalpel

PURPOSE

Although endoscopic staple-assisted esophagodiverticulostomy (ESED) has become the initial treatment of choice for most patients with Zenker's diverticulum (ZD), anatomical restraints prevent its use in all cases. We describe an endoscopic approach for treating ZD using the harmonic scalpel, which can be used in certain cases where diverticulum anatomy precludes ESED.

MATERIALS AND METHODS

Medical records of 7 consecutive patients who underwent endoscopic repair of ZD using the harmonic scalpel (Harmonic Ace, Ethicon Endo-Surgery, Inc, Cincinnati, OH) were reviewed. Data collected included demographics, symptoms, surgical details, complications, and postoperative outcomes. Main outcome measures were time to resumption of oral diet, symptom resolution, and complications.

RESULTS

All patients (N = 7) who underwent endoscopic repair of ZD using the harmonic scalpel resumed an oral diet at initial follow-up visit after surgery (mean, 7 days; range, 4-9 days) and rated their symptoms as being completely resolved at subsequent follow-up (mean, 4 months; range, 1.5-8 months). There were no complications.

CONCLUSIONS

Endoscopic repair of ZD using the ultrasonic cutting shears is a safe and efficacious procedure that allows for endoscopic treatment in certain cases that cannot be treated by ESED. Further study is warranted in larger series to determine efficacy and safety compared with established endoscopic techniques.

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.

Staple-assisted endoscopic management of Zenker's diverticula: a role in the geriatric population

Endoscopic stapling technique (modified Dohlman procedure) for treatment of hypopharyngeal diverticula (Zenker) has been shown to produce outcomes similar to open techniques but with shorter operating times and shorter hospitalization.

Staged surgical management of hypopharyngeal traction diverticulum

A 50-year-old woman who had undergone cervical spine fixation 6 years earlier presented with dysphagia, regurgitation of undigested food, halitosis, and weight loss. Operative examination demonstrated a hypopharyngeal diverticulum with spinal hardware visible in a defect in the mucosa. She underwent an open cervical approach to removal of the hardware. Endoscopic staple diverticulotomy as described by Scher and Richtsmeier was performed 8 weeks later in the ambulatory surgical setting. After a period of enteral feeding via a nasogastric tube in the initial postoperative period, she was able to resume oral nutrition in the interim between the surgical procedures. After the second procedure, she was able to resume a normal diet immediately and she experienced minimal symptoms. It is established that traction diverticulum is appropriately treated by removing the inciting anatomic factor(s). We propose that staged surgical management begin with the removal of the nidus followed by marsupialization of the diverticulum pouch. Standard staple diverticulotomy is a viable option for the second stage. This technique allows the patient to minimize the length of, or avoid, the second hospitalization for diverticulum management.

Endoscopic management of Zenker's diverticulum: factors predictive of success or failure

OBJECTIVES

We review our experience with endoscopic management of Zenker's diverticulum. We sought to analyze and determine risk factors for success or failure of endoscopic diverticulum treatment.

METHODS

We performed a retrospective review of 72 consecutive patients who underwent attempted endoscopic management of a Zenker's diverticulum between January 2000 and April 2006. The procedures were performed by either of 2 otolaryngologists. There were 50 men and 22 women ranging in age from 44 to 93 years. A total of 85 procedures were performed. The medical records were reviewed for preoperative diverticulum size (small, 1 to 2 cm; moderate, 2.1 to 3.0 cm; and large, more than 3.0 cm), intraoperative diverticulum characteristics, patient anatomic limitations that prevented adequate endoscopic visualization, surgical complications, and management of recurrences.

RESULTS

Of our 72 patients, 61 (85%) were able to undergo endoscopic cricopharyngeal myotomy with diverticulum elimination. Of the 61 endoscopic procedures, 47 (77%) resulted in complete symptom resolution. The most common risk factors for recurrence were diverticulum size (more than 3 cm) and amount of redundant mucosa. Of the 14 patients with a recurrence, 10 (71%) underwent a repeat procedure. Six of the 14 (43%) had a successful excision via a cervical approach, and 4 of the 14 (29%) underwent a repeat endoscopic myotomy. There was 1 major complication (esophageal tear), and there were 3 minor complications (mucosal abrasions).

