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

Zenker's peroral endoscopic myotomy for management of large Zenker's diverticulum

BACKGROUND

Zenker's diverticulum peroral endoscopic myotomy (zPOEM) is a minimally invasive treatment strategy for Zenker's diverticulum, with excellent results for management of small-to-moderate Zenker's diverticulum. We evaluated its use in the management of large Zenker's diverticulum.

METHODS

This was a retrospective multicenter cohort study across 11 international centers including adult patients with large Zenker's diverticulum ≥ 40 mm treated by zPOEM between March 2017 and March 2022. The primary outcome was clinical success (dysphagia score ≤ 1 without need for further intervention). Secondary outcomes included technical success (complete myotomy as intended), adverse events (AEs), and rate of recurrence.

RESULTS

83 patients (male 62.7 %, mean age 72.6 [SD 11.5] years) underwent zPOEM for treatment of large Zenker's diverticulum (median size 50 mm, interquartile range [IQR] 41-55 mm, range 40-80 mm). The zPOEM procedure was technically successful in 82 patients (98.8 %), with a mean procedure time of 48.7 (SD 23.2) minutes. Clinical success was achieved in 71 patients (85.5 %). Median (IQR) symptom scores improved significantly from baseline for dysphagia (2 2 3 vs. 0 [0-2]; P < 0.001), regurgitation (3 2 3 4 vs. 0 [0-0]; P < 0.001), and respiratory symptoms (2 [0-3] vs. 0 [0-0]; P < 0.001). Among patients achieving clinical success, only one recurrence (1.4 %) was recorded during a median follow-up of 12.2 months (IQR 3-28). Post-procedure AEs, all mild to moderate, occurred in four patients (4.8 %).

CONCLUSION

This study demonstrated safe and effective use of zPOEM in the management of large Zenker's diverticulum.

Surgical treatment of cervical oesophageal diverticula

AIM OF THE STUDY: The aim of our study is to present the results of surgical treatment of patients with cervical diverticula of the oesophagus in a period of 20 years. MATERIAL AND METHODS: A retrospective analysis of 65 patients treated between 2000 and 2020. Patients with symptoms such as dysphagia, vomiting, chocking, recurrent respiratory tract inflammation, as well as patients with diverticular recurrence or poor outcome of primary surgery, were qualified for surgical resection of the oesophageal diverticulum with myotomy using an open technique. Patients were evaluated for the degree of dysphagia before and after surgery, associated perioperative complications, and overall comfort after surgical treatment. RESULTS: Sixty-five patients underwent surgical treatment, 7(10.7%) of whom were treated for diverticular recurrence or poor outcome of primary treatment. The predominant symptom was dysphagia, which was found in 55(84.6%) patients, increasing over 6 to 48 months with a mean of 17.6 months. The size of the diverticulum ranged from 2 to 6 cm with a mean of 4.8 cm. One patient (1.5%) who experienced the suture line leak was treated conservatively and the fistula healed. Another patient had permanent vocal cord damage, and 1(1.5%) patient had transient damage. The surgical outcome was very good in 48 patients, good in 15 patients, and poor in 2 patients. No postoperative death occurred. CONCLUSIONS: The technique of open resection with myotomy continues to be an effective method of treating cervical diverticula. It has a zero-mortality rate, low perioperative complication rate, good functional outcome, and low recurrence rate.

Surgical management of recurrent Zenker's diverticulum: A multi-institutional cohort study

OBJECTIVE

This study identifies how recurrent Zenker's diverticula are treated.

METHODS

A retrospective chart review was performed from four tertiary referral academic voice and swallowing centers to identify individuals who underwent surgery for recurrent Zenker's diverticulum. Demographic data, surgical modalities for primary and revision surgery, symptoms pre and post revision and complications were recorded.

RESULTS

56 individuals met inclusion criteria. Primary surgery was open in 30.3% (n = 17) and endoscopic in 69.6% (n = 39). Revision surgery was performed via an open approach in 37.5% of cases (N = 21) and via an endoscopic approach in 62.5% of cases (N = 35). Revision surgical technique was based on pouch size, patient age and comorbidities, as well as patient and surgeon preference. There were no major complications and few minor complications.

