Systematic review on treatment of Zenker’s diverticulum

Comprehensive assessment and treatment strategies for dysphagia in the elderly population: Current status and prospects

As the population ages, the prevalence of dysphagia among older adults is a growing concern. Age-related declines in physiological function, coupled with neurological disorders and structural changes in the pharynx associated with aging, can result in weakened tongue propulsion, a prolonged reaction time of the submental muscles, delayed closure of the laryngeal vestibule, and delayed opening of the upper esophageal sphincter (UES), increasing the risk of dysphagia. Dysphagia impacts the physical health of the elderly, leading to serious complications such as dehydration, aspiration pneumonia, malnutrition, and even life-threatening conditions, and it also detrimentally affects their psychological and social well-being. There is a significant correlation between frailty, sarcopenia, and dysphagia in the elderly population. Therefore, older adults should be screened for dysphagia to identify both frailty and sarcopenia. A reasonable diagnostic approach for dysphagia involves screening, clinical assessment, and instrumental diagnosis. In terms of treatment, multidisciplinary collaboration, rehabilitation training, and the utilization of new technologies are essential. Future research will continue to concentrate on these areas to enhance the diagnosis and treatment of dysphagia, with the ultimate aim of enhancing the quality of life of the elderly population.

Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative

OBJECTIVES

The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication.

METHODS

Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi-institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management.

RESULTS

There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases (n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases (p = 0.002); postoperative diet was not different between open and endoscopic (p = 0.26).

CONCLUSIONS

Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction.

LEVEL OF EVIDENCE

Level III Laryngoscope, 134:2678-2683, 2024.

Effectiveness and safety of stag beetle knife (SB knife) in management of Zenker's diverticulum: a systematic review and meta-analysis

Stag Beetle Knife (SB Knife) is increasingly being utilized for Zenker's Diverticulectomy (ZD). Our study assessed the effectiveness and safety of the SB Knife for the management of ZD. Ovid EBM reviews, Ovid Embase, Ovid Medline, ClinicalTrials.gov, Scopus, and Web of Science were searched to identify studies that utilized SB knife for ZD. Pooled proportions (PP) were calculated using the random-effects model. Heterogeneity was evaluated using I2 statistics. A total of 7 studies with 268 patients were included in the final analysis. Dysphagia and regurgitation were the most common clinical symptoms. The mean size of the ZD was 2.8 ± 0.7 cm and 28 (of 148) patients had undergone previous treatments. The PP of technical success was 98% (95% CI: 92.3-99.5; I20) with a mean procedure duration of 26.2 ± 8.3 minutes. The PP of clinical response at first follow-up and relapse after index procedure was 87.9% (95% CI: 81.6-92.3; I219) and 13.5% (95% CI: 9.6-18.6; I22), respectively. At final follow-up, the PP of clinical remission was 96.2% (95% CI: 91-98.4; I230.6) while the PP of procedure failure was 3.6% (95% CI: 1.6-8.1; I20). No severe adverse events (AEs) were noted while using the SB Knife. However, the PP of intraprocedural and postprocedural AEs was 13.2% (95% CI: 9.6-17.8; I20) and 9.3% (95% CI: 5.7-14.9; I2 < 20.9), respectively. SB Knife is highly safe and effective for Zenker's Diverticulectomy with a failure rate of only 3.6%.

A Multidisciplinary Minimally Invasive Approach Is Necessary for the Contemporary Management of Esophageal Diverticula

Background: Esophageal diverticula were traditionally treated with open surgery, which is associated with significant morbidity and mortality rates. Management has shifted to minimally invasive approaches with several advantages. We examine outcomes in patients with esophageal diverticula treated with minimally invasive techniques by a multidisciplinary surgical team at a single center. Materials and Methods: A retrospective review of a prospectively maintained database was performed for patients who underwent minimally invasive surgery for esophageal diverticula at our institution from June 2010 to December 2022. Primary outcomes were 30-day morbidity and mortality rates. Secondary outcomes were symptom resolution, length of stay (LOS), readmission, and need for reintervention. Results: A total of 28 patients were identified. Twelve patients had pharyngeal diverticula, 7 patients had midesophageal diverticula, and 9 patients had epiphrenic diverticula. Thirty-day morbidity and readmission rates were 10.7% (3 patients), 1 pharyngeal (sepsis), 1 midesophageal (refractory nausea), and 1 epiphrenic (poor oral intake). There were no esophageal leaks. Average LOS was 2.3 days, with the pharyngeal group experiencing a significantly shorter LOS (1.3 days versus 3.4 days for midesophageal, P < .01 versus 2.8 days for epiphrenic, P < .05). Symptom resolution after initial operation was 78.6%. Reintervention rate was 17.9%, and symptom resolution after reintervention was 100%. There were no mortalities. Conclusion: This study demonstrates that esophageal diverticula can be repaired safely and efficiently when performed by a multidisciplinary team utilizing advanced minimally invasive endoscopic and robotic surgical techniques. We advocate for the management of this rare condition at a high-volume center with extensive experience in foregut surgery.

Understanding Zenker's Diverticulum Treatment: Transoral CO2 Laser Microsurgery

The authors present a case of a 36-year-old woman with a recurrent throat foreign body sensation and persistent dysphagia. On physical examination, a polypoid mass was visible at the postcricoid region, mobile with swallowing. A barium swallowing test confirmed the diagnosis of Zenker's diverticulum. The patient underwent transoral CO2 laser microsurgery for excision of the pharyngeal pouch. At the four-month evaluation, the patient was remarkably asymptomatic and without evidence of recurrence. This clinical case illustrates in detail the endoscopic view of the pre and postoperative aspects of the pharyngeal pouch, showing a step-by-step transoral CO2 laser microsurgery technique, with video.

Surgical Outcomes in Zenker Diverticula: A Multicenter, Prospective, Longitudinal Study

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.

Endoluminal treatment for Zenker's diverticulum - a population-based observational study

BACKGROUND

Zenker's diverticulum is a false diverticulum arising in the oesophago-pharyngeal junction. It may cause symptoms like dysphagia and regurgitation. In Central Norway, treatment is centralized to St. Olavs hospital, either as an endoscopic stapled oesophago-diverticulostomy procedure at the Department of Gastrointestinal Surgery or as laser diverticulostomy at the Department of Ear, Nose and Throat Surgery, depending on diverticulum size.

METHODS

Retrospective, population-based, study from 2001-2020 on patients treated for Zenker's diverticulum, at the time with a rigid endoscopic approach. Patients were identified through the in-hospital register for operations. The two treatment groups were compared on relevant pre-, intra-, and postoperative variables by review of the individual patient records.

RESULTS

78 consecutive patients, 36 at Dept. of Ear, Nose and Throat Surgery and 42 at Dept. of Gastrointestinal Surgery, were treated with a total of 104 interventions. Crude incidence for a surgery-demanding Zenker's diverticulum was 0.57 per 100 000 per year. The Dept. of Ear, Nose and Throat Surgery administered significantly less often prophylactic antibiotics than the Dept. of Gastrointestinal Surgery (p < 0.001), administered more frequently intraoperative dexamethasone (p < 0.001), and had significantly more postoperative infections (19.6% vs 3.4%, p = 0.01). No procedure-related mortality was registered. Although no standardized follow-up took place, at a median of 119 months elapsed, observed clinical recurrence was 35% for the endostapler treatment and 51% for the laser treatment procedure.

