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Norton B, Siggens K, Papaefthymiou A, Telese A, Duku M, Murino A, Johnson G, Murray C, Mohammadi B, Mughal M, Bisschops R, Bhandari P, Birchall M, Haidry R. The safety and efficacy of endoscopic approaches for the management of Zenker's diverticulum: a multicentre retrospective study. Surg Endosc 2024:10.1007/s00464-024-11164-4. [PMID: 39160304 DOI: 10.1007/s00464-024-11164-4] [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: 04/16/2024] [Accepted: 08/05/2024] [Indexed: 08/21/2024]
Abstract
INTRODUCTION Minimally invasive endoscopic options are safe and effective alternatives to surgery for the treatment of symptomatic Zenker's diverticulum (ZD). However, there is no consensus on the gold-standard approach. We compared the safety and efficacy of Zenker's peroral endoscopic myotomy (Z-POEM), flexible diverticulotomy (FD), and rigid diverticulotomy (RD) for the management of ZD. METHODS Patients undergoing treatment for ZD at three UK tertiary referral centres were identified and analysed between 2013 and 2023. Patient demographics, procedural details, clinical success, and 30-day adverse events (AE) were recorded. The primary outcomes were technical and clinical success defined as a fall in Dakkak and Bennett dysphagia score to ≤ 1 without re-intervention. RESULTS There was no difference in baseline characteristics amongst 126 patients undergoing intervention (50 RD, 31 FD, 45 Z-POEM). Technical success for RD, FD, and Z-POEM was 80%, 100%, and 100%, respectively (p < 0.001). Over a mean follow-up of 11.0 months (95% CI 8.2-13.9), clinical success amongst those treated was 85.3% (RD), 74.1% (FD), and 83.7% (Z-POEM; p = 0.48) with recurrence in 17.2% (RD), 20.0% (FD), and 8.3% (Z-POEM; p = 0.50). AEs were equivalent between groups (p = 0.98). During this time, 11 patients underwent surgical myotomy with low clinical success (36.4%) and high morbidity. CONCLUSION Endoscopic options for the treatment of ZD show equivalent rates of success, but failed RD often led to open myotomy with worse outcomes. Flexible endoscopic modalities are both safe and highly effective treatments that may be considered first-line in experienced centres and should be offered before surgery.
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Affiliation(s)
- Benjamin Norton
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK.
- Department of Gastroenterology, University College London Hospital, Euston Road, London, NW1 2BU, UK.
- Centre for Obesity Research, University College London, London, UK.
| | - Katie Siggens
- Department of Gastroenterology, Portsmouth University Hospitals, Portsmouth, UK
| | | | - Andrea Telese
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Margaret Duku
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Alberto Murino
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Gavin Johnson
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Charles Murray
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Borzoueh Mohammadi
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Muntzer Mughal
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, UZ Leuven. TARGID, Louvain, KU, Belgium
| | - Pradeep Bhandari
- Department of Gastroenterology, Portsmouth University Hospitals, Portsmouth, UK
| | - Martin Birchall
- Royal National Ear Nose and Throat and Eastman Dental Hospitals, University College London Hospital, London, UK
- The Ear Institute University College London, London, UK
| | - Rehan Haidry
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
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Ward MA, Fair L, Misenhimer J, Esteva S, Greenberg I, Ogola G, Aladegbami B, Leeds SG, Kedia P. Per-oral endoscopic myotomy is a safe and effective treatment for Zenker's diverticulum: a retrospective multicenter study. Dis Esophagus 2023; 36:doad041. [PMID: 37391268 DOI: 10.1093/dote/doad041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/14/2023] [Indexed: 07/02/2023]
Abstract
Zenker per-oral endoscopic myotomy (ZPOEM) has become a promising technique for Zenker's diverticulum (ZD). The aim of this study was to add to the limited body of literature evaluating the safety and efficacy of ZPOEM. A prospectively maintained database was retrospectively reviewed to identify patients who underwent ZPOEM at two separate institutions between January 2020 and January 2022. Demographics, preoperative and postoperative clinical data, intraoperative data, adverse events, and length of stay were analyzed. A total of 40 patients (mean age 72.5 years, 62.5% male) were included. Average operative time was 54.7 minutes and average length of stay was 1.1 days. There were three adverse events, and only one was related to the technical aspects of the procedure. Patients showed improvement in the Functional Oral Intake Scale (FOIS) scores at 1 month (5 vs 7, p < 0.0001). The median FOIS scores remained 7 at both 6 and 12 months, although this improvement was not statistically significant at these time intervals (p = 0.46 and 0.37, respectively). Median dysphagia scores were decreased at 1 (2.5 vs 0, p < 0.0001), 6 (2.5 vs 0, p < 0.0001), and 12 months (2.5 vs 0, p = 0.016). The number of patients reporting ≥1 symptom was also decreased at 1 (40 vs 9, p < 0.0001) and 6 months (40 vs 1, p = 0.041). Although the number of patients reporting ≥1 symptom remained consistent at 12 months, this was not statistically significant (40 vs 1, p = 0.13). ZPOEM is a safe and highly effective treatment for the management of ZD. .