CONCLUSION

Zenker's diverticulum symptoms can recur regardless of primary treatment modality. Both endoscopic and open approaches can safely treat recurrent Zenker's diverticula.

Zenker diverticulum treatment: retrospective comparison of flexible endoscopic window technique and surgical approaches

INTRODUCTION

Different treatments exist for Zenker diverticulum. We compared flexible endoscopic myotomy of the cricopharyngeal muscle, using a technique called the "window technique" in order to improve the field of view, to surgical approaches.

MATERIALS AND METHODS

Patients were retrospectively included and divided into a gastrointestinal group, with flexible endoscopic myotomy, and an ear-nose-throat treatments group with either rigid endoscopic treatment, either cervicotomy. We evaluated effectiveness in terms of quality of life (on a scale on 0 to 10) safety and technical aspects of each procedure.

RESULTS

A total 106 patients who underwent 128 interventions were included. Rigid endoscopic procedures were the shortest (p < 0.001), with no difference for adverse event. Endoscopic approaches, flexible and rigid ones, were associated with shorter time to intake resumption (1 and 3 days, respectively, vs 6 after cervicotomy) and shorter length of hospital stay (3 and 4 days, respectively, vs 7 after cervicotomy) (p = 0.001). Post-operative QoL was better after flexible endoscopy (9/10) and open cervicotomy (9/10) than after rigid endoscopy (7/10) (p = 0.004). Patients declared fewer residual symptoms after open cervicotomy (77% of low symptomatic patients) and flexible endoscopy (80%) than after rigid endoscopy (43%) (p = 0.003). Conversion to open surgery was more frequent during rigid than flexible endoscopies (18% vs 0%, p = 0.0008).

CONCLUSION

Flexible endoscopic approach of Zenker diverticulum treatment seems to be safe and effective and may be an alternative to surgical approaches. Myotomy can be eventually helped by the window technique.

Adverse Events after Rigid and Flexible Endoscopic Repair of Zenker’s Diverticula: A Systematic Review and Meta-analysis

Objective

To determine adverse events after endoscopic flexible vs endoscopic rigid cricopharyngeal myotomy for treatment of Zenker’s diverticulum (ZD).

Data Sources

Systematic review of MEDLINE, Web of Science, CINAHL, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials for all years according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional studies were identified from review citations and a by hand search of manuscripts referencing ZD.

Review Methods

A structured literature search was conducted to identify studies for this systematic review. Methodological Index for Non-randomized Studies (MINORS) criteria were applied to assess study quality. For inclusion, each study had to provide data for at least 10 adult patients who had undergone endoscopic ZD repair reporting clear association with the postprocedure course in each case. Data extracted included all reported adverse events, recurrences, follow-up, and operative times.

Results

In total, 115 studies were included. All but 8 were retrospective case series. Sixty-one reported series of patients after rigid endoscopic stapler repair, 31 after rigid laser repair, and 13 with other rigid endoscopic instruments. Twenty-nine flexible endoscopic studies were included. Mortality, infection, and perforation were not significantly more likely in either the rigid or the flexible group, but bleeding and recurrence were more likely after flexible endoscopic techniques (20% vs <10% and 4% vs 0%, respectively). Dental injury and vocal fold palsy were reported rarely in the rigid endoscopic groups.

Conclusions

Adverse events are rare after endoscopic Zenker’s repair. The flexible approach minimizes exposure limitations and can be completed in some patients without general anesthesia. Transoral rigid approaches result in fewer revision surgeries compared with flexible diverticulotomy.

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.

Pharyngoesophageal diverticuli: diagnosis, incidence and management

PURPOSE OF REVIEW

Pharyngoesophageal diverticuli such as Zenker's diverticulum are relatively rare diseases that may have a significant impact on a patient's quality of life. Open surgical techniques have historically been the mainstay of treatment for Zenker's diverticuli and remain the preferred approach for many surgeons operating on Killian-Jamieson diverticuli (KJD) and pharyngoceles. However, advances in technology in recent decades have allowed for the development of successful endoscopic surgical techniques for the management of these conditions.