CONCLUSIONS

Most patients with a Zenker's diverticulum are good candidates for endoscopic management. In our series, 84% of those who underwent endoscopic treatment ultimately achieved relief of symptoms. The patient morbidity is minimal. A large diverticulum with redundant mucosa is a risk factor for recurrence after endoscopic treatment.

Microlaryngoscopic repair of iatrogenic pharyngeal pouch perforations: Treatment of choice?

BACKGROUND

Endoscopic stapled diverticulostomy (ESD) has become the preferred technique for managing pharyngeal pouches. Iatrogenic perforation, created during stapling, is a rare but serious complication with significant morbidity and mortality. The conventional management in these instances is to convert it to an external procedure and excise the pouch.

METHODS

Iatrogenic perforations were noticed after stapling in 3 cases in our series of 73 patients who underwent ESD. They were repaired using microlaryngoscopic techniques.

RESULTS

All patients had an unremarkable postoperative course.

CONCLUSIONS

Selected cases with iatrogenic perforations can be repaired primarily and observed with excellent outcome, obviating the need for an external pouch excision.

Endoscopic myotomy of the cricopharyngeal muscle with CO2 laser surgery

BACKGROUND

Cricopharyngeal dysfunction may lead to severe dysphagia and aspiration. Several treatment modalities are available, such as external myotomy of the muscle, dilatation, and local infiltration with botulinum toxin. Recently, endoscopic transmucosal myotomies using a CO2 laser have been described.

METHODS

Endoscopic cricopharyngeal myotomy using a CO2 laser was performed in 10 consecutive patients with dysphagia supposedly caused by cricopharyngeal muscle dysfunction without Zenker's diverticulum. All patients received prophylactic antibiotics and a feeding tube. Assessment was composed of clinical observation, a questionnaire, and a physical examination including flexible endoscopy and videofluoroscopy.

RESULTS

In all the patients, the procedure was feasible and without complications. Improvement of the complaints occurred in most patients. One patient had recurrent dysphagia and required a second endoscopic procedure.

CONCLUSIONS

Endoscopic laser surgery seems to be a safe and effective technique to treat cricopharyngeal dysfunction.

Pharyngeal pouch: associations and complications

The aetiopathogenesis of pharyngeal pouch remains obscure. This review highlights the associations and complications of pharyngeal pouch to better understand the pathogenesis and management of the pouch. A search of the MEDLINE was conducted to identify studies that looked at associations and/or complications of the pharyngeal pouch. The Medical Subject Headings (MeSH) included Zenker's diverticulum and hypopharyngeal diverticulum. A total of 64 papers were included for the analysis. They consisted mainly of single case reports, case series and review articles and one case control study. A summary of evidence from the literature is discussed. This review shows the various associations and complications that can occur with pharyngeal pouches. It is important to be aware that pharyngeal pouch can co-exist with other pathologies and treatment needs to be altered to incorporate the treatment of the associated pathology too. Surgeons should also be aware of the complications that can occur within and outside the pouch.

Myotomy length determinants in endoscopic staple-assisted esophagodiverticulostomy for small Zenker's diverticula

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.

[Zenker's diverticulum. The endoscopic-microscopic, staple-assisted esophagodiverticulostomy]

BACKGROUND

The endoscopic-microscopic staple-assisted esophagodivertikulostomy of Zenker's diverticulum is a new modification of endoscopic operation techniques which minimizes complications and is able to speed up the patient's convalescence.

PATIENTS AND METHODS

A total of 22 out of 32 patients with Zenker's diverticulum underwent surgery. The operation involves cutting the wall between the diverticular sac and the oesophagus and, at the same time, closing the mucosal wound edges using the "closed" surgery method.

RESULTS

All operations were effective and uncomplicated. A total of 28 operations were performed on 22 patients. The operations due to relapse were predominantly necessary among younger patients, of whom three were operated endoscopically and three through the cricopharyngeal myotomy.

CONCLUSIONS

The "closed" endoscopic-microscopic staple-assisted esophagodivertikulostomy of Zenker's diverticulum avoids opening the retropharyngeal and retrooesophageal areas and allows a quick convalescence in the mostly elderly patients. This technique is effective, safe and has no major complications.

