1
|
Howell R, Johnson C, Allen J, Altaye M, Amin M, Bayan S, Belafsky P, Cervenka B, Desilva B, Dion GR, Ekbom D, Friedman A, Fritz M, Giliberto JP, Guardiani E, Kasperbauer J, Kim B, Krekeler BN, Kuhn M, Kwak P, Ma Y, Madden LL, Matrka L, Mayerhoff R, McKeon M, Piraka C, Rosen CA, Tabangin M, Wahab SA, Wilson K, Wright C, Young VN, Postma G. Surgical Outcomes in Zenker Diverticula: A Multicenter, Prospective, Longitudinal Study. Laryngoscope 2024; 134:97-102. [PMID: 37191092 DOI: 10.1002/lary.30753] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/19/2023] [Accepted: 05/03/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To compare improvement in patient-reported outcomes (PROM) in persons undergoing endoscopic and open surgical management of Zenker diverticula (ZD). METHODOLOGY Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgery for ZD. Patient survey, radiography reports, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were abstracted from a REDCap database, which summarized means, medians, percentages, and frequencies of. Outcome based on operative intervention (endoscopic vs. open) was compared using t-test, Wilcoxon rank sum test or chi-square test, as appropriate. RESULTS One hundred and forty-seven persons were prospectively followed. The mean age (SD) of the cohort was 68.7 (11.0). Overall, 66% of patients reported 100% improvement in EAT-10; 81% of patients had greater than 75% improvement; and 88% had greater than 50% improvement. Endoscopic was used for n = 109 patients, and open surgical intervention was used for n = 38. The median [interquartile range, IQR] EAT-10 percent improvement for endoscopic treatment was 93.3% [72, 100], and open was 100% [92.3, 100] (p = 0.05). The incidence of intraoperative complications was 3.7% for endoscopic and 7.9% for open surgical management. The median [IQR] in follow-up was 86 and 97.5 days, respectively. CONCLUSION Both endoscopic and open surgical management of ZD provide significant improvement in patient-reported outcomes. The data suggest that open diverticulectomy may provide a modest advantage in symptomatic improvement compared to endoscopic management. The data suggest that the postoperative complication rate is higher in the open surgical group. LEVEL OF EVIDENCE 3 Laryngoscope, 134:97-102, 2024.
Collapse
Affiliation(s)
- Rebecca Howell
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Christopher Johnson
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - Jacqui Allen
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Mekibib Altaye
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Milan Amin
- Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, New York, New York, U.S.A
| | - Semirra Bayan
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Peter Belafsky
- Department of Otolaryngology-Head and Neck Surgery, University of California-Davis, Davis, California, U.S.A
| | - Brian Cervenka
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Brad Desilva
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, U.S.A
| | - Gregory R Dion
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Dale Ekbom
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron Friedman
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Mark Fritz
- Department of Otolaryngology-Head and Neck Surgery, University of Kentucky, Lexington, Kentucky, U.S.A
| | - John Paul Giliberto
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Elizabeth Guardiani
- Department of Otolaryngology-Head and Neck Surgery, University of Maryland, Baltimore, Maryland, U.S.A
| | - Jan Kasperbauer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Brandon Kim
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, U.S.A
| | - Brittany N Krekeler
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
- Department of Communication Sciences and Disorders, University of Cincinnati College of Allied Health Sciences, Cincinnati, Ohio, U.S.A
| | - Maggie Kuhn
- Department of Otolaryngology-Head and Neck Surgery, University of California-Davis, Davis, California, U.S.A
| | - Paul Kwak
- Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, New York, New York, U.S.A
| | - Yue Ma
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Lyndsay L Madden
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest University, Winston-Salem, North Carolina, U.S.A
| | - Laura Matrka
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, U.S.A
| | - Ross Mayerhoff
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan, U.S.A
| | - Mallory McKeon
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Cyrus Piraka
- Department of Gastroenterology/Hepatology, Henry Ford Health System, Detroit, Michigan, U.S.A
| | - Clark A Rosen
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Meredith Tabangin
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Shaun A Wahab
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Keith Wilson
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Carter Wright
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest University, Winston-Salem, North Carolina, U.S.A