RECENT FINDINGS

Endoscopic management of Zenker's diverticulum with carbon dioxide laser-assisted diverticulotomy or endoscopic stapler-assisted diverticulostomy has gained wide acceptance in recent years. This is based on studies showing high rates of successful outcomes, low rates of complications and shorter operative time with an associated impact on overall cost and patient recovery. Endoscopic management of KJD and pharyngoceles has recently been described, but remains controversial with many surgeons preferring open surgical approaches for the ability to identify and protect the recurrent laryngeal nerve.

SUMMARY

Open and endoscopic techniques are accepted for the treatment of Zenker's diverticulum with open approaches remaining the traditional technique for management of non-Zenker's diverticulum. Further investigation of endoscopic approaches for management of KJD is necessary to assess safety and efficacy.

Simulation of KTP Laser-Based Zenker Diverticulotomy with a Porcine Model and Laryngeal Dissection Station

Zenker’s diverticulum is a rare cause of progressive dysphagia that is treated surgically. Potassium titanyl phosphate (KTP) laser–based diverticulotomy is one effective treatment. Developing a simulation model is helpful for rare conditions. Pigs have a natural hypopharyngeal pouch similar to a diverticulum. We present a model for performing rigid endoscopic KTP laser diverticulotomy in a porcine model with a laryngeal dissection station. Eleven pigs were examined to confirm presence of the hypopharyngeal pouch. A specimen was mounted on the modified laryngeal dissection station, and a KTP laser–based diverticulotomy was performed. Novel aspects include use of the laryngeal dissection station and application of the model for simulating rigid endoscopic KTP laser diverticulotomy. This model allows trainees to practice equipment setup, positioning of the laryngoscope to isolate the cricopharyngeal bar, tissue handling, laser safety techniques, and use of the KTP laser through the laryngoscope under microscopic visualization.

Endoscopic versus surgical approach in the treatment of Zenker's diverticulum: systematic review and meta-analysis

BACKGROUND

Zenker's diverticulum is a rare disease in the general population. Its treatment can be carried out by either an endoscopic or surgical approach. The objective of this study was to systematically identify all reports that compare both treatment modalities and to assess the outcomes in terms of length of procedure, length of hospitalization, time until diet introduction, complication rates, and recurrence rates.

METHODS

A search of Medline and Embase selected all studies that compared different methods of surgical and endoscopic treatment for Zenker's diverticulum published in the English, Portuguese, and Spanish languages between 1975 and 2014. The meta-analysis was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Data were extracted and analyzed for five different outcomes.

RESULTS

Eleven studies met the inclusion criteria, describing outcomes of endoscopic versus surgical treatment for 596 patients with Zenker's diverticulum. A meta-analysis of the studies suggested a statistically significant reduction in operating time and length of hospitalization, favoring endoscopic treatment (standardized mean difference (SMD) - 78.06, 95 %CI - 90.63, - 65.48 and SMD - 3.72, 95 %CI - 4.49, - 2.95, respectively), just as with the reduction in the fasting period (SMD - 4.30, 95 %CI - 5.18, - 3.42) and risk of complications (SMD - 0.09, 95 %CI 0.03, 0.43) for patients who had undergone the endoscopic approach in comparison with the surgical group. Also, a statistically significant reduction in the risk of symptom recurrence was seen when the treatment of Zenker's diverticulum was carried out by a surgical approach compared with endoscopic treatment (SMD 0.08, 95 %CI 0.03, 0.13).

CONCLUSION

Compared with a surgical approach, endoscopic treatment appeared to result in a shorter length of procedure and hospitalization, earlier diet introduction, and lower rates of complications, but in higher rates of symptom recurrence.

Esophageal surgery in minimally invasive era

The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.

Pharyngeal pouch: which technique?