Outpatient endoscopic Zenker diverticulotomy

OBJECTIVES/HYPOTHESIS

Staple-assisted, endoscopic Zenker diverticulotomy has been shown to decrease both cost of treatment and length of convalescence when compared with the standard open approach. Although the endoscopic technique is generally considered to be safe, the feasibility of outpatient endoscopic Zenker diverticulotomy has never been reported.

STUDY DESIGN

Retrospective cohort study.

METHODS

All endoscopic Zenker diverticulotomy procedures performed at Oregon Health and Science University (Portland, OR) between 1998 and 2002 were reviewed. The study group was limited to patients whose surgeries were planned on an outpatient basis. Medical charts were reviewed for indications, demographics, operative findings, complications, and resolution of symptoms.

RESULTS

Of the 51 patients who underwent endoscopic, staple-assisted Zenker diverticulotomy, 40 were treated with the intent of outpatient management. Thirty-two cases were primary surgeries, and eight cases were revision treatments. The average patient age was 68 years (age range, 35-91 y), and the mean follow-up period was 5.9 months (range, 1-37 mo). Eight (20%) complications were noted in the study group. Intraoperative complications included 3 patients (7.5%) with mucosal disruptions. These patients underwent uneventful suture repair of small hypopharyngeal mucosal tears encountered intraoperatively and were temporarily observed in the hospital. One patient was admitted for postoperative urinary retention and another for fever and tachycardia 48 hours after surgery. One patient sustained a myocardial infarction. The remainder of patients were fed immediately and discharged home on the day of surgery. Two patients (5%) had iatrogenic tooth fracture.

CONCLUSION

Appropriately selected patients undergoing endoscopic, staple-assisted Zenker diverticulotomy can be managed safely on an outpatient basis. Intraoperative complications, such as a mucosal disruption, warrant conversion to inpatient monitoring.

Endoscopic management of Zenker diverticulum: the staple-assisted approach

Hypopharyngeal (Zenker) diverticulum is a physiologic obstruction of the esophageal entroitus due, at least in part, to reflux irritation. Endoscopic techniques have largely replaced the traditional treatment, comprising external excision and myotomy. In this article, the classic Dohlman technique is compared with the newer endoscopic staple-assisted esophagodiverticulostomy, which provides an endoscopic approach to Zenker diverticulum-associated dysphasia. This technique can be practiced with a simulator, requires little experience, has a good safety record, and has acceptable results.

Cricopharyngeal spasm and Zenker's diverticulum

Cricopharyngeal spasm and Zenker's diverticulum represent disorders of the pharyngoesophageal junction for which a unifying theory of etiology has yet to be established. There is, however, a large body of evidence that supports an association with gastroesophageal reflux. Cricopharyngeal myotomy is the key to successful management of both disorders. Newer transoral endoscopic techniques of management have a lower overall morbidity than traditional open approaches in appropriately selected patients and are therefore gaining popularity as the preferred method of treatment.

Pathogenesis and methods of treatment of Zenker's diverticulum

In the literature, various theories concerning the cause of Zenker's diverticulum have been propounded. I believe that an anatomic predisposition plays a prominent role in the pathogenesis. This conclusion will be discussed in light of a study of the literature and characteristics of a series of 646 patients with Zenker's diverticulum. The current methods of treatment by an external surgical approach, as well as the (micro)endoscopic procedures, are described.

Endoscopic staple diverticulostomy for Zenker's diverticulum: review of literature and experience in 159 consecutive cases

OBJECTIVES/HYPOTHESIS

Several reports since the early 1990s have advocated a minimally invasive technique, endoscopic staple diverticulostomy (ESD), to treat Zenker's diverticulum. However, long-term results and comparisons with the reported experience with external or other endoscopic approaches have been lacking in the literature. We present follow-up on our experience with ESD since 1995 and compare it with the results obtained by other endoscopic or external techniques for treatment of Zenker's diverticulum.

STUDY DESIGN

Retrospective review of 159 consecutive ESD procedures performed on 150 unique patients with Zenker's diverticulum between March 1995 and August 2002. Telephone interviews of patients were conducted to assess long-term treatment outcome. Review of the literature was performed by Ovid MEDLINE search for all reports on the surgical treatment of Zenker's diverticulum in the English language between January 1990 and August 2002.