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Affiliation(s)
- Marc A Ward
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
- Texas A&M College of Medicine, Bryan, TX, USA
| | - Lucas Fair
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
- Research Institute, Baylor Scott and White Health, Dallas, TX, USA
| | - Jennifer Misenhimer
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
| | - Simón Esteva
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
- Texas A&M College of Medicine, Bryan, TX, USA
| | | | - Gerald Ogola
- Research Institute, Baylor Scott and White Health, Dallas, TX, USA
| | - Bola Aladegbami
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
- Texas A&M College of Medicine, Bryan, TX, USA
| | - Steven G Leeds
- Department of Minimally Invasive Surgery, Baylor University Medical Center, Dallas, TX, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
- Texas A&M College of Medicine, Bryan, TX, USA
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Mandarino FV, Vespa E, Barchi A, Fasulo E, Sinagra E, Azzolini F, Danese S. Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review. Life (Basel) 2023; 13:2143. [PMID: 38004283 PMCID: PMC10672509 DOI: 10.3390/life13112143] [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: 09/25/2023] [Revised: 10/28/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
Our review delves into the realm of peroral endoscopic myotomies (POEMs) in the upper gastrointestinal tract (UGT). In recent years, POEMs have brought about a revolution in the treatment of UGT motility disorders. Esophageal POEM, the first to be introduced, has now been validated as the primary treatment for achalasia. Subsequently developed, G-POEM displays promising results in addressing refractory gastroparesis. Over time, multiple endoscopic myotomy techniques have emerged for the treatment of Zenker's diverticulum, including Z-POEM, POES, and hybrid approaches. Despite the well-established efficacy outcomes, new challenges arise in the realm of POEMs in the UGT. For esophageal POEM, the future scenario lies in customizing the myotomy extent to the minimum necessary, while for G-POEM, it involves identifying patients who can optimally benefit from the treatment. For ZD, it is crucial to validate an algorithm that considers various myotomy options according to the diverticulum's size and in relation to individual patients. These challenges align with the concept of precision endoscopy, personalizing the technique for each subject. Within our text, we comprehensively examine each myotomy technique, analyzing indications, outcomes, and adverse events. Additionally, we explore the emerging challenges posed by myotomies within the context of the evolving field of precision endoscopy.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Edoardo Vespa
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Ernesto Fasulo
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele Giglio, 90015 Cefalù, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
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Guo TT, Dong YB, Liu YH, Lu C, Li WX. Diagnosis and Open Surgical Management of Laimer's Diverticulum: Case Series and Review of the Literature. EAR, NOSE & THROAT JOURNAL 2023:1455613231202245. [PMID: 37752849 DOI: 10.1177/01455613231202245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
Objectives: Laimer's diverticulum (LD) is a very rare clinical entity originating between the cricopharyngeus muscle (CPM) and circular muscular fibers of the esophagus. Its diagnosis and management remain to be elucidated. This article summarizes our experience in its diagnosis and open surgical management.Methods: A retrospective review of LD cases treated at our tertiary medical institution was conducted between July 2018 and May 2023. The clinical and demographic data were retrieved from case notes.Results: Three cases were included in this review. There were 2 male patients and 1 female patient. The average and median ages were 47.3 and 54 years, respectively. Presenting symptoms included hoarseness, pharyngeal foreign body sensation, and neck mass. All 3 diverticula were on the left side, with the first 2 cases discovered accidentally on gastric endoscopic or cervical MRI examinations. After evaluating esophageal swallowing with barium sulfate or urografin contrast media, all the patients consented to undergo an open surgical procedure. During surgical exploration, the diverticula were found to be on the posterior part of the cervical esophagus, below CPM, and away from the recurrent laryngeal nerve, and only then, could the diagnosis of LD be established. Then, diverticulectomy and manual suturing of the esophagus was performed. Recovery of all 3 patients was uneventful. Nasogastric tube feeding lasted 7 to 12 days until esophageal examinations demonstrated no leak, and then, oral liquid feeding resumed. The median duration of follow-up was 50 months. No recurrence of symptoms or diverticulum was observed, and the swallowing function of all 3 patients was excellent.Conclusions: An open surgical approach is not only important for the diagnosis of LD, but can also be utilized as a safe and effective treatment.