Background:

Pharyngeal pouches have been recognised as a cause of dysphagia for centuries and have been treated in a variety of ways over that time.

Objective:

This article aimed to analyse the results of surgery by a variety of techniques, as performed by one surgeon.

Method:

A retrospective analysis of a case series was conducted, analysing the variables of patient age, sex, type of surgery, length of hospital stay, leak, recurrence and other complications.

Results:

A total of 121 patients were treated by 135 operations. There were no leaks in the group treated by endoscopic stapling and this group also had a significantly shorter hospital stay. As for recurrence, the lowest rate appeared to be in the group treated by excision of the pouch.

Conclusion:

The techniques used by the author all still seem to have a role in the management of pharyngeal pouch, with the endoscopic stapling approach associated with a low rate of complications and short hospital stay.

Zenker's Diverticulum

Zenker's diverticulum (ZD) is an outpouching of tissue through the Killian triangle that is believed to be caused by dysfunction of the cricopharyngeal muscle. ZD is a relatively uncommon disorder occurring in the elderly. The predominant symptom of ZD is dysphagia, and the most serious consequence is pulmonary aspiration. Videofluoroscopy confirms the diagnosis. Therapy of symptomatic ZD has evolved from an open surgical approach to less invasive transoral endoscopic techniques. Transoral endoscopic therapy using rigid instruments is performed primarily by otorhinolaryngologists, whereas transoral therapy using flexible endoscopes is performed by surgical endoscopists and gastroenterologists. The common goal of all modalities is severing of the septum between the esophageal lumen and the diverticulum containing the cricopharyngeal muscle. Although flexible endoscopic therapy was described nearly 20 years ago, it has experienced a recent resurgence paralleling the advancements of therapeutic endoscopy in other areas, such as endoscopic submucosal dissection. Direct head-to-head comparisons of rigid and flexible endoscopic therapy are lacking, and each approach has variations in techniques as well as advantages and disadvantages. In this article, we review the pathophysiology and management of patients with ZD with an emphasis on flexible endoscopic therapy.

Foreign body in a Zenker's diverticulum (looking for the lost dentures)

Zenker's diverticulum (ZD), an acquired false pharyngoesophageal diverticulum, is a rare pathology. The prevalence of ZD among the general population is believed to be between 0.01% and 0.11%. Most patients are elderly men with symptoms of dysphagia. The most common treatments are open surgical diverticulectomy with or without cricopharyngeal myotomy and endoscopic myotomy. The authors report the case of a dental prosthesis lodged within an asymptomatic ZD in a 73-year-old man. It was safely removed endoscopically. So far, there have only been single reports of entrapment of an enteroscopy capsule lodged in a ZD in medical literature.

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.

Zenker's diverticulum: outcome of endoscopic surgery is dependent on the intraoperative exposure

The purpose of the present study is to evaluate long-term outcome and patients' satisfaction after endoscopic therapy of Zenker's diverticulum (ZD) and to analyze the results of the stapler technique in comparison with the application of the carbon dioxide (CO2) laser. A retrospective cohort study with outcome analysis of patients undergoing endoscopic cricopharyngeal myotomy with either stapler or CO2 laser between October 2000 and December 2010 by a single surgeon was performed. Patient's medical charts were reviewed with respect to symptoms before intervention, intra and post operative complications, reasons for the choice of endoscopic technique, and postoperative relief of symptoms. Long-term follow-up was acquired by a standardized self-assessment questionnaire. Seventy-four patients (51 men, 23 women) with a median age at operation of 74 years (range 45-93 years) were enrolled in this study. Forty-five patients underwent endoscopic repair of a ZD with stapler, 29 patients with CO2 laser. The mean follow-up was 4.7 years. We did not observe significant differences for intra and post operative complications, hospital stay, time until normal oral food intake, need for revision, and long-term subjective symptom relief between the two groups. Overall complication (12 %) and recurrence rate (11 %) for the endoscopic techniques were low. Endoscopic surgery had also a high success rate in recurrence cases (87.5 %). According to our study, the most important factor for the success rate of endoscopic treatment was the intraoperative exposure of the ZD. The endoscopic minimally invasive approach is a safe and effective treatment modality and can be considered as the treatment of choice for primary and recurrent ZD. The intraoperative exposure is decisive for the technique applied and the long-term success.