METHODS

Data were retrospectively reviewed and information was tabulated for age, sex, size of diverticulum, symptoms, duration of symptoms, operative time, length of hospital stay, time before oral intake, complications, and relief of symptoms at first postoperative visit. Follow-up interviews of patients were conducted to assess current status of symptoms and, if any symptoms returned, how many months after the procedure they recurred. All case series in the literature in the English language since 1990 that were found in the Ovid MEDLINE database and referenced from identified articles were also tabulated for the same information.

RESULTS

At the time of initial follow-up after ESD, 98% of patients reported complete or improved symptoms. Average hospital stay was 0.76 days, with a diet started on postoperative day 0.25. There was a 2.0% significant complication rate without mortality. Further follow-up (average, 32.2 mo) identified a recurrence rate of 11.8%. On review of the literature, patients who underwent ESD had shorter perioperative courses, quicker return to diet, and lower complication and mortality rates compared with external procedures. ESD had comparable operative times and mortality rates, but fewer complications and more rapid convalescent times compared with other endoscopic procedures. Recurrence rates were found to be variable.

CONCLUSIONS

Overall, ESD is an outpatient procedure with few complications. The technique has a faster operative and convalescence period with fewer complication rates compared with other endoscopic or external transcervical approaches. The results in the present study and those reported in the English language literature advocate that ESD be the initial preferred treatment for Zenker's diverticulum.

Endoscopic staple diverticulostomy for recurrent Zenker's diverticulum

OBJECTIVES

The purpose of this study was to evaluate the technical feasibility, effectiveness, and morbidity of using endoscopic staple diverticulostomy (ESD) as treatment for Zenker's diverticulum (ZD) recurring after either prior endoscopic treatment or external diverticulectomy or diverticulopexy.

STUDY DESIGN

A retrospective review of a case series of 18 patients with recurrent ZD.

METHODS

All patients cared for with ZD were evaluated to identify those patients with recurrent ZD. The clinical records of patients with recurrent ZD were reviewed for: demographics, prior treatment, time to recurrence, factors associated with recurrence, technical feasibility of treatment, complications, effectiveness and duration of symptom relief.

RESULTS

Between March 1995 and July 2001, a total of 127 consecutive patients with ZD received care. Eighteen of these patients were treated for recurrent ZD: nine treated originally by ESD, and nine by external approach (seven by diverticulectomy and two by diverticulopexy), with three of these patients treated twice. Seventeen patients had partial or complete relief of symptoms after their initial treatment, with recurrence of symptoms noted 0 to 60 months later. Specific factors associated with recurrence of symptoms were identified in only one patient. Treatment of recurrent ZD by ESD was technically feasible in 16 of the patients. Complete or improved symptom relief has been reported by 16 of the patients after revision ESD, with follow-up from 9 to 69 months. No significant treatment complications occurred. Fifteen patients resumed clear liquid diet on the day of surgery, and one on the day after surgery. All patients were discharged from the hospital by the second postoperative day (mean = 0.6 d).

CONCLUSIONS

ESD is an effective, technically feasible, and safe treatment for patients with ZD recurring after prior endoscopic or external treatment, and it should be the initial treatment of choice for these patients.

Simulated Zenker's endoscopic staple-assisted esophagodiverticulostomy (ESED) surgery

PURPOSE

The process of learning new surgical procedures remains a challenge in otolaryngology-head and neck (OHN) surgery. Endoscopic surgery for Zenker's diverticulum presents a dilemma mandating simulated surgery because there is no animal model or cadaver situation resembling the pathologic condition.

STUDY DESIGN

The author has developed an inexpensive model for ESED using a utility latex glove to provide a simulated pharynx with a Zenker's diverticula.

METHODS

First, the thumb and index finger are isolated with a staple line and a rubber band is placed around the long and ring fingers to simulate the cricopharyngeus muscle. The long finger, which will act as the larynx, is cannulated with a noncompressible endotracheal tube. The ring finger then simulates the esophagus and the little finger, the Zenker's diverticular pouch. The glove and the endotracheal tube are positioned inside a 1-ft length of 3-in polyvinyl chloride (PVC) pipe. A bivalving laryngoscope is suspended to visualize the "postcricoid area" and the parting wall. The rubber band pulls the inferior aspect of the "esophagus" up against the "larynx," simulating the tight cricopharyngeal segment. Using video-telescopic control, the endoscopic stapler is used in the standard fashion as described for ESED.