CONCLUSION

Both rigid endoscopic stapled oesophago-diverticulostomy and laser diverticulostomy are safe treatments for Zenker's diverticulum, however with a substantial risk of recurrence.

Per-oral endoscopic myotomy is a safe and effective treatment for Zenker's diverticulum: a retrospective multicenter study

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. .

Diagnosis and Open Surgical Management of Laimer's Diverticulum: Case Series and Review of the Literature

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.

Management of the Zenker diverticulum: multicenter retrospective comparative study of open surgery and rigid endoscopy versus flexible endoscopy

BACKGROUND AND STUDY AIM

Zenker's diverticulum is a rare disease that affects quality of life due to dysphagia and regurgitation. This condition can be treated by various surgical or endoscopic methods.

PATIENTS AND METHOD

Patients treated for Zenker's diverticulum in three centers in the south of France between 2014 and 2019 were included. The primary objective was clinical efficacy. Secondary objectives were technical success, morbidities, recurrences, and need for a new procedure.

RESULTS

One hundred forty-four patients with a total of one hundred sixty-five procedures performed were included. A significant difference was found between the different groups in terms of clinical success (97% for open surgery versus 79% for rigid endoscopy versus 90% for flexible endoscopy, p = 0.009). Technical failure occurred more frequently in the rigid endoscopy group than in the flexible endoscopy and surgical groups (p = 0.014). Median procedure duration, median time to resumption of feeding, and hospital discharge were statistically shorter for endoscopies than for open surgery. On the other hand, more recurrences occurred in patients treated by endoscopy than those treated by surgery, and more reinterventions were required.

CONCLUSION

Flexible endoscopy appears to be as effective and safe as open surgery in the treatment of Zenker's diverticulum. Endoscopy allows a shorter hospital stay at the expense of a higher risk of recurrence of symptoms. It could be used as an alternative to open surgery for the treatment of Zenker's diverticulum, especially in frail patients.

Flexible Endoscopy Versus Rigid Endoscopy or Surgery for the Management of Zenker's Diverticulum: A Systematic Review and Meta-Analysis

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.

Postoperative Complications and Reoperative Surgery in the Treatment of Patients With Zenker Diverticulum

Importance

The association of the surgical approach, surgical specialty, and other factors with the outcomes of surgical treatment of Zenker diverticulum (ZD) have been debated in the literature.

Objectives

To explore the outcomes of 3 different surgical methods used in the management of ZD and determine the associations between patient characteristics, such as preoperative comorbidities and treatment outcomes.

Design, Setting, and Participants

This retrospective, population-based cohort study examined patient records of patients who underwent surgical treatment for ZD from the Care Register for Healthcare database in Finland between January 1996 and December 2015. Data review and analysis were completed in 2021.

Exposure

Surgical treatment for ZD.

Main Outcome and Measures

Complications of surgical procedures used in the management of ZD.

Results

In this study, 1044 patients (median [IQR] age, 70.0 [22.0-98.0] years; 416 female individuals [39.8%]) surgically treated for ZD were identified. Most patients (606 [58.0%]) had no preoperative comorbidities. A total of 67 (6.4%) complications were recorded, with a mortality rate of 0.9%. The likelihood of complications was associated with patient age (t [1042] = 2.28; Cohen d, 0.29; 95%, CI 0.04, 0.54), surgical approach (Cramer V = 0.14 [95% CI 0.07-0.21]), and surgical specialty (Cramer V, 0.16; 95% CI, 0.06-0.28). The median (IQR) length of stay in association with the primary surgical intervention was 3.0 (0-85.0) days. Length of stay was associated with patient age (Cramer V, 0.14; 95% CI, 0.06-0.25), especially in patients older than 90 years, surgical approach (F [2, 466.2] = 26.9; ηp2 = 0.08; 95% CI, 0.05-0.11), and surgical specialty (F [4, 22.1] = 11.0; ηp2 = 0.07; 95% CI, 0.04-0.10). Reoperation was associated with the initial surgical approach (Cramer V, 0.18; 95% CI, 0.12-0.23) and surgical specialty (Cramer V, 0.14; 95% CI, 0.09-0.21).

Conclusions and Relevance

The results of this cohort study suggest that the outcomes of surgical management depended on the surgical approach, surgical specialty, and patient age. Overall, surgical treatment may be considered safe and may be considered for all patients with symptomatic ZD.

Long-term outcomes of Zenker's peroral endoscopic myotomy (Z-POEM) for treatment of Zenker's diverticulum

Background and study aims  Z-POEM is now an established therapy for symptomatic Zenker's diverticulum (ZD). Short-term follow-up of up to 1-year post Z-POEM suggests excellent efficacy and safety; however, long-term outcomes are not known. Thus, we sought to report on longer-term outcomes (≥ 2 years) following Z-POEM for treatment of ZD. Patients and methods  This was an International multicenter retrospective study at eight institutions across North America, Europe, and Asia over a 5-year period (from December 3, 2015 to March 13, 2020) of patients who underwent Z-POEM for management of ZD with a minimum 2-year follow-up. The primary outcome was clinical success, defined as improvement in dysphagia score to ≤ 1 without need for further procedures during the first 6 months. Secondary outcomes included rate of recurrence in patients initially meeting clinical success, rate of reintervention, and adverse events (AEs). Results  A total of 89 patients (male 57.3 %, mean age 71 ± 12 years) underwent Z-POEM for treatment of ZD (mean diverticulum size was 3.4 ± 1.3 cm). Technical success was achieved in 97.8 % of patients (n = 87) with a mean procedure time of 43.8 ± 19.2 minutes. The median post-procedure hospital stay was 1 day. There were eight AEs (9 %) (3 mild, 5 moderate). Overall, clinical success was achieved in 84 patients (94 %). Mean dysphagia, regurgitation, and respiratory scores all improved dramatically from 2.1 ± 0.8, 2.8 ± 1.3, and 1.8 ± 1.6 pre-procedure to 0.13 ± 0.5, 0.11 ± 0.5, and 0.05 ± 0.4, respectively, post-procedure at most recent follow-up (all P  < 0.0001). Recurrence occurred in six patients (6.7 %) during a mean length of follow-up of 37 months (range 24 to 63 months). Conclusions  Z-POEM is a highly safe and effective treatment for Zenker's diverticulum with durable treatment effect to at least 2 years.