Video-assisted thoracoscopic surgery for large Zenker's diverticulum: report of two cases

INTRODUCTION

Zenker's diverticulum is a propulsion diverticulum in the pharynx. Current practice for the management of symptomatic pharyngeal pouches includes endoscopic pharyngeal stapling, performed trans-orally, and external approaches via a cervical incision. There is no published recommendation on how to approach diverticula with extension into the mediastinum, which may not be adequately treated with the above methods.

CASES

We describe two cases in which thoracoscopic mobilisation of Zenker's diverticulum was performed using video-assisted thoracoscopic surgery together with traditional transcervical mobilisation and excision of the pouch. This allowed safe surgical access to the inferior limit of the pouch, and delivery of the sac into the neck incision following division of any inferior adhesions (to the great vessels in one case).

DISCUSSION

In the first report of this technique, we describe a thorough, safe method of dissecting large diverticula that extend into the mediastinum, which minimises the risk to mediastinal structures.

Open Staple Diverticulectomy for a Large Recurrent Zenker's Diverticulum: Still a Valid Procedure

Objectives:

We demonstrate indications for external mechanical stapler diverticulectomy in the modern era of endoscopic treatment. We review treatment of a large diverticulum and discuss considerations that should be made in deciding on the type of surgical treatment.

Methods:

The index case was in a 75-year-old man who had undergone open cricopharyngeal myotomy with diverticulopexy 35 years earlier. He presented with 25 years of recurrent symptoms. A swallow study showed a 6.5 × 5.0-cm diverticulum. The diverticulum was deemed too large for standard endoscopic myotomy, so diverticulectomy was performed with a stapler.

Results:

The patient was discharged on postoperative day 3 without complications. A swallow study on postoperative day 5 demonstrated no diverticulum or extravasation of barium. The patient resumed a normal diet with resolution of dysphagia. Two additional patients with large Zenker's diverticula that were managed similarly are also discussed.

Conclusions:

Although endoscopic laser cricopharyngeal myotomy and stapler diverticulostomy have become standard treatments for Zenker's diverticulum, this case of a large recurrent diverticulum illustrates a situation in which older techniques may be preferred. Use of the mechanical stapler allowed for a shorter surgery time than traditional suture techniques, and the potential for an earlier return to a normal diet.

Endoscopic or external approach revision surgery for pharyngeal pouch following primary endoscopic stapling: which is the favoured approach?

This study aimed to assess outcomes of revision endoscopic stapling and external excision of pharyngeal pouch. A 5-year prospective study was performed on all patients requiring revision pouch surgery following primary endoscopic stapling. Data were collected retrospectively. Eighteen patients underwent revision pouch surgery. In seven patients, pouch size was down-graded from 3 to 2, and these were stapled endoscopically. Two leaks resulted. Eleven patients with grade 1 or 3 pouches underwent external excision of pouch, with no post-operative complications. As per results external excision of pouch is safe for grade 1 and 3 pouches. It avoids risking redundant mucosa and recurrence of symptoms which can complicate stapling and enables a myotomy to be performed to reduce cricopharyngeal hypertonicity. The highest predictable success is with grade 2 pouches, whose size is amenable to adequate endoscopic stapling. However, the "staple over staple" effect of revision stapling leads to unpredictable fibrosis, which can contribute to risk of perforation.

Management of Zenker's diverticulum in the endoscopic age: current practice patterns

OBJECTIVES

Zenker's diverticulum (ZD) is a common source of dysphagia with a well-established surgical treatment history. Variations may exist between practitioners in the preoperative, intraoperative, and postoperative management of patients with ZD because of recent evolutions in surgical approach toward an endoscopic technique.