RESULTS

This model provides an opportunity for OHN surgeons to become familiar with endoscopic stapling and suturing devices, and experience the difficulty of using long telescopes, suspension laryngoscopes, and staplers in a confined area.

CONCLUSION

Part of the experience of endoscopic surgery of the pharynx can be gained through an inexpensive simulation of a Zenker's diverticulum.

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.

Feasibility and outcome of endoscopic staple-assisted esophagodiverticulostomy for Zenker's diverticulum

OBJECTIVES/HYPOTHESIS

Endoscopic staple-assisted esophagodiverticulostomy (ESED) is a newly described method of surgically correcting Zenker's diverticulum. Initial reports on the ease and success of the surgery have been quite enthusiastic, making it seem the procedure of choice. We initiated the procedure in an algorithm of treatment of Zenker's diverticulum, to further explore the feasibility and outcome of this new technique.

STUDY DESIGN

This is a case series of 23 patients with Zenker's diverticulum who have undergone surgical repair. For each patient, an attempt at ESED was made. If unsuccessful, an open approach was then taken.

RESULTS

Seven of 23 patients (30%) were unable to be treated with ESED because of inability to expose the diverticulum or unfavorable anatomy of the diverticulum itself. Of the remaining 16 patients, ESED was successful in resolving the symptoms of diverticulum in 14 (87%). Two patients (13%) were somewhat improved but had persistent dysphagia. No significant complications occurred. All patients resumed oral diet within the first 24 hours after surgery.

CONCLUSION

Esophagodiverticulostomy is an excellent method of surgically correcting Zenker's diverticulum in many patients, but anatomical considerations may prevent its use, making open approaches of continued importance in a surgeon's armamentarium.

Zenker's diverticulostomy with cricopharyngeal myotomy: the endoscopic approach

BACKGROUND

The gold standard for the surgical treatment of Zenker's diverticulum is diverticulectomy and cricopharyngeal myotomy by an external approach. Unfortunately, many of the patients who present with this entity are elderly and have significant comorbidities that increase operative risk. Traditional minimally invasive approaches have not met with widespread success. However, by combining the exposure afforded by the otolaryngologist's newer bivalved operating laryngoscopes with the operative techniques made possible by the general surgeon's laparoscopic instrumentation and staplers, it is possible to achieve reliable and safe endoscopic outpatient management of this disease entity, with resumption of a normal diet on the same day.

METHODS

We reviewed the physiologic basis, instrumentation, and technical considerations for this endoscopic procedure. We also documented our operative experience with 21 patients treated over an 18-month period.

RESULTS

Successful minimally invasive management of Zenker's diverticulum was possible in 18 of 21 patients. In two patients, anatomic limitations of mouth and neck anatomy precluded exposure of the diverticulum; in another patient, the diverticulum was too small. Small operative perforations of the apex of the diverticulum occurred in three cases. Two of these perforations were repaired primarily with minimally invasive techniques; in the other case, treatment consisted of observation alone. In all but this last patient, oral diet was resumed on the day of the operation. Eleven of the patients were discharged from the hospital on the same day; the remaining patients went home the following morning.

CONCLUSIONS

With proper patient selection, minimally invasive management of Zenker's diverticulum is a safe and effective surgical technique that allows for outpatient management of the majority of patients who present with this disease.

Endoscopic staple-assisted esophagodiverticulostomy: an excellent treatment of choice for Zenker's diverticulum

OBJECTIVES

The objectives of the present study are to review the technique of endoscopic staple-assisted esophagodiverticulostomy (ESED) for the treatment of Zenker's diverticulum and to describe our experience and modifications with ESED and the advantages of ESED over previous treatments of Zenker's diverticulum.

STUDY DESIGN

Retrospective review of 74 cases of ESED performed for the treatment of Zenker's diverticulum.

METHODS

Patient's records were retrospectively reviewed and tabulated for age, sex, size of diverticulum, symptoms, duration of symptoms, operative time, length of postoperative hospital stay, oral intake, complications, and relief of symptoms.