Transoral septotomy with septum traction is an effective treatment for recurrent Zenker diverticulum

Symptoms of Zenker diverticulum can recur whatever the type of primary treatment administered. A modified transoral stapler-assisted septotomy (TS) was introduced in clinical practice a few years ago to improve the results of this mini-invasive technique. The aim of this prospective, controlled study was to assess the outcome of TS in patients with recurrent Zenker diverticulum (RZD), as compared with patients with treatment-naïve Zenker diverticulum (NZD). Patients diagnosed with NZD or RZD, and treated with TS between 2015 and 2021 were compared. Symptoms were recorded and scored using a detailed questionnaire. Barium swallow and endoscopy were performed before and after the TS procedure. In sum, 89 patients were enrolled during the study period: 68 had NZD and 21 had RZD. The patients' demographic and clinical data were similar in the two groups. Three mucosal lesions were detected intra-operatively, and one came to light at post-operative radiological assessment in the NZD group. No mucosal lesions were detected in the RZD group. The median follow-up was 36 months (interquartile range 23-60). The treatment was successful in 97% NZD patients and 95% of RZD patients (P = 0.56). This is the first comparative study based on prospectively collected data to assess the outcome of TS in patients with RZD. Traction on the septum during the procedure proved effective in the treatment of RZD, achieving a success rate that was excellent, and comparable with the outcome in treating NZD.

The impact of prior endoscopic or surgical therapy on open Zenker's diverticulum surgery: analysis on a large single center cohort : Comparison of primary and revisional open surgery for Zenker's diverticulum

BACKGROUND

Endoscopic treatment of Zenker's diverticulum is an attractive minimally invasive alternative compared to the classic open approach. However, increased recurrence rate were reported. In case of relapse, endoscopic therapy might be repeated, or alternatively open surgery is performed. This study aimed to identify potential differences in the outcomes between primary or secondary surgical treatment in Zenker's diverticulum.

METHODS

From January 2003 to April 2019, 227 subsequent patients underwent surgical diverticulectomy and cervical myotomy at the surgical department of TUM. 41 of 227 patients had received previous therapy, either open or endoscopic. Perioperative parameters in priorly untreated patients were retrospectively compared to those after previous therapy (mostly endoscopic) with special regard to perioperative data and postoperative complications. Univariate and multivariate regression analyses were performed to identify predictors for postoperative complications.

RESULTS

We could show that the number of complications (p = 0.047) in pretreated patients is significant higher as well as the severity after Clavien-Dindo (p = 0.025). Stapler line leakage, wound infections, and operative revision rate was higher also pretreated group. Pretreatment and surgery time showed a significant association with postoperative complications in univariate analysis. In multivariate analysis, pretreatment remained a significant independent predictor of complications.

CONCLUSION

The present data indicate that endoscopic therapy might represent a risk factor for postoperative complications in case of relapse surgery. Therefore primary open surgery should be debated in patients with an increased high risk of relapse.

Peroral cricopharyngeal myotomy for the management of Zenker's diverticulum in the hands of a general surgeon

BACKGROUND

The treatment of Zenker's diverticulum has been shifted from open cricopharyngeal myotomy and rigid endoscopy to the use of flexible endoscopy. Few studies evaluate general surgeon's performance of flexible endoscopic management of Zenker's diverticulum as the majority are performed by gastroenterologists. The objective of our case series is to show that general surgeons trained in surgical endoscopy can perform this procedure with favorable outcomes.

METHODS

A retrospective review of peroral cricopharyngeal myotomies performed at Spectrum Health hospital in Grand Rapids, Michigan by a single surgical endoscopist between the 2018 and 2021 was conducted. The primary outcome was the improvement of dysphagia. Intra-procedural complications, post-procedural complications, hospital length of stay, time to oral intake, and recurrence were also evaluated. Age, sex, body mass index, diverticulum size, and procedure time were abstracted. Median (ranges) and frequencies (percentages) are used to describe the patient population and outcomes.

RESULTS

Forty patients were included in the study. Median age was 74 years old (60-95) with a male predominance (n = 27, 67.5%). Median BMI was 28 kg/m2 (18-43), average procedure length of 64 min (41-119), diverticulum size of 28 mm (19-90), and average length of stay of 0.9 days (0-8). There were no intra-procedural complications. All patients had a post-procedural esophagram prior to initiation of diet. Esophageal leak was the only complication that occurred, which was found on post-procedural esophagram (n = 5). Only two patients had clinical sequelae. All leaks closed without additional surgical intervention. The majority of patients had their diet resumed and discharged the same day of the procedure. Frequency of recurrence was 17.5% (n = 7).

CONCLUSION

Our study demonstrates that general surgeons trained in endoscopy can perform endoscopic myotomies for Zenker's diverticula on a wide range of sizes, with favorable patient outcomes, and few complications.

Evolving field of third-space endoscopy: Derivatives of peroral endoscopic myotomy

Third-space endoscopy, also known as submucosal endoscopy, allows for a wide range of therapeutic interventions within the submucosal layer and even into the muscular or subserosal layers of the gastrointestinal lumen. The technical development of peroral endoscopic myotomy (POEM) for achalasia has revolutionized the field of therapeutic endoscopy and the method has been continuously refined and modified. Although POEM has been applied to treat primary achalasia, it shows a favorable clinical response in other esophageal motility disorders and as a salvage treatment after previously failed intervention. Gastroesophageal reflux after POEM has drawn considerable attention and there have been major advancements in its prevention and management. POEM has led to advantageous derivatives such as peroral endoscopic tumor resection or submucosal tunneling endoscopic resection for resection of subepithelial lesions, Zenker POEM for hypopharyngeal diverticula, diverticular POEM for epiphrenic esophageal diverticula, and gastric POEM for refractory gastroparesis. These techniques have a similar concept, which constitutes submucosal tunneling with a mucosal flap valve and secure mucosal incision closure. The submucosal tunneling technique is widely accepted and continues to evolve. This study aimed to review in detail the indications, outcomes, and technical variations in POEM and explore several emerging submucosal tunneling procedures. This review will benefit future studies by providing a summary of recent developments in this field.

Malnutrition and Postoperative Outcomes Following Transcervical Zenker Diverticulectomy

OBJECTIVES

Hypoalbuminemia has been used as a proxy for poor nutrition, and has been associated with poor postoperative outcomes in varying surgical procedures. This study investigates the association between albumin status and complications following transcervical Zenker diverticulectomy.

STUDY DESIGN

Retrospective database review.

METHODS

The National Surgical Quality Improvement Program database was queried for patients who underwent transcervical Zenker diverticulectomy between 2005 and 2018. Univariate and multivariable analyses were conducted to determine associations between albumin status and postoperative complications.

RESULTS

318 patients undergoing transcervical Zenker diverticulectomy with available albumin values were queried. The mean serum albumin was 3.90 g/dL (SD = 0.56). Univariate analysis showed that hypoalbuminemia was associated with increased age (77.68 vs. 70.03 years) and female gender (54.4% vs. 45.6%), as well as sepsis (p = 0.045), reintubation (p = 0.040), urinary tract infection (p = 0.017), any medical complication (p < 0.001), any life-threatening complication (p = 0.017), and mortality (p = 0.012). Multivariable analyses found no associations between hypoalbuminemia and mortality (OR 33.136, 95% CI N/A, p = 1.000), any medical complication (OR 1.154, 95% CI 0.326-4.079, p = 0.824), any life-threatening complication (OR 0.604, 95% CI 0.079-4.586, p = 0.604), and length of stay (p = 0.249).

CONCLUSIONS

This study suggests no association between hypoalbuminemia and postoperative complications in transcervical Zenker diverticulectomy. Hypoalbuminemia and malnutrition may not be a contraindication for surgery correcting Zenker diverticulectomy.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:1402-1408, 2023.