METHODS

An online survey instrument was prepared and forwarded to the membership of the American Broncho-Esophagological Association (ABEA) to ascertain the current practice patterns of its members regarding numerous care parameters for patients with ZD.

RESULTS

Data on preoperative evaluation, operative care, postoperative management, and recalled incidence of complications, including mediastinitis, were evaluated. Subgroup analysis demonstrated significant differences in multiple care parameters for those surgeons who predominantly perform endoscopic operations (more than 80% willingness to perform endoscopic operations) compared to those who occasionally perform endoscopic operations (less than 80%), including average case number, advancement of oral intake, hospital discharge, use of antibiotics, and views on the efficacy of endoscopic surgical techniques. These changes were noted despite similar times since graduation from training for the two groups.

CONCLUSIONS

These data present a contemporary snapshot of clinical care patterns of the ABEA membership for patients with ZD and suggest differences in care patterns for surgeons with a higher enthusiasm for endoscopic techniques and larger case volumes.

Evaluation of the different transcervical approaches for Zenker diverticulum

OBJECTIVE

The aim of this study was to evaluate the results of open surgical techniques in the treatment of Zenker diverticulum.

STUDY DESIGN

Case series with chart review.

SETTING

Academic tertiary referral center.

SUBJECTS AND METHODS

Fifty-four patients with Zenker diverticulum were treated using a transcervical approach. Three with a Brombart I diverticulum underwent a simple myotomy of the cricopharyngeal muscle. Myotomy was combined with a diverticulum inversion in 14 patients and myotomy with diverticulectomy was performed in 37 patients. The surgical procedures were compared with regard to mean anesthesia time, duration of hospitalization, overall complication rate and rate of serious complications, recurrence rate, and follow-up results.

RESULTS

Hospitalization times were significantly shorter in the inversion group (P = .024). No statistically significant differences were observed between the transcervical modalities for any of the other variables investigated.

CONCLUSIONS

Inversion is an effective modality and is by definition less traumatic than traditional diverticulectomy. Although the size of the diverticulum appeared to be a helpful criterion, careful intraoperative evaluation is the key element in deciding which transcervical procedure should be used. In the authors' view, inversion always should be considered if the individual anatomy of the diverticulum sac (in terms of pharyngeal pouch size and intactness of the mucosa) allows it.

Divertículo de Zenker: tratamento endoscópico versus cirúrgico

OBJETIVO: Revisar a evidência da segurança e efetividade dos tratamentos endoscópico e cirúrgico do divertículo de Zenker. MÉTODOS: pesquisa no MEDLINE, LILACS e SciELO por "Zenker's diverticulum or pharyngoesophageal diverticulum", e seleção de estudos para avaliação da qualidade e extração dos dados para uma metanálise. RESULTADOS: a pesquisa não localizou nenhum ensaio clínico randomizado. Encontramos cinco estudos comparativos não randomizados com grupo controle, com um total de 630 pacientes, 339 no braço endoscópico e 291 no cirúrgico. Os valores para segurança foram uma mortalidade de 0,29% e morbidade 7% para o tratamento endoscópico, e mortalidade 0,34% e morbidade 5% para o tratamento cirúrgico. O valor para efetividade foi 84% e 85%, respectivamente. O efeito das abordagens endoscópica e cirúrgica para o tratamento do divertículo de Zenker foi comparável, a odds ratio para morbidade foi 1,24 (0,56-2,74), e a odds ratio para o sucesso foi 0,66 (0,41-1,05). CONCLUSÃO: os estudos sobre o tratamento do divertículo de Zenker têm baixo nível de evidência e não são capazes de definir qual o melhor tratamento em termos de segurança e efetividade.

Endoscopic laser-assisted diverticulotomy versus open surgical approach in the treatment of Zenker's diverticulum

OBJECTIVES/HYPOTHESIS

This study aimed to evaluate the results of endoscopic laser-assisted diverticulotomy and the transcervical approach in treating Zenker's diverticulum.

STUDY DESIGN

Retrospective clinical study.