RESULTS

The senior author (R.L.S) previously reported results in 36 cases of ESED performed in 34 patients with Zenker's diverticulum. We have performed an additional 38 cases of ESED in 37 patients between March 1997 and August 1999. The rate of success of ESED was similar between the two series The average perioperative time, time until oral intake, and length of postoperative hospital stay decreased in the second series. Overall, there were no mortalities and few complications with ESED. Compared with other forms of treatment of Zenker's diverticulum, such as Dohlman's procedure, diverticulectomy, and diverticulopexy, ESED has a similar rate of success, decreased perioperative time, decreased convalescence, and decreased mortality and complications.

CONCLUSIONS

Cost-effectiveness, safety, and efficacy of ESED offer new advantages over previously used treatments for Zenker's diverticulum. These results continue to support the use of ESED as the initial treatment of choice for patients with Zenker's diverticulum.

Endoscopic stapled diverticulotomy: treatment of choice for Zenker's diverticulum

OBJECTIVE

To evaluate the efficacy and safety of endoscopic stapled diverticulotomy in the treatment of patients with Zenker's diverticulum.

STUDY DESIGN

Cohort study.

METHODS

Fourteen elderly patients (11 men and 3 women) with Zenker's diverticulum were evaluated in a community hospital setting from July 1996 to November 1999. Before surgery patients had significant dysphagia, regurgitation, cough, or aspiration pneumonia. The common septum between the diverticulum and cervical esophagus was visualized with a Weerda diverticuloscope. While using videoendoscopic monitoring, the septum was divided and the edges simultaneously sealed with a linear endoscopic stapler. Average operative time was 31 minutes.

RESULTS

The operation was successfully performed in 11 of 14 patients. In the three unsuccessful cases, one patient's pouch was too small to staple and the other two patients had a septum that was difficult to visualize with the diverticuloscope. There was no significant postoperative morbidity or mortality. Patients started a liquid diet on the first postoperative day and resumed a soft diet a week later. They were usually discharged on the first postoperative day. Most patients reported significant improvement with resolution of dysphagia and regurgitation.

CONCLUSIONS

Compared with the traditional open technique, the endoscopic stapled diverticulotomy technique is safe, quick, and effective and requires a shorter length of stay in the hospital. Therefore it has become our treatment of choice for elderly, high-risk patients with a large (>2 cm) hypopharyngeal (Zenker's) diverticulum.

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.

The treatment of Zenker's diverticula: a review

A historical review reveals that the treatment of Zenker's diverticula has paralleled its presumed pathophysiology. With the development of technical facilities to better evaluate the pharyngoesophageal region, incomplete relaxation of the upper esophageal sphincter (UES) seems to represent the key element in the development of high pharyngeal pressures with a subsequent outpouching responsible for the diverticulum formation. Many studies have justified myotomy as an essential component in the treatment of pharyngoesophageal diverticula because it represents an efficient therapy with little morbidity. A diverticulopexy should be added for pouches between 1 and 4 cm and a diverticulectomy should be performed for sacs greater than 5 cm to expect the best relief of symptoms. Other treatment modalities have recently been used such as the endoscopic division of the common wall between the cervical esophagus and the diverticulum with either electrocautery (Dohlman's procedure), a laser, or a stapling device. This method is gaining popularity because it achieves a good clinical outcome, especially in high-risk patients. However, more studies are needed to confirm its long-term effectiveness.

Endoscopic diverticulotomy for the treatment of Zenker's diverticulum: results in 102 patients with staple-assisted endoscopy