Epidemiology and Management of Zenker Diverticulum in a Low-Threshold Single-payer Health Care System

Importance

The incidence of Zenker diverticulum has been established; previous estimates have been extrapolated from small institutional cohorts.

Objective

To describe the population-wide incidence of Zenker diverticulum over a 20-year period and characterize management strategies across specialties and treatment settings.

Design, Setting, and Participants

This retrospective national cohort study was conducted from January 1, 1996, through December 31, 2015, and reviewed patient records from the Care Register for Healthcare in Finland, from which patients with Zenker diverticulum were identified. The data were analyzed in October 2021.

Exposures

Zenker diverticulum.

Main Outcome and Measure

The incidence of Zenker diverticulum per 100 000 person-years.

Results

A total of 2736 patients (median [IQR] age at diagnosis 72.0 [19-106] years; 1278 women [46.7%]) were identified, making the annual incidence of Zenker diverticulum in Finland 2.9/100 000 person-years. Men had higher incidence (3.7/100 000 person-years) compared with women (2.3/100 000 person-years), with an incidence rate ratio of 1.61 (95% CI, 1.48-1.76; P < .001). Within the study population, 1044 patients (38.2%) underwent surgical treatment and 227 (8.3%) underwent 2 or more surgeries. The choice of initial operative approach depended on the medical specialty (Cramer V = 0.41) and on specific catchment area (Cramer V = 0.41). Overall, endoscopic approaches for initial operations were most popular.

Conclusions and Relevance

The cohort study results found that the incidence of Zenker diverticulum was 2.9/100 000 person-years. Most patients with Zenker diverticulum did not undergo definitive therapy. Some hospital districts and some medical specialties were more likely to opt for conservative treatment than others. The choice of operative approach depended more on physician-level factors rather than patient profiles.

Cricopharyngeal Myotomy in National Surgical Quality Improvement Program (NSQIP): Complications for Otolaryngologists Versus Non-otolaryngologists

Objective: Comparing outcomes after cricopharyngeal myotomy (CM) performed by otolaryngologists (OTO) and non-otolaryngologists (NO).

Methods: A retrospective analysis of the 2014-19 ACS-NSQIP database (American College of Surgeons National Surgical Quality Improvement Program) of patients who underwent open CM (CPT code 43030) as their primary procedure. Analyzed variables include medical comorbidities, operative time, the total length of stay, readmission, reoperation, concurrent procedures, postoperative complications, and postoperative diagnoses. 183 patients were included, 97 (53%) females and 86 (47%) males. 120 had surgery by OTO and 63 by NO. 

Results: There were no differences in preoperative morbidity. OTO had more outpatient surgeries compared to NO (p<.001). OTO had a longer mean operating time (p=.008). OTO had a higher proportion of concurrent laryngeal procedures and other unspecified procedures compared to NO, while NO had a higher proportion of concurrent esophageal procedures (p=.028). The total length of stay was not significantly different between the two groups. 5.8% OTO and 7.9% NO patients were readmitted for a related reason (p=.586). Complications were similar between the two groups (p>.05). NO had more postop diagnoses of acquired diverticula and achalasia of the stomach cardia, while OTO had more diagnoses of dysphagia and muscular dystrophy (p<.001). 

Conclusion: There were differences in the surgical setting, length of procedure, concurrent procedures, and postop diagnoses between NO and OTO surgeons but similar complication rates.

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.

KTP laser endoscopic cricopharyngeal myotomy and pharyngeal pouch diverticulotomy: how I do it

BACKGROUND

Various endoscopic methods of dividing the cricopharyngeus muscle and the common wall of pharyngeal pouches have been described, most commonly the carbon dioxide laser and stapler. The potassium titanyl phosphate (KTP) laser is an alternate endoscopic method of treatment.

METHODS

The KTP laser is used in a similar fashion to the carbon dioxide laser to carefully divide the cricopharyngeus muscle fibres ± the common wall of the pharyngeal pouch, under microscopic visualization.

CONCLUSION

The KTP laser is an alternative and safe technique for these surgeries.

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.

Cap-Assisted Endoscopic Septotomy of Zenker's Diverticulum: Early and Long-Term Outcomes

INTRODUCTION

Multiple therapeutic modalities including surgery and rigid and flexible endoscopy have been adopted to manage Zenker's diverticulum (ZD). Minimally invasive flexible endoscopic septotomy (FES) techniques have been increasingly favored over the past 20 years; however, long-term data are still scanty. The aim of this study is to evaluate early and long-term outcomes of FES for naive ZD in a single-center setting.

METHODS

From 2010 to 2017, ZD patients treated with FES were included in a prospectively maintained database (NCT03948438). Those who had already been treated surgically or endoscopically were excluded from the analysis. The Dakkak and Bennett dysphagia scale was used to rate the dysphagia. Persistent complete or near-complete resolution of symptoms (Dakkak and Bennett 0 or 1) was defined as clinical success. Postprocedural adverse events were reported according to ASGE lexicon.

RESULTS

Overall, 256 consecutive patients were treated. Mean pouch size was 29.8 ± 11.3 mm. The procedure was successfully completed in all scheduled patients, with an early clinical success of 96.1%. Adverse events occurred in 3.5% (9/256) of patients. Eight of them were mild/moderate with no fatal events, whereas one patient required surgery. Recurrences occurred in 31.3% (80/256) of treated patients after a mean time of 9 ± 3 months and 95% of recurrences were treated by a second FES. At an average follow-up of 5.5 years, 95.3% of patients were asymptomatic after a mean number of 1.3 procedures.

DISCUSSION

FES is a safe and effective treatment modality for patients with ZD. Recurrence rate is significant; however, endoscopic reintervention is associated with long-term relief of dysphagia.

Peroral endoscopic myotomy as treatment for Zenker's diverticulum (Z-POEM): a multi-center international study

BACKGROUND

Peroral endoscopic myotomy for the treatment of Zenker's diverticulum (Z-POEM) is a novel technique that has been described in several recent reports. This method utilizes the third space (submucosal layer) to create a tunnel to facilitate complete visualization of the septum and hence cutting it entirely. Conventional endoscopic septotomy carries the risk of recurrence due to incomplete visualization of the septum. While surgical correction is a risky and lengthy procedure in old comorbid patients with Zenker's diverticulum. The aim of this study is to assess the efficacy and safety of Z-POEM.

METHODS

The study enrolled 24 patients diagnosed with Zenker's diverticulum (ZD) who underwent Z-POEM at seven independent endoscopy centers in five different countries.

RESULTS

Mean patient age ± standard deviation (SD) was 74.3 ± 11 years. Most of the patients were males (n = 20, 83.3%); four (16.7%) were females. More than 50% of the patients (n = 14, 58.3%) had associated comorbidities. The mean size of the diverticula was 4 cm (range 2-7 cm). The Kothari-Haber Score was used to assess clinical symptoms; values ranged from 6 to 14 (median = 9). We achieved 100% technical success with a median procedure time of 61 min and no adverse events. Median hospital stay was 1 day (range 1-5 days). There is a significant reduction in the Kothari-Haber Score after Z-POEM (P < 0.0001). Technical success was achieved in 100% of the patients. Clinical success was achieved in 23/24 (95.8%) of the patients with a median follow-up of 10 months (range 6-24 months).