| | - VyVy N Young
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Gregory Postma
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| |
Collapse
|
2
|
Kelley JK, Vanwyk A, Fritz GD, Sanford L, Zambito GM, Banks-Venegoni AL. The robot can break bars with the best of them: a novel approach to treating cricopharyngeal bars with myotomy. Surg Endosc 2023; 37:8099-8103. [PMID: 37702878 DOI: 10.1007/s00464-023-10415-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 08/20/2023] [Indexed: 09/14/2023]
Abstract
INTRODUCTION Failure of the cricopharyngeus to relax results in oropharyngeal dysphagia, which over time results in hypertrophy and increased risk for aspiration. Open myotomy is one definitive treatment option, however there are several drawbacks attributable to the long neck incision, ± drain placement, and invasiveness of the procedure. We aim to share our experience using the DaVinci robotic platform to perform a minimally invasive cricopharyngeal myotomy, which has never been described before in the literature. METHODS All robotic cricopharyngeal myotomies performed in adult patients by a single surgeon from 2021 to 2022 were retrospectively reviewed. No patients were excluded. Outcomes of interest included length of procedure, time to diet resumption, hospital length of stay, complications, symptom improvement at follow-up, and symptom recurrence. RESULTS Eight robotic cricopharyngeal myotomies were performed. The median age was 65 years old (62-91) and mostly female (n = 5, 56%) with a median BMI of 28.9 kg/m2 (21.7-39.5). The median procedure length was 113 min (94-141) and there were no intraoperative complications. All patients underwent a post-procedural esophagram with no leaks were identified. All patients were started on clear liquids in recovery and transitioned to full liquids prior to discharge. All but one patient was subsequently discharged home on the same day as procedure. All patients had routine 2-week post-operative follow-up in addition to phone follow-up at a later date (6-11 months post-operative). All patients reported resolution of symptoms. There were no complications or readmissions. No instances of recurrence were reported. On cost analysis, the minimally invasive robotic approach allows for an outpatient procedure with similar cost to an open approach with a one-night stay. CONCLUSION Our experience with the novel technique of minimally invasive robotic cricopharyngeal myotomy for cricopharyngeal bars with cervical dysphagia is safe, efficacious, less invasive, and cost saving, with excellent patient outcomes.
Collapse
Affiliation(s)
- Jesse K Kelley
- Michigan State University/Corewell Health General Surgery Residency, Grand Rapids, MI, USA.
| | - Austin Vanwyk
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | - Gregory Dane Fritz
- Michigan State University/Corewell Health General Surgery Residency, Grand Rapids, MI, USA
| | - Luke Sanford
- Corewell Health Department of General Surgery, Grand Rapids, MI, USA
| | | | | |
Collapse
|
3
|
Toro-Ortiz JP, Fernández-García F, Pinazo-Bandera J, Alcaín Martínez GJ, Lavín Castejón I. Endoscopic septotomy of Zenker's diverticulum with Stag-Beetle Knife™: A descriptive observational study and literature review. Gastroenterol Hepatol 2021:S0210-5705(21)00199-0. [PMID: 34129902 DOI: 10.1016/j.gastrohep.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/20/2021] [Accepted: 06/04/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Zenker's diverticulum (ZD) is a protrusion of the hypopharyngeal mucosa with a prevalence of 2/100,000 inhabitants. The symptoms of the patients determine the need for treatment, which can be surgical or endoscopic. The latter, known as endoscopic septotomy or diverticulotomy (ED), this involves dissecting the diverticular septum, which can be performed with different dissection devices. AIM The aim of our study was to evaluate the efficacy and safety of ED with Stag-Beetle-Knife™ device, as well as to conduct a literature review to assess the position of the technique in the current scientific panorama. MATERIAL AND METHODS Descriptive retrospective study that includes patients who underwent ED with SB-Knife™ between June 2017 and February 2020. Literature review of the available evidence between January 2013 and April 2020 of ED with SB-Knife™ technique and its variants. RESULTS Twelve patients (66% male) with a median age of 70.5 years were collected. The median size of diverticular was 32.5mm and complete remission was observed in 75% of the cases. Fourteen interventions were performed with a technical success of 92.8. There were no serious complications. A literature review was carried out, finding 13 papers, of which 8 were finally included (6 retrospective studies, a series of cases and a clinical case). CONCLUSION Based on our experience and the reviewed literature, we consider ED with SB-Knife™ is a safe, effective and reproducible technique, and may be a better alternative to surgery in patients with ZD.