METHODS

Results of 155 cases after endoscopic laser-assisted diverticulotomy and the transcervical approach were retrospectively compared.

RESULTS

Primary treatment consisted of endoscopic laser-assisted diverticulotomy in 65.2%, and 34.8% were treated by a transcervical approach. Average follow-up time was 61.8 months. Surgical time, duration of hospitalization, and occurrence of minor complications were significantly lower after endoscopic approach. Recurrence rate showed a statistically significant difference in favor of open approach. Including the recurrences, 38.7% could be cured only by transcervical techniques. Patient perception of success was found to be similar for the compared treatment modalities.

CONCLUSIONS

Endoscopic approach proved to be the treatment of first choice. However, the fact that open techniques were necessary in nearly 40% of our cases suggests that this operative technique retains a substantial role in treatment of this disease.

Modern pathophysiology and treatment of esophageal diverticula

INTRODUCTION

Esophageal diverticula are rare. They may occur in the pharyngoesophageal area (Zenker's), midesophagus, or distally (epiphrenic). A motility disorder (either at the level of the esophageal sphincters or body) is frequently associated with esophageal diverticula. The risk of malignant transformation is low.

METHODS

A literature search was performed using Medline/PubMed database.

RESULTS

The treatment of esophageal diverticula must be based on the pathophysiology and natural history of the disease: (a) asymptomatic diverticula do not need a specific treatment, (b) small diverticula may be left in place and not resected, (c) medium-size diverticula may be either treated by diverticulectomy, diverticulopexy, or esophagodiverticulostomy in case of pharyngoesophageal diverticula, (d) resection is probably the ideal therapy for larger diverticula, and (e) a myotomy should always be included to the procedure.

CONCLUSIONS

Due to its rarity, esophageal diverticula must be treated by esophageal surgeons since even in experienced hands the complication rate can be significant.

Effect of cricopharyngeus muscle surgery on the pharynx

OBJECTIVES/HYPOTHESIS

Cricopharyngeus muscle dysfunction (CPD) ranges from asymptomatic cricopharyngeal bar (CPB) to Zenker's diverticulum. Previous work suggests that CPD can result in dilation and weakening of the pharynx above the obstruction. The purpose of this investigation was to evaluate the ability of surgery on the cricopharyngeus muscle to improve pharyngeal area and strength.

STUDY DESIGN

Retrospective case study.

METHODS

Videofluoroscopic swallowing studies of all persons with CPD who underwent cricopharyngeus (CP) intervention followed by routine postoperative fluoroscopic study, between October 1, 1999 and January 1, 2010 were reviewed. Objective measures of pharyngeal area and constriction were obtained from pretreatment and post-treatment studies. Paired t tests and repeated measures analysis of variance were employed to compare results.

RESULTS

Fifty-four patients were included. Pharyngeal constriction and pharyngoesophageal segment (PES) opening improved significantly after intervention (P < .05).Pharyngeal dilation was unchanged (P > .05). PES opening improved more with CP myotomy than with dilation and botulinum toxin.

CONCLUSIONS

Relief of CP obstruction by surgery or dilation improves pharyngeal constriction and PES opening. Dilation of the pharynx possibly related to prolonged outlet obstruction does not improve. CP myotomy appears more effective than dilation or botulinum toxin in relieving obstruction.

Pharyngeal dilation in cricopharyngeus muscle dysfunction and Zenker diverticulum

OBJECTIVES/HYPOTHESIS

Prolonged obstruction at the level of the lower esophageal sphincter is associated with a dilated, poorly contractile esophagus. The association between prolonged obstruction at the level of the upper esophageal sphincter (UES) and dilation and diminished contractility of the pharynx is uncertain. The purpose of this investigation was to evaluate the association between prolonged obstruction at the level of the UES and dilation and diminished contractility of the pharynx.

STUDY DESIGN

Case-control study.