CONCLUSION

Z-POEM is a safe and effective modality for managing ZD.

Foregut Diverticula

Diverticular disease can present anywhere along the gastrointestinal (GI) tract. It can result from various pathologies such as abnormal contraction within the GI tract or inflammation causing scar tissue and the resulting forces surrounding the GI tract. Its clinical presentation can vary from asymptomatic to severe symptoms, with significant decrease in quality of life. The treatment for various diverticula along the GI tract can also vary, depending on the severity of symptoms. This article describes diverticular disease occurring within the foregut, with emphasis on pathophysiology, clinical presentation, and treatment.

Transoral Laser-Assisted Diverticulectomy: Swallow Study Results after Complete Endoscopic Pouch Excision for Zenker's Diverticulum

OBJECTIVE

Transoral endoscopic laser-assisted diverticulotomy (TELD) with diverticulectomy and diverticuloplasty (TELD + DD) for the management of Zenker's diverticulum (ZD) has been utilized by our institution since 2016 in attempts to reduce residual pouch size. This technique involves complete endoscopic pouch excision with partial advancement of mucosal flaps. Our study compares the subjective outcomes, objective outcomes, and complication rates between TELD and TELD + DD.

METHODS

A retrospective cohort study was performed on patients who underwent TELD or TELD + DD by a single surgeon at a tertiary academic center (2013-2019). Videofluoroscopic swallow studies (VFSS) with esophagram, Eating Assessment Tool (EAT-10), Reflux Symptom Index (RSI), and Functional Outcome Swallowing Scale (FOSS) were collected at preoperative and 3 month follow-up visits. A single blinded reviewer recorded height, width, and depth of pre and postoperative pouches with volumetric analysis performed assuming an ellipsoid shape. Comorbidities, complications, postoperative course, and recurrence were recorded.

RESULTS

Of the 75 patients that met criteria, 27 underwent TELD + DD and 48 underwent TELD. Eighteen TELD + DD and 37 TELD had both pre and post-operative VFSS. TELD + DD and TELD had a 96 ± 7% and 87 ± 16% reduction in pouch volume, respectively (t-test; P = .01). Complications (TELD + DD 7%, TELD 17%, fisher's exact; P = .31) and final subjective outcomes after adjusting for initial were not significantly different between methods (EAT-10 with TELD + DD ∆ + 1.3, P = .18; RSI ∆ + 1.4, P = .29; FOSS ∆-0.02, P = .91). One short-term recurrence was reported with TELD.

CONCLUSION

Use of TELD + DD is associated with a statistically significantly decreased residual pouch size with no significant difference in short-term subjective outcomes. Complication rates and short-term recurrence rates are comparable. Long-term recurrence rates will require further studies to characterize.

LEVEL OF EVIDENCE

Level 3.

Comparison of Surgical Treatments for Zenker Diverticulum: A Systematic Review and Network Meta-analysis

Importance

Zenker diverticulum (ZD) can cause significant dysphagia, and symptoms can return or persist after surgery. This systematic review and network meta-analysis is the first to our knowledge to compare 3 common surgical techniques for ZD.

Objective

To compare the 3 most common surgical techniques-endoscopic laser-assisted diverticulotomy, endoscopic stapler-assisted diverticulotomy, and transcervical diverticulectomy with cricopharyngeal myotomy-in adult patients with ZD.

Data Sources

The published literature was searched using strategies designed by a medical librarian (search performed September 21, 2018). Strategies were established using a combination of controlled vocabulary terms and keywords and were executed in Ovid MEDLINE (1946 to September 21, 2018), Embase (1947 to September 21, 2018), Scopus (1823 to September 21, 2018), Cochrane Library, and ClinicalTrials.gov. Results were limited to English using database-supplied filters, which generated studies from 1997 to 2017.

Study Selection

Inclusion criteria were cohort studies or randomized clinical trials. Studies that included patients needing revision surgery or undergoing an alternative technique were excluded.

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-analyses-Network Meta-analyses (PRISMA-NMA) checklist was used to report the study findings. Two authors independently reviewed the studies.

Main Outcome and Measure

The primary outcome measure was the incidence of persistent or recurrent symptoms following surgery. The primary study outcome was planned before data collection began.

Results

The search generated 529 studies. After applying inclusion and exclusion criteria, 9 cohort studies remained, consisting of 903 patients treated with either laser-assisted diverticulotomy (n = 283), transcervical diverticulectomy (n = 150), or stapler-assisted diverticulotomy (n = 470). A network meta-analysis was performed. Between endoscopic laser-assisted diverticulotomy and open diverticulectomy, the open approach showed a statistically lower likelihood of persistent/recurrent symptoms following treatment (odds ratio [OR], 0.20; 95% CI, 0.04-0.91). Comparing laser-assisted diverticulotomy with the stapler-assisted technique, there was not a significant difference between the 2 techniques (OR, 0.83; 95% CI, 0.43-1.60). The consistency model for the network meta-analysis was supported (χ21 = 0.12; P = .73).

Conclusions and Relevance

This systematic review and meta-analysis compared 3 common techniques for treating ZD. The open approach showed a decreased likelihood of persistent or recurrent symptoms following surgery compared with the 2 other techniques.

Endoscopic Treatment of Zenker's Diverticulum: Comparable Treatment Outcomes in Treatment-Naïve and Pretreated Patients

Background and Aims

Flexible endoscopic treatment plays an important role in the treatment of Zenker's diverticulum (ZD). This study analyzes long-term symptom control and the rate of adverse events in treatment-naïve patients and patients with recurrence, using the stag beetle knife junior (sb knife jr).

Methods

From August 2013 to May 2019, 100 patients with symptomatic ZD were treated with flexible endoscopy using the sb knife jr. Before treatment, as well as 1 and 6 months afterwards, symptoms were obtained by a nine-point questionnaire, with symptoms weighted from 0 to 4.

Results

Overall, 126 interventions were performed. The median follow-up period was 41 months (range 7-74). For the three most frequent symptoms, regurgitation, dysphagia, and dry cough, a significant reduction of the mean score could be achieved, from 2.85/3.45/2.85 before the initial treatment to 0.56/1.09/0.98 6 months later. 17 patients were retreated because of recurrence. Out of these, 12 patients underwent a 2^nd, 4 patients a 3^rd, and 1 patient a 4^th session, respectively. The mean dysphagia score for successfully treated patients could be reduced from initially 2.34 to 0.49/0.33/0.67 after the 1^st/2^nd/3^rd session, the frequency of dysphagia from 3.45 to 0.92/1.00/1.33, and the score for regurgitations from 2.85 to 0.35/1.00/0.67. In first-line treatment, as well as in retreatment, no severe adverse event occurred.

Conclusion

Patients with ZD can be treated safely and effectively with the sb knife jr. Retreatment leads to equal symptom relief as compared to a successful first-line treatment and is not associated with a higher rate of adverse events.