Collapse
|
5
|
Visser LJ, Hardillo JAU, Monserez DA, Wieringa MH, Baatenburg de Jong RJ. Zenker's diverticulum: Rotterdam experience. Eur Arch Otorhinolaryngol 2015; 273:2755-63. [PMID: 26576954 PMCID: PMC4974285 DOI: 10.1007/s00405-015-3825-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 10/29/2015] [Indexed: 11/23/2022]
Abstract
Different surgical techniques exist for the treatment of Zenker’s diverticulum (ZD), of which minimally invasive techniques have become the standard. We reviewed our experience with management and treatment of ZD and sought to determine what type of treatment is most effective and efficient. We selected patients who underwent treatment for ZD between January 2004 and January 2014 at our tertiary referral center. All procedures were performed by ENT surgeons. The medical records were reviewed for pre- and intraoperative characteristics and follow-up. Of our 94 patients (58 male, 36 female), 75 underwent endoscopic cricopharyngeal myotomy (42 stapler, 33 laser) and 6 received treatment via transcervical approach. 13 interventions were aborted. Mean operating time was 49.0 min for stapler, 68.3 for laser and 124.0 for the transcervical approach. Its respective median post-operative admission durations were 2.0, 3.0 and 3.0 days. After the first treatment, of the 75 endoscopic procedures, 45 patients (23 stapler, 22 laser) had complete symptom resolution. In the transcervical group 4 (67 %) patients were symptom free and one patient died of complications. In the endoscopically treated patients, ten complications occurred, of which 8 G1 and 2 G2 (Clavien Dindo classification). In the transcervical group 2 complications occurred, 1 G3b and 1 G5. Both endoscopic techniques provide efficient management of Zenker’s diverticulum with the stapler-assisted modality providing a shorter surgery duration and hospital admission. Although there is no significant difference in terms of complications or recurrence rates for both endoscopic techniques, it seems that stapler patients are at higher risk of having a re-intervention and of having more severe complications.
Collapse
Affiliation(s)
- L J Visser
- Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus University Medical Center, 's-Gravendijkwal 230, 3015CE, Rotterdam, The Netherlands.