Endoscopic diverticulotomy for the treatment of Zenker's diverticulum has been reported infrequently in the literature and has engendered considerable controversy. Between March 1992 and September 1996, we attempted to treat 102 patients with endoscopic treatment for pharyngoesophageal diverticula. In 98 patients, the endoscopic surgery was successfully completed. Conversion to open surgery was required in 4 patients (3.92%). One cartridge of staples in 16 patients (16.32%), 2 cartridges in 78 patients (79.59%), and 3 cartridges in 4 patients (4.08%) were used, according to the size of the diverticulum; the median duration of the procedure was 20 minutes (10 to 60 minutes). No postoperative morbidity or mortality was recorded. Oral feeding was started following radiologic control after a median of 2 days; the median hospital stay was 4 days. The median follow-up is 16 months (1 to 45 months). Four patients operated on before the introduction of the modified stapler showed a persistent diverticular pouch: 3 underwent repeat endoscopic operation, and 1 underwent conventional open surgery. All treated patients are asymptomatic. Manometric study performed in 15 patients showed a significant reduction of basal upper esophageal sphincter pressure compared to preoperative data (48.30+/-21.74 versus 29.38+/-5.68 mm Hg; p<.01). We therefore recommend endoscopic diverticulotomy, considering that the procedure is relatively safe and effective, with minimal patient discomfort, and the results are equal to those of the external approach. This procedure offers the advantages of short hospitalization, rapid convalescence, brief operative time, absence of skin incision. predictable resolution of symptoms, and reduced morbidity.

Endoscopic management of lateral pharyngeal pouch

A patient with dysphagia including symptoms of regurgitation of food and worsening pulmonary symptoms was found to have a lateral pharyngeal pouch. The diagnosis was made by barium swallow study and confirmed by endoscopy. The characteristic barium swallow findings include retention of barium in a sac or diverticulum. Endoscopy showed a pouch in the left lateral pharynx, adjacent to the vallecula. Surgical therapy consisting of endoscopic stapling of the mucosal band separating the pouch from the pharynx was performed successfully, and the patient improved dramatically.

Comparison of the endoscopic stapling technique with more established procedures for pharyngeal pouches: results and patient satisfaction survey

Pharyngeal pouch surgery by the external approach has been shown to be effective but has a relatively high complication rate. We compared the outcome of 17 patients who had cricopharyngeal myotomy alone or combined with excision/inversion/suspension, simple pouch excision and Dohlman's procedure with 17 patients who had the relatively new Endo GIA-30 endoscopic stapling technique. Results were obtained retrospectively by postal questionnaire and medical records. We conclude that endoscopic stapling shortens the return to normal diet and in-patient stay. These patients also experience better swallowing and are generally more satisfied with the procedure. We have accepted endoscopic stapling as the method of choice for the treatment of pharyngeal pouches.

Endoscopic treatment of Zenker's diverticulum

BACKGROUND

The most important aspect of the surgical management of Zenker's diverticulum is probably the cricopharyngeal myotomy. Endoscopic diverticulotomy can be performed with a needle-knife papillotome, which allows simultaneous myotomy of the upper esophageal sphincter.

METHODS

Since 1978, 47 patients (28 men and 19 women 51 to 81 years of age) underwent endoscopic diverticulotomy. Most patients underwent more than one treatment session (mean value 2.2). The procedure was performed with sedation. Tubes were not used, and oral intake of food was begun the first day after the operation.

RESULTS

Forty-five (95.74%) patients had no dysphagia or only occasional, mild dysphagia during the postoperative course. No fistula, no recurrent laryngeal paralysis, and no deaths occurred.

CONCLUSION

Endoscopic diverticulotomy seems to be a good choice of therapy at least for patients with associated diseases that increase surgical risk.

Endoscopic stapling treatment of pharyngeal pouch

BACKGROUND

We describe our experience of a recently reported endoscopic stapling technique for the treatment of pharyngeal pouch.

METHODS

In contrast to other endoscopic procedures, which only divide the common wall between oesophagus and diverticulum, the linear cutting stapler also tightly seals the divided edges of mucosa and muscle.

RESULTS

The procedure was performed without complications in three patients with complete resolution of pre-treatment symptoms.

CONCLUSIONS

To our knowledge this is the first report of the use of this procedure in Australia. This endoscopic stapling operation appears to be safe, simple and cost-effective and offers advantages over previously used techniques.

Surgical therapy for swallowing disorders

In a physiologic act as complex as swallowing, there are myriad causes of dysfunction that can disorder feeding and respiration with grave consequences. The appropriate diagnostic evaluation of dysphagia and aspiration along with a review of a range of surgical strategies to correct swallowing and aspiration disorders are presented in this article.