Pharyngeal Pouch Surgery in Octo- and Nonagenarians is Safe and Effective: A Multicentre Comparative Cohort Study

BACKGROUND

Surgery is the only effective treatment strategy for a symptomatic pharyngeal pouch. However, octo- and nonagenarians are often denied referral to a surgeon because of perceived increased risks. Here, we compare the outcomes of pharyngeal pouch surgery in octo- and nonagenarians with patients under 80 years-of-age and determine the factors which predict post-operative complications and improvement in swallowing.

METHODS

Analysis of a prospectively maintained database of patients who underwent pharyngeal pouch surgery across seven hospitals over 15 years.

RESULTS

In total, 113 patients (≥80 years-of-age: 27, <80 years-of-age: 86) underwent endoscopic or open pharyngeal pouch surgery. Despite more comorbidities and a longer hospital stay (median: one extra day), patients ≥80 years-of-age had comparable operative time, complication profile, intensive care admission, emergency reoperation, and revisional pouch surgery as their younger counterparts. Furthermore, the severity of complications was not significantly different between the two age cohorts. No surgical mortality was recorded. Multivariate analysis demonstrated that diverticulectomy combined with cricopharyngeal myotomy independently predicted higher rates of complications (OR: 4.53, 95% CI: 1.43-14.33, p = 0.010), but also greater symptomatic improvement (OR: 4.36, 95% CI: 1.50-12.67, p = 0.007). Importantly, a greater proportion of octo- and nonagenarians experienced improved swallowing than patients <80 years-of-age (96.3% vs. 74.4%, p = 0.013). Moreover, advanced age was not predictive of post-operative complications on multivariate analysis.

CONCLUSIONS

Pharyngeal pouch surgery in octo- and nonagenarians is safe and effective. Surgical correction in this age group alleviates symptoms and improves quality-of-life for most patients. These patients should not be denied surgery on the basis of advanced age alone.

Cricopharyngeal Myotomy in Inclusion Body Myositis: Comparison of Endoscopic and Transcervical Approaches

OBJECTIVE

Inclusion body myositis (IBM) is a progressive inflammatory myopathy with dysphagia as a debilitating sequalae. Otolaryngologists are consulted for surgical candidacy when there are findings of cricopharyngeal dysfunction. We aim to compare transcervical cricopharyngeal myotomy (TCPM) versus endoscopic cricopharyngeal myotomy (ECPM) in the IBM population with particular focus on objective swallow study outcomes, complications, and recurrence rates.

METHODS

A retrospective cohort study was performed on IBM patients who underwent TCPM or ECPM (1981-2020) in the Department of Otolaryngology at a tertiary academic center with a high volume IBM referral base. Videofluoroscopic swallow studies, Eating Assessment Tool (EAT-10), Reflux Symptom Index (RSI), and Functional Outcome Swallowing Scale (FOSS) were collected at preoperative and follow-up visits. Baseline patient characteristics, intraoperative data, and postoperative course were recorded.

RESULTS

Forty-one patients were identified (18 TCPM; 23 ECPM). There was no significant difference in the recurrence rates, complications, hospitalization length, operative time, or return to preoperative diet between approaches. For the 12 patients (11 ECPM; 1 TCPM) that had subjective swallow data, there was a statistically significant difference in the pre and postoperative scores for EAT-10, RSI, and FOSS (P < .05). There was a statistically significant improvement in the degree of narrowing between pre and postoperative imaging for both approaches (P < .05).

CONCLUSION

Both TCPM and ECPM are safe approaches for the management of dysphagia in patients with IBM with objective evidence of cricopharyngeal dysfunction. Cricopharyngeal myotomy is a durable technique that has demonstrated improved subjective and objective outcomes in this patient population.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E2426-E2431, 2021.

Per Oral Endoscopic Myotomy for the Management of Large Esophageal Diverticula (D-POEM): Safe and Effective Modality for Complete Septotomy

With the advent of the technique of sub-mucosal tunnelling, peroral endoscopic myotomy (POEM) has been used for the treatment of esophageal diverticulum, which otherwise is a recurring problem with conventional flexible endoscopic treatment due to incompleteness of septotomy. This study reports our experience of the use of diverticular POEM (D-POEM) technique in the management of large esophageal diverticulum. This is a retrospective study of prospectively maintained database including all consecutive patients with symptomatic esophageal diverticulum presenting at a tertiary care academic center. D-POEM was performed using the technique of submucosal tunnelling and septotomy. Besides baseline parameters, technical success, clinical success, size of diverticula, procedure time, complications and symptom recurrence on follow up were noted. A total of five patients (4 males; median age 72) were included with an average Charlson comorbidity index of 3.2 ± 0.8. Of them, three had Zenker's while two had epiphrenic diverticulum. The median symptom duration was 12 months with a mean diverticulum size of 68.8 ± 1.9 mm. The mean procedure time was 64.80 ± 12.6 min. with a mean septotomy/myotomy length of 79.44 ± 12.2 mm. Minor adverse events were noted intra-procedure in two cases. Clinical success achieved in all cases with a significant mean dysphagia score reduction from 2.20 to 0.20 post procedure (p = 0.011). On a median follow up of 280 days (range 98-330), none had recurrence of symptoms. Our data highlighted that complete septotomy by D-POEM technique can be achieved for the management of large esophageal diverticulum and is safe and effective.

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.

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.

30-Day Postoperative Outcomes Following Transcervical Zenker's Diverticulectomy in the Elderly: Analysis of the NSQIP Database

OBJECTIVE

To compare the effect of patient factors, including age, on 30-day postoperative outcomes and complications for patients undergoing transcervical Zenker's diverticulectomy.

STUDY DESIGN

Retrospective cross-sectional analysis.

SETTING

American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database.

METHODS

Patients who underwent open Zenker's diverticulectomy (Current Procedural Terminology code 43130) were queried via the NSQIP (2006-2018). Outcomes analyzed include patient demographics, medical comorbidities, admission type, operative characteristics, length of admission, postoperative complication, readmission, and reoperation.

RESULTS

A total of 614 patients were identified. Mean age at time of surgery was 71.1 years, with 13.4% older than 85 years. Outpatient procedures were performed in 29.8%. Postoperative complications occurred in 6.7%, with reoperation and readmission rates of 6.4% and 7.2%, respectively. A mortality rate of 0.3% was observed. Only smoking status (odds ratio, 2.94; P = .008) and history of congestive heart failure (odds ratio, 10.00; P = .014) were shown to have a significant effect on postoperative complications.

CONCLUSION

Smoking status confers a high risk for postoperative complication. Age was not an independent risk factor associated with adverse outcomes following open diverticulectomy, suggesting this procedure can be safely performed in patients with advanced age.

Early Adverse Events Following Transcervical Hypopharyngeal Diverticulum Surgery

Objective:

To describe rates of short-term morbidity following transcervical surgical treatment of hypopharyngeal diverticulum (HD) and analyze predictors of adverse events.

Methods:

The 2005 to 2017 National Surgical Quality Improvement Program database was queried to identify patients diagnosed with HD undergoing open transcervical diverticulectomy.

