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McKeon M, McCoy N, Johnson C, Allen J, Altaye M, Amin M, Bayan S, Belafsky P, DeSilva B, Dion G, 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, Piraka C, Rosen CA, Tabangin M, Wahab S, Wilson K, Wright C, Young VN, Postma G, Howell RJ. Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative. Laryngoscope 2024; 134:2678-2683. [PMID: 38146791 DOI: 10.1002/lary.31226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 11/02/2023] [Accepted: 11/27/2023] [Indexed: 12/27/2023]
Abstract
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.
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Affiliation(s)
- Mallory McKeon
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Nicole McCoy
- 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 Health, 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, 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
| | - Brad DeSilva
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, U.S.A
| | - Greg 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, College of Allied Health Sciences, University of Cincinnati, 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, 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
| | - 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 Wahab
- Department of Radiology, University of Cincinnati, 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 Health, Augusta, Georgia, U.S.A
| | - Rebecca J Howell
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
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Zhao NW, Stasyuk A, Hernandez BO, Cates DJ, Kuhn MA, Belafsky PC. Objective Fluoroscopic Outcomes After Endoscopic Staple Versus Laser Zenker's Diverticulotomy. Laryngoscope 2023; 133:3057-3060. [PMID: 37129356 DOI: 10.1002/lary.30726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Endoscopic Zenker's diverticulotomy (EZD) is typically performed via stapling (endoscopic staple diverticulotomy; ESD) or CO2 laser (endoscopic laser diverticulotomy; ELD). Conflicting reports exist on which approach provides optimal outcomes. This investigation compared objective fluoroscopic data between ESD and ELD. METHODS A retrospective review of all patients undergoing primary EZD at a tertiary center between January 1, 2014 and January 10, 2022 was performed. Patients undergoing ESD and ELD were matched by preoperative diverticulum size. Primary outcome measures were postoperative diverticulum size and change in diverticulum size from pre- to postoperative swallowing fluoroscopy. Secondary outcome measures were the Eating Assessment Tool (EAT-10) score, penetration aspiration scale (PAS), pharyngeal constriction ratio (PCR), and pharyngoesophageal segment opening (PESo). RESULTS Thirteen matched pairs with complete fluoroscopic data were identified. The mean (±SD) age of the cohort was 74.0 (±8.5) years. There were no age or gender differences between groups (p > 0.05). The mean pre-operative ZD size was 1.98 (±0.69) cm for ESD and 1.97 (±0.72) cm for ELD; the mean postoperative size was 0.84 (±0.62) cm for ESD and 0.34 (±0.27) cm for ELD (p < 0.05). Mean diverticulum size improved by 1.14 (±0.59) cm after ESD and 1.62 (±0.59) cm after ELD (p < 0.05). There were no significant differences in postoperative EAT-10, PAS, PCR, or PESo between groups. CONCLUSION The data suggest that endoscopic laser Zenker's diverticulotomy results in a greater improvement in diverticulum size than endoscopic staple diverticulotomy. The data did not suggest a difference in postoperative dysphagia symptom scores or other objective fluoroscopic parameters between staple and laser diverticulotomy. LEVEL OF EVIDENCES Level 3 Laryngoscope, 133:3057-3060, 2023.
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Affiliation(s)
- Nina W Zhao
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, U.S.A
| | - Anastasiya Stasyuk
- School of Medicine, University of California, Davis, Sacramento, California, U.S.A
| | - Brian O Hernandez
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Daniel J Cates
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Maggie A Kuhn
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
| | - Peter C Belafsky
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento, California, U.S.A
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Kana M, Kalfert D, Lukes P, Zabrodsky M, Plzak J. C-reactive protein as an early marker of postoperative leakage in patients after endoscopic laser assisted Zenker's diverticulotomy. Eur Arch Otorhinolaryngol 2023; 280:2007-2016. [PMID: 36449093 DOI: 10.1007/s00405-022-07764-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/22/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND AND AIM Minimally invasive endoscopic techniques are the treatment of choice for Zenker's diverticulum (ZD). Our objective was to evaluate the results and efficacy of endoscopic and open approaches, to determine whether postoperative C-reactive protein (CRP) serum levels can be used as a marker to exclude the presence of esophageal leakage, and to identify risk factors for development of postoperative leakage and complications. MATERIALS AND METHODS Patients who underwent transcervical myotomy and diverticulotomy (TMD) or endoscopic cricopharyngeal myotomy (ECM) with CO2 laser for ZD in years 2008-2021 at our department were included in this retrospective study. RESULTS Of the 101 patients enrolled, 83 patients underwent ECM and 18 TMD. The procedure time of the endoscopic technique was significantly shorter compared to that of transcervical method (p < 0.001). The median time to oral intake was 6 days for ECM and 10.5 days in the TMD group (p < 0.001). There was a 13% (n = 11) and 16.7% (n = 3) symptomatic recurrence rate and 3.6% (n = 3) and 16.7% (n = 3) major complications rate for ECM and TMD groups, respectively. The incidence of contrast leak (CL) evaluated by postoperative swallow study was 8.9% (9 from 83 patients in the ECM group only). In patients with CL, a significant increase in CRP levels on postoperative day (POD) 2 and 3 was detected when compared to patients without CL. CONCLUSIONS Endoscopic diverticulotomy with CO2 laser represents a safe and efficient treatment of ZD. Elevation of postoperative CRP serum levels over 123.8 mg/L on POD2 and 98.8 mg/L on POD3 may indicate presence of an esophageal leakage.