| | - J A U Hardillo
- Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus University Medical Center, 's-Gravendijkwal 230, 3015CE, Rotterdam, The Netherlands
| | - D A Monserez
- Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus University Medical Center, 's-Gravendijkwal 230, 3015CE, Rotterdam, The Netherlands
| | - M H Wieringa
- Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus University Medical Center, 's-Gravendijkwal 230, 3015CE, Rotterdam, The Netherlands
| | - R J Baatenburg de Jong
- Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus University Medical Center, 's-Gravendijkwal 230, 3015CE, Rotterdam, The Netherlands
| |
Collapse
|
6
|
Pescarus R, Shlomovitz E, Sharata AM, Cassera MA, Reavis KM, Dunst CM, Swanström LL. Trans-oral cricomyotomy using a flexible endoscope: technique and clinical outcomes. Surg Endosc 2016; 30:1784-9. [PMID: 26194262 DOI: 10.1007/s00464-015-4445-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 07/13/2015] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Zenker's diverticulum (ZD) is a rare upper esophageal pathology that is most prevalent in the sixth and seventh decade. Three different therapeutical options are available: (1) open trans-cervical approach, (2) rigid endoscopy and (3) flexible endoscopy. Our hypothesis is that a flexible endoscopic cricomyotomy represents a safe and effective treatment of ZD as well as cricopharyngeal spasm. METHODS A retrospective analysis of all patients that underwent a flexible endoscopic cricomyotomy at our institution between October 2008 and May 2014 was performed. Preoperative and postoperative (1 month and long-term follow-up) symptom scores and clinical outcomes were collected. Briefly, the ZD is carefully identified endoscopically and the common wall is divided using needle knife cautery with the help of an endoscopic cap. Clips are used to close the mucosal defect starting with the apex. RESULTS Twenty-six patients underwent a flexible endoscopic myotomy for a ZD. Of 26 patients, five (19.2 %) had a history of previous open or stapled trans-oral myotomy and four (15.4 %) underwent a concomitant foregut procedure. Mean length of stay was 1.5 days (range 1-11). Mean operative time was 68 min (range 28-149). One patient presented with a postoperative leak, and one patient presented with a retained clip. Both were treated endoscopically. Recurrent weekly dysphagia was present in 3/26 (11.5 %). One patient (3.8 %) underwent an endoscopic bougie dilatation postoperatively. With regard to clinical outcomes, there was a statistically significant improvement in both short-term (1 month) and long-term (median follow-up 21.8 months; range 1-68.2 months) dysphagia (p < 0.001; p < 0.001), regurgitation (p = 0.001; p = 0.017), cough (p = 0.006; p = 0.025) and aspiration (p = 0.013; p = 0.013). CONCLUSION Flexible endoscopic cricomyotomy offers durable relief of dysphagia, regurgitation, cough and aspiration in ZD patients. It appears to have a good safety profile with symptomatic recurrence occurring in up to 11.5 % of cases.
Collapse
|
9
|
Constantin A, Mates IN, Predescu D, Hoara P, Achim FI, Constantinoiu S. Principles of surgical treatment of Zenker diverticulum. J Med Life 2012; 5:92-7. [PMID: 22574094 PMCID: PMC3307087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 01/27/2012] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Pharyngo-esophageal diverticula are most frequently described in elderly patients, having symptoms such as dysphagia, regurgitation, chronic cough, aspiration and weight loss. The etiology remains controversial, although most of the theories are linked to structural or functional abnormalities of the crico-pharyngeal muscle. With the therapeutic attitude varying from conservative to surgical (with associated morbidity and mortality), the importance of knowing the etiopathology and clinical implications of the disease for establishing the management of the case is mandatory. The aim of the study is the reevaluation of the methods and therapeutic principles in pharyngo-esophageal diverticular disease, starting from the etio pathogeny. MATERIALS AND METHODS Our study group is made up of 11 patients with surgical indication for Zenker diverticulum, operated between 2001 and 2011. RESULTS During that period, more patients were diagnosed with this pathology, but the surgical indication was carefully established, in conformity with the actual practice guides, which involve the evaluation of the clinical manifestations determined by the diverticulum, as well as the identification and interception of the pathological mechanisms by the therapeutic gesture. CONCLUSION Although it has a "benign" pathology, the esophageal diverticulum requires complex surgical procedure that implies significant morbidity.
Collapse
Affiliation(s)
- A Constantin
- General and Esophageal Surgery Clinic, “Sf. Maria” Clinic Hospital, Bucharest, Romania
| | - IN Mates
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - D Predescu
- General and Esophageal Surgery Clinic, “Sf. Maria” Clinic Hospital, Bucharest, Romania
| | - P Hoara
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - FI Achim
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - S Constantinoiu
- General and Esophageal Surgery Clinic, “Sf. Maria” Clinic Hospital, Bucharest, Romania
| |
Collapse
|