Results:

A total of 597 patients with a mean age of 71.4 ± 12.3 years were included. Thirty-day adverse events were experienced by 63 (10.6%) subjects, including 6.5% unplanned reoperations, 4.2% surgical complications, 4.4% medical complications, 2.7% readmissions, and 0.7% deaths. Medical complications notably included pneumonia (2.0%), reintubation (1.2%), sepsis (1.2%), intubation >48 hours (0.5%), urinary tract infection (0.5%), or deep vein thrombosis (0.5%), while surgical complications included organ/space infection (2.0%) and superficial (1.3%) or deep (1.0%) surgical site infection. Gender, race, functional status, diabetes, dyspnea, hypertension, steroid use, and recent weight loss were not associated with adverse events. Length of operation and hospitalization were both higher among those with adverse events (127.4 ± 107.9 vs 95.7 ± 59.8 minutes, P = 0.027, and 7.4 ± 7.4 vs 2.8 ± 3.6 days, P < 0.001). On multivariable logistic regression, high American Society of Anesthesiologists (ASA) class (OR = 2.02, P = 0.017), smoking (OR = 2.10, P = 0.044), and operation time (OR = 1.01; P = 0.005) were independent predictors of adverse events. Obesity was not associated with length of stay, readmission/reoperation, or complications. However, increased age was associated with shorter operations ( P = 0.020), higher length of hospitalization ( P < 0.001), and higher mortality ( P = 0.027) and readmission rates ( P = 0.023).

Conclusion:

Understanding clinical factors associated with complications following open surgery for HD such as ASA score, smoking status, length of operation, and age can help optimize surgical outcomes for at-risk patients.

Flexible endoscopy assisted by Ligasure™ for treatment of Zenker's diverticulum: an effective and safe procedure

BACKGROUND

Flexible endoscopy allows use of the vessel-tissue sealer Ligasure™ (Covidien, Massachusetts, USA) to perform diverticulotomy. Few studies have used this endoscopic approach in the uncommon disorder Zenker's diverticulum. The aim of the present study was to evaluate the effectiveness and safety of flexible endoscopy treatment assisted by Ligasure™.

METHODS

The single-center prospective and descriptive study included patients treated by flexible endoscopy using Ligasure™ for resection of Zenker's diverticulum. Consecutive patients were included from March 2009 to April 2018. Patients were censored until the end of follow-up or death. Complications, symptoms before treatment, type of sedation, and number of interventions needed to resolve Zenker's diverticulum were analyzed. Bleeding complications were considered when a case required a second endoscopy.

RESULTS

A total of 46 symptomatic patients with Zenker's diverticulum were included in the final analysis (41.3% women, median age of 73.7 ± 11 years). The median follow-up period was 37.21 ± 28 months. Of all cases, 58.7% were considered small (< 3 cm). Solid or semi-solid food-related dysphagia was present in 55.6% of patients previously to the procedure. The technique was successful in a single procedure in 78.3% of cases. However, the success rate increased to 89.1% with a second procedure, and we had a complication rate of 4.3% with this technique. Most patients (79.66%) were managed as out-patients or with short (< 24 h) admission.

CONCLUSION

In this large case series, treatment of Zenker's diverticulum based on flexible endoscopy assisted by Ligasure™ was a safe and effective procedure with a high success rate in a few endoscopy sessions and low complication rate.

Z-POEM as a Treatment Option for Zenker’s Diverticulum: Our Experience at a Tertiary Care Centre in India

Background This study was aimed to evaluate efficacy and safety of Z–peroral endoscopic myotomy (Z-POEM; submucosal tunneling endoscopic myotomy) for Zenker’s diverticulum (ZD).

Methods This is a retrospective study at a single tertiary care center in India. The Z-POEM technique was performed using principles of submucosal tunneling endoscopy with prior experience from POEM technique for achalasia cardia

Results Sixteen patients (male, 62.5%; mean age, 73.2 ± 5.2 years) were included with a mean Charleson’s comorbidity index of 4.32. The mean size of ZD was 34.8 ± 10.0 mm. The technical success rate was 100%. Clinical success was achieved in 100% (16/16) with a decrease in mean dysphagia score from 2.9 to 0.2 (p <0.0001). The mean procedure time was 47 ± 7.9 minutes and mean length of septotomy was 31.9 ± 9.4 mm. The mean length of hospital stay was 1.2 ± 0.4 days. No major adverse events were noted. Capnomediastinum was noted in two cases on follow-up Gastrografin study after 24 hours (12.5%). This did not merit any treatment. One patient had intraprocedural bleed which was controlled easily. At the 18-month follow-up, two (12.5%) patients reported dysphagia recurrence (Dakkak and Bennett score 1) but did not require repeat intervention.

Conclusion Endoscopic management of ZD using the POEM technique is a promising technique with improved efficacy and safety. However, long-term follow-up is needed to ensure the durability of response.

Endoscopic stapling versus laser for Zenker diverticulum: a retrospective cohort study

PURPOSE

Despite the evolution of the endoscopic techniques for the treatment of symptomatic Zenker diverticulum, comparative studies are lacking. Aim of this observational study was to compare safety, efficacy, and outcomes of endoscopic stapling (ES) versus Laser (EL).

METHODS

A prospectively collected database of patients who underwent treatment for Zenker diverticulum at a single institution was reviewed. Consecutive patients treated by ES or EL were included in the study. Demographic data, presenting symptoms, diverticulum characteristics, and intra- and postoperative data were analyzed. The Functional Outcome Swallowing Scale (FOSS) and MD Anderson Dysphagia Inventory (MDADI) questionnaires were administered to assess severity of dysphagia and quality of life before and after treatment.

RESULTS

Between March 2017 and September 2018, 36 patients underwent ES or EL. In the TL group (n = 19), the diverticulum size was smaller compared to the EL group (n = 17) (p = 0.002). Two perforations occurred in the EL group, one treated conservatively and the other requiring drainage of a mediastinal abscess. At a median follow-up of 16 months, symptoms improved in both groups but the number of patients with a postoperative FOSS score ≥ 2 significantly decreased only after EL (p < 0.001). The scores of all items of the MDADI questionnaire significantly increased in both groups, but the average delta values were greater in the EL patients (p < 0.001).

CONCLUSIONS

Both TL and ES are effective treatment options for Zenker diverticulum. Postoperative quality of life was significantly higher in patients undergoing EL compared to ES.

Interdisciplinary Comparison of Endoscopic Laser-Assisted Diverticulotomy vs. Transcervical Myotomy as a Treatment for Zenker's Diverticulum

BACKGROUND

Currently, there are different competing techniques for the treatment of Zenker's diverticulum (ZD). To improve patient selection, we compared endoscopic laser-assisted diverticulotomy (ELAD) with transcervical myotomy (TCM) with regard to possible risk factors for treatment failure.

METHODS

Data of ZD patients (n = 104) treated between 2004 and 2016 with either TCM (38%) or ELAD (62%) were analyzed retrospectively. Univariate and multivariate analyses were performed.

RESULTS

TCM is associated with a higher morbidity (27.8% vs. 10.2%; p = 0.095) but lower recurrence rate (7.3% vs. 19.3%; p = 0.095). Preoperative reflux disease (OR 8.755; p = 0.021) was identified as an independent risk factor for complications.