METHODS

The fluoroscopic swallow studies of all persons with cricopharyngeus muscle dysfunction (CPD) diagnosed between January 1, 2006 and December 31, 2008 were retrospectively reviewed from a clinical database. Three categories of CPD were defined: nonobstructing cricopharyngeal bars (CPBs), obstructing CPBs, and Zenker diverticulum (ZD). The primary outcome measure was the pharyngeal constriction ratio (PCR), a surrogate measure of pharyngeal strength on fluoroscopy. Secondary outcome measures included pharyngeal area in the lateral fluoroscopic view and UES opening. The outcome measures were compared between groups and to a cohort of nondysphagic age- and gender-matched controls with the analysis of variance.

RESULTS

A total of 100 fluoroscopic swallow studies were evaluated. The mean age (+ or -standard deviation) of the cohort was 70 years (+ or -10 years). Thirty-six percent were female. The mean PCR progressively increased, indicating diminishing pharyngeal strength, from the normal (0.08), to the nonobstructing CPB (0.13), to the obstructing CPB (0.22), to the ZD group (0.28) (P < .001 with trend for linearity). There was a linear increase in pharyngeal area from the normal (8.75 cm(2)) to the nonobstructing CPB (10.00 cm(2)), to the obstructing CPB (10.46 cm(2)), to the ZD group (11.82 cm(2)) (P < .01 with trend for linearity).

CONCLUSIONS

The data suggest that there is an association between cricopharyngeus muscle dysfunction and progressive dilation and weakness of the pharynx. Laryngoscope, 2010.

Pharyngeal pouch surgery in north Glasgow: NICE (National Institute for Health and Clinical Excellence) practice or not?

Aim:

To evaluate endoscopic pharyngeal pouch surgery practice in north Glasgow by comparing it to National Institute for Health and Clinical Excellence recommendations.

Methods:

We reviewed the case notes of patients who had undergone pharyngeal pouch surgery from 1998 to 2008. Data obtained included patient demographics, procedures performed, complications and outcomes.

Results:

One hundred patient case notes were reviewed. Surgical procedures performed included endoscopic stapling (n = 58), endoscopic laser surgery (26), external excision (one), cricopharyngeal myotomy (two) and pharyngoscopy with dilatation (three). Endoscopic stapling was abandoned in 10 patients (14.7 per cent), three of whom declined further surgery. There was a 2.2 per cent perforation rate for endoscopic procedures. Twenty-one per cent of patients required further surgery.

Conclusion:

Our practice was not in keeping with National Institute for Health and Clinical Excellence recommendations. Our complication rates were similar to other published series, although our rates for abandoned and revision procedures were higher. We suggest that pharyngeal pouch surgical procedures should be undertaken only by otolaryngologists with a primary head and neck interest.

Tracheobronchoscopy and esophagoscopy in current ear-nose-throat practice: an update

Rigid and flexible bronchoscopies and upper aerodigestive endoscopy are important diagnostic and therapeutic tools in ENT. The use of flexible upper aerodigestive endoscopy allows simultaneous percutaneous endoscopic gastrostomy (PEG) placement. Based on a similar study analyzing endoscopies performed in 1995, an anonymous questionnaire was developed by the Arbeitsgemeinschaft Endoskopie of the German Society of Oto-Rhino-Laryngology Head and Neck Surgery to determine current trends in the use of bronchoscopy and upper aerodigestive endoscopy. Questionnaires were sent to 165 different ENT institutions in Germany. 57 questionnaires were evaluated. 4,294 rigid and 3,965 flexible bronchoscopies were performed as well as 8,897 rigid and 2,211 flexible upper aerodigestive endoscopies. These results are shown according to the size (number of beds) of the performing institutions. Foreign body removals and PEG placements were also analyzed and compared with previous studies. In conclusion, the survey shows that the total number of procedures performed is comparable to the number performed in 1995. There is, however, a considerable increase in the number of flexible procedures performed, especially in upper aerodigestive endoscopies. It is commendable that all 57 institutions provide PEGs for their patients. However, only about one-fifth of these is placed by the treating ENT, despite the fact that panendoscopies provide an ideal setting for the performance of this procedure. An improvement of this situation would be desirable.