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Affiliation(s)
- Ting-Ting Guo
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yan-Bo Dong
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yu-He Liu
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Cheng Lu
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wan-Xin Li
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Cadena Aguirre DP, de Moura DTH, Hirsch B, Peixoto de Oliveira GH, Kum AST, Mahmood S, Bernardo WM, Sharma NR, De Moura EG. Flexible Endoscopy Versus Rigid Endoscopy or Surgery for the Management of Zenker's Diverticulum: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e43021. [PMID: 37680421 PMCID: PMC10480577 DOI: 10.7759/cureus.43021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2023] [Indexed: 09/09/2023] Open
Abstract
Zenker's diverticulum treatment options range from endoscopic rigid or flexible procedures to surgery. There are limited studies available comparing these techniques. Frequently, the choice of treatment depends on the physician's preference or experience, as well as the institution's resources and capacity. Therefore, this study aims to define the best approach based on the highest efficacy and the lowest severe adverse events. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search was performed. Only comparative studies were included, analyzing flexible endoscopy versus rigid endoscopy or surgery. The outcomes analyzed were clinical and technical success, severe adverse events, length of stay, and duration of the procedure. Analysis was performed using Review Manager 5.4.1 (RevMan 5.4, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Eight retrospective cohort studies met the inclusion criteria. A total of 1281 patients were identified, 492 underwent flexible endoscopy, 453 underwent rigid endoscopy, and 336 underwent surgery. There was no difference in clinical success [risk difference (RD), 0.07 (95% CI -0.05 to 0.19%); P = 0.26], technical success [RD, 0.07 (95% CI -0.03 to 0.16); P = 0.18], severe adverse events [RD, -0.03 (95% CI -0.13 to 0.07; P = 0.052), perforation [RD, 0.07 (95% CI -0.04 to 0.19); P = 0.22] or procedure time [mean difference (MD), - 10.03 (95% CI -26.93 to 6.88); P = 0.24). There was lower length of stay with flexible endoscopy compared to the other approaches [MD, -1.98 (95% CI -3.56 to -0.40); P = 0.001]. Based on the current evidence, the three main techniques are effective for the treatment of Zenker's diverticulum. Although there was no significant difference in the safety of each technique in this meta-analysis, this result should be interpreted cautiously due to the limited data and the risk of vies between the techniques, considering that the results tend to favor flexible endoscopy, mainly explained by the newer and safer devices. Length of stay is lower with flexible endoscopy versus the other techniques, which can be beneficial considering the geriatric populations where Zenker's diverticulum mainly occurs.
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Affiliation(s)
- Diego P Cadena Aguirre
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Diogo Turiani Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Bruno Hirsch
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Guilherme Henrique Peixoto de Oliveira
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Angelo So Taa Kum
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | | | - Wanderley Marques Bernardo
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Neil R Sharma
- Division of Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Health, Fort Wayne, USA
| | - Eduardo Guimarães De Moura
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
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Maselli R, Spadaccini M, Pellegatta G, Repici A. Peroral Endoscopic Myotomy Technique, from Mouth to Anus. Gastrointest Endosc Clin N Am 2023; 33:127-142. [PMID: 36375877 DOI: 10.1016/j.giec.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The peroral endoscopic myotomy (POEM) procedure, as described over 10 years ago, is a submucosal endoscopy procedure that allows access to the muscle layers throughout the gastrointestinal (GI) tract. With this access, and ability to cut the muscle fibers, POEM can be performed not only for motility disorders but for structural pathology as well, such as Zenker diverticulum. Regardless of the location, there are 4 steps to the procedure: mucosotomy, submucosal tunneling, myotomy, and mucostomy closure. This review outlines these key components as well as variations in techniques for POEM throughout the GI tract.
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Affiliation(s)
- Roberta Maselli
- Department of Biomedical Sciences, Pieve Emanuele, Humanitas University, Rozzano, Italy; Humanitas Clinical and Research Center -IRCCS-, Endoscopy Unit, Rozzano, Italy
| | - Marco Spadaccini
- Department of Biomedical Sciences, Pieve Emanuele, Humanitas University, Rozzano, Italy; Humanitas Clinical and Research Center -IRCCS-, Endoscopy Unit, Rozzano, Italy.
| | - Gaia Pellegatta
- Humanitas Clinical and Research Center -IRCCS-, Endoscopy Unit, Rozzano, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Pieve Emanuele, Humanitas University, Rozzano, Italy; Humanitas Clinical and Research Center -IRCCS-, Endoscopy Unit, Rozzano, Italy
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Maehata T, Sato Y, Nakamoto Y, Kato M, Kawashima A, Kiyokawa H, Yasuda H, Yamamoto H, Tateishi K. Updates in the Field of Submucosal Endoscopy. LIFE (BASEL, SWITZERLAND) 2022; 13:life13010104. [PMID: 36676053 PMCID: PMC9864725 DOI: 10.3390/life13010104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 12/24/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022]
Abstract
Submucosal endoscopy (third-space endoscopy) can be defined as an endoscopic procedure performed in the submucosal space. This procedure is novel and has been utilized for delivery to the submucosal space in a variety of gastrointestinal diseases, such as a tumor, achalasia, gastroparesis, and subepithelial tumors. The main submucosal endoscopy includes peroral endoscopic myotomy, gastric peroral endoscopic myotomy, Zenker peroral endoscopic myotomy, submucosal tunneling for endoscopic resection, and endoscopic submucosal tunnel dissection. Submucosal endoscopy has been used as a viable alternative to surgical techniques because it is minimally invasive in the treatment and diagnosis of gastrointestinal diseases and disorders. However, there is limited evidence to prove this. This article reviews the current applications and evidence regarding submucosal endoscopy while exploring the possible future clinical applications in this field. As our understanding of these procedures improves, the future of submucosal endoscopy could be promising in the fields of diagnostic and therapeutic endoscopy.
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