CONCLUSIONS

Although short-term outcome and symptom relief are similar, TCM tends to have a higher complication rate but better long-term results. Preoperative reflux disease is an independent risk factor for postoperative complications.

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.

Endoscopic treatment of Zenker's diverticulum by complete septotomy: initial experience in 19 patients

Background and study aims  Endoscopic treatment of Zenker's Diverticulum (ZD) using a flexible endoscope and a diverticuloscope consists of myotomy of the cricopharyngeus muscle, sparing the lower part of the diverticular septum. However, recurrence occurs in up to 54 % of patients at 4 years. We assessed the feasibility and safety of a complete septotomy in endoscopic treatment of ZD. Patients and methods  We conducted a retrospective analysis of a prospectively collected database at a single referral center. All consecutive patients treated by complete resection of the diverticular wall were included. The endoscopic technique used a distal attachment cap and division of the ZD septum using a Dual Knife or a Triangle Tip knife in endocut mode, until the esophageal muscularis propria was seen and no residual diverticulum remained. Symptoms were evaluated using the Augsburger questionnaire. Results  Nineteen patients, 10 of whom were men with mean age 79 ± 12 years, were treated by complete septotomy for a symptomatic ZD with a median size of 2.5 cm (range 1-5 cm). The clinical success rate was 100 % and the complication rate was 10 % (one pneumonia and one atrial fibrillation). Median hospital stay was 2 days (range 1-3 days). On Day 1 esophagogram, no extraesophageal contrast leakage was seen, periesophageal CO ₂ was still visible in two patients, and complete ZD regression was seen in 63 % of patients. The 6-month clinical success rate was 100 %, with two patients lost to follow-up, and a median symptom score of 0 (range 0-4). After a mean ± SD follow-up of 9 ± 5 months, the clinical success rate was 94 % (16/17). Conclusion  Complete endoscopic septotomy is a feasible and safe therapeutic modality in patients with symptomatic ZD that does not require use of a diverticuloscope, and with good short-term efficacy. The complete regression of the diverticulum observed on Day 1 in 63 % of patients could be a marker of long-term clinical success.

Feasibility of Early Discharge after Open Hypopharyngeal Surgery for Dysphagia

Objective:

To determine the rate of surgical complications, unplanned readmission, and functional status after open hypopharyngeal surgery for dysphagia with early return to oral diet and hospital discharge.

Methods:

Retrospective chart review of patients who underwent open hypopharyngeal surgery for management of dysphagia from March 2013 to June 2018 at a single academic institution. A clear liquid diet is restarted the day of surgery and is advanced to a soft diet on postoperative day one. Univariate and multivariate logistic regression was performed to identify risk factors for postoperative complications and unplanned readmission.

Results:

Ninety patients met eligibility criteria; 62 patients underwent open cricopharyngeal myotomy, 13 underwent Zenker’s diverticulectomy, 15 had a Zenker’s diverticulopexy. Mean inpatient length of stay was 2.0 ± 2.0 days (range 0-11 days); 57 patients (63.3%) were discharged on the same day as surgery or on postoperative day one. Seven patients (7.8%) had postoperative complications; the most common complication was esophageal leak (n = 6). Six patients (6.7%) had unplanned readmissions within 30 days. Mean time to unplanned readmission was 12 days (range 2-19 days). Open diverticulectomy was associated with an increased risk of unplanned readmission with an OR = 7.63 (95% CI 1.29, 45.45, P = .025). At last follow-up, 70% of patients had an increased functional oral intake by at least one scale score (FOIS) after surgery (mean follow-up 0.8 ± 1.1 years, range 0.02-5.1 years).

Conclusion:

An early diet and discharge may be safe for patients undergoing open surgery without a mechanical or suture closure of their esophageal mucosa, whereas in those undergoing diverticulectomy, NPO status and a radiological check before resuming drinking and eating are advised.

Level of Evidence:

4

Is nasogastric tube feeding necessary after hypopharyngeal diverticulum surgery?

OBJECTIVES

Nasogastric tubes (NGT) are often placed after surgery for cricopharyngeal muscle pathology due to risk of infection and mediastinitis. The aim of this study was to examine if this practice is necessary.

METHODS

A retrospective case series of subjects who underwent surgery for hypopharyngeal diverticula or cricopharyngeal bars from March 2011 to June 2018 was conducted. Demographic data, type of surgery, placement of feeding tube, initiation of oral feeding, and any complications were recorded.

RESULTS

Sixty-four surgeries were performed for Zenker's diverticula (ZD; N = 52), Killian-Jamieson diverticula (N = 2), and cricopharyngeal bar (N = 10). Mean age and ZD pouch size were 74.0 ± 10.6 years and 3.1 ± 1.8 cm, respectively. Procedures included 48 carbon dioxide laser-assisted myotomies, 14 open diverticulectomies, and 2 endoscopic stapler-assisted diverticulotomies. Of the 64 patients, 19 (29.7%) received intraoperative NGTs while the remaining 45 (70.3%) did not receive NGTs. The former cohort had the NGTs removed on post-operative day (POD) 4.5 ± 2.5, and the non-NGT cohort started clear liquid diet (CLD) on POD 1.2 ± 0.7 days, where 38 patients (84.4%) started CLD on POD 1, and 5 patients (7.8%) were started on oral diet on POD 2-4. Over time, fewer NGTs were placed and oral diets were started sooner. There were 5 complications occurring in 3 patients from the NGT cohort (15.5%) and 2 from the non-NGT cohort (4.4%).

CONCLUSIONS

Surgery for hypopharyngeal diverticula and CPB may not require routine perioperative NGT placement which can be associated with higher rates of complication. Patients can safely receive CLD on POD 1.

Killian-Jamieson diverticulum safely resected using a manual intraoperative neural monitoring system: a case report

BACKGROUND

Killian-Jamieson diverticulum is a rare pharyngoesophageal diverticulum. The risk of intraoperative injury of the recurrent laryngeal nerve (RLN) is high during surgical resection of Killian-Jamieson diverticulum because the RLN usually runs next to the base of the diverticulum. We present a case of Killian-Jamieson diverticulum that was safely resected with effective use of an intraoperative nerve monitoring (IONM) system with a handheld stimulating probe to prevent RLN injury.

CASE PRESENTATION

A 69-year-old man complaining of dysphagia was diagnosed with Killian-Jamieson diverticulum and underwent open transcervical diverticulectomy. Because the anterior aspect of the diverticulum was expected to be close to the RLN, the accurate location of the RLN was checked during dissection by intermittent stimulation using a handheld probe of the IONM system to avoid mechanical and thermal injury. The diverticulum was transected longitudinally using a linear stapler, and the staple line was buried using absorbable sutures from the distal end. During its closure, RLN was identified very close to the diverticulum stump by IONM, and the upper side of the stump was left unburied to avoid RLN injury. The postoperative course was uneventful and the patient was discharged on postoperative day 7. Postoperative evaluation showed no vocal cord paralysis.

CONCLUSION

IONM may be beneficial during open surgery for Killian-Jamieson diverticulum, which usually protrudes just lateral to the RLN.