Long-term experience with endoscopic staple-assisted esophagodiverticulostomy for Zenker's diverticulum

The authors have previously described the endoscopic staple-assisted esophagodiverticulostomy (ESED) technique for treatment of Zenker's diverticulum. In the initial series of six patients, ESED was shown to be safe and effective in the short term, with a significant reduction in hospital stay and convalescence as compared with other surgical techniques. This report documents the authors' long-term experience with ESED (average follow-up, 9.3 months; range, 1.5 to 25 months) and discusses the long-term results of this therapy, technical issues, and variations they have utilized, as well as the advantages and limitations of this approach. Thirty-six patients with Zenker's diverticula have been treated from March 1995 to March 1997. In 34 of the patients, ESED was accomplished, resulting in successful resolution of preoperative symptoms in 32 (94%). Two patients had persistent dysphagia after initial ESED; a revision ESED was successfully performed without complication in both. Two patients were unable to be treated with ESED because of inability to expose the diverticulum with the Weerda laryngoscope. Oral liquid diet has been resumed, on average, 0.8 days after surgery (range, 0 to 4 days), with solid diet resumed by day 5 (range, 1 to 14 days). The average hospital stay has been 1.3 days (range, 1 to 4 days). There have been no postoperative deaths, infections, or airway difficulties. Perioperative morbidity to date has included one case of iatrogenic pharyngeal perforation, one postoperative fever, one transient true vocal fold paralysis, and two dental injuries, with no long-term sequelae. The results support the use of ESED as the initial treatment of choice for patients with Zenker's diverticula.

Telescopic laryngeal and pharyngeal surgery

Surgery of the hypopharynx and larynx has traditionally been performed with either direct, unaided vision or the operating microscope. We proposed to extend the surgical capability provided by angled Hopkins telescopes to the larynx and hypopharynx. Forty-eight cases in which rigid telescopes were employed primarily for intervention were reviewed. We found significant advantages of the telescopic system when performing procedures on surfaces that were not 90 degrees from the observer, such as the walls of the hypopharynx, the petiole of the epiglottis, the ventricle, and the posterior commissure. Both 30 degree and 70 degree telescopes were found useful, but required complementary instruments. The potassium titanyl phosphate laser's flexible fiber provided a distinct advantage in resecting lesions that presented on vertical surfaces. Telescopes also permitted the use of large instruments designed for intraperitoneal and intrathoracic surgery that blocked the view of the operating microscope. Telescopic pharyngeal and laryngeal visualization allowed surgical procedures complementary to more traditional forms of endoscopic surgery.

Endoscopic laser myotomy in the treatment of pharyngeal diverticula

The endoscopic approach is a simple and cost-effective option in the treatment of hypopharyngeal diverticula. Whereas almost a third of all endoscopic myotomies performed by UK otolaryngologists are carried out with the stapling technique, CO2 laser diverticulotomy has not been given as much consideration (Koay et al., in press). We report on the first British series of 15 patients treated between 1985 and 1993 with microscopic laser diverticulotomy. The follow-up period was four to 11 years. Complications occurred in three patients, two patients required a repeat myotomy and 11 patients have been satisfied with their swallow since the operation. Our results are similar to those of larger studies. The laser technique is more established than the stapling gun myotomy and it has the advantage of superior visualization. It may also be used in small pouches which do not admit the insertion of a stapling gun.

Surgical outcome in 87 patients with Zenker's diverticulum

Surgical treatment of Zenker's diverticulum is controversial because many different procedures exist. We retrospectively reviewed 87 consecutive patients surgically treated for Zenker's diverticulum at a tertiary care institution from 1976 through 1993. Four surgical procedures were performed: cricopharyngeal myotomy alone (n = 16), excision (hand-sewn) plus myotomy (n = 51), excision (stapler) plus myotomy (n = 11), and diverticulopexy plus myotomy (n = 9). There were three surgical mortalities (3.5%) and a complication rate of 24%. Eighty patients (92%) were available for follow up. Sixty-eight patients (78%) reported excellent relief of symptoms, 10 (13%) reported improvement with occasional symptoms, and two (3%) described persistent dysphagia. No statistical difference in complication rate was found among surgical groups (P = 0.15). Myotomy alone patients had worse outcomes (P = 0.04) compared with the other surgical groups. Median follow-up was 7.5 months.