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Affiliation(s)
- Martin Kana
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Motol, First Faculty of Medicine, Charles University, V Uvalu 84, 150 06, Prague, Czech Republic
| | - David Kalfert
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Motol, First Faculty of Medicine, Charles University, V Uvalu 84, 150 06, Prague, Czech Republic.
| | - Petr Lukes
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Motol, First Faculty of Medicine, Charles University, V Uvalu 84, 150 06, Prague, Czech Republic
| | - Michal Zabrodsky
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Motol, First Faculty of Medicine, Charles University, V Uvalu 84, 150 06, Prague, Czech Republic
| | - Jan Plzak
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Motol, First Faculty of Medicine, Charles University, V Uvalu 84, 150 06, Prague, Czech Republic
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Martinez Paredes JF, Al Fakir R, Rutt AL. Clinical Symptoms Contributing to Zenker's Diverticulum Repair: A Retrospective Review. Cureus 2022; 14:e22369. [PMID: 35371686 PMCID: PMC8940557 DOI: 10.7759/cureus.22369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 11/05/2022] Open
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Menéndez Del Castro M, Fernández Morais R, Martínez P, Fernández Pello M, Carreño M, Carlos Álvarez J. Results of laser surgery in the treatment of Zenker's diverticulum. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2021; 72:381-386. [PMID: 34844677 DOI: 10.1016/j.otoeng.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/21/2020] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
| | | | - Patricia Martínez
- Servicio de Otorrinolaringología, Hospital Universitario de Cabueñes, Gijón, Spain
| | | | - Marcos Carreño
- Servicio de Otorrinolaringología, Hospital Universitario de Cabueñes, Gijón, Spain
| | - Juan Carlos Álvarez
- Servicio de Otorrinolaringología, Hospital Universitario de Cabueñes, Gijón, Spain
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Martinez-Paredes JF, Alfakir R, Kasperbauer JL, Rutt A. Zenker Diverticulum: Does Size Correlate With Preoperative Symptoms? Int Arch Otorhinolaryngol 2021; 26:e334-e338. [PMID: 35846818 PMCID: PMC9282963 DOI: 10.1055/s-0041-1730457] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/14/2021] [Indexed: 10/29/2022] Open
Abstract
Abstract
Introduction Zenker diverticulum (ZD) usually affects adults after the 7th decade of life. Treatment for ZD is indicated for all symptomatic patients, but some patients prefer to defer surgical treatment until symptoms get worse and decrease their quality of life.
Objective To evaluate the association of the preoperative symptoms in ZD patients with the size of the ZD.
Methods A retrospective study design. Electronic medical records were used to identify patients diagnosed with ZD and treated over 11 years. Data collection included the chief complaints and symptoms, medical history, and findings on radiologic swallow evaluations of the patients. The diverticulum size was stratified into 3 groups: small (< 1 cm), moderate (1–3 cm), and large (> 3 cm).
Results A total of 165 patients were enrolled and stratified by diverticulum size (48 small, 67 medium, and 50 large). Dysphagia, cough, and regurgitation were the most prevalent symptoms. Dysphonia was more frequent among patients with a small pouch. Logistic regression analysis showed that dysphagia and choking were associated with large and medium diverticulum size (p < 0.05). Additionally, dysphonia was significantly associated with the presence of a small-sized ZD (p < 0.04).
Conclusion Upper gastrointestinal symptoms such as dysphagia and choking may be associated with a ZD > 1 cm and should always be evaluated. Additionally, the presence of dysphonia was found to be correlated with a ZD < 1 cm, suggesting that a prompt and appropriate fluoroscopic evaluation must be considered in those patients in whom no other clear cause of dysphonia is evident.
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Affiliation(s)
- Jhon F. Martinez-Paredes
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Razan Alfakir
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Jan L. Kasperbauer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Amy Rutt
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Jacksonville, Florida, United States
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Włodarczyk J, Obarski P, Hauer Ł. Surgical treatment of cervical oesophageal diverticula. POLISH JOURNAL OF SURGERY 2021; 94:41-47. [DOI: 10.5604/01.3001.0015.3190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
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Affiliation(s)
- Janusz Włodarczyk
- Department of Thoracic and Surgical Oncology, Jagiellonian University Collegium Medicum, John Paul II Hospital, Cracow, Poland
| | - Piotr Obarski
- Department of Thoracic and Surgical Oncology, Jagiellonian University Collegium Medicum, John Paul II Hospital, Cracow, Poland
| | - Łukasz Hauer
- Department of Thoracic and Surgical Oncology, Jagiellonian University Collegium Medicum, John Paul II Hospital, Cracow, Poland
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Bhatt NK, Mendoza J, Kallogjeri D, Hardi AC, Bradley JP. Comparison of Surgical Treatments for Zenker Diverticulum: A Systematic Review and Network Meta-analysis. JAMA Otolaryngol Head Neck Surg 2021; 147:190-196. [PMID: 33270099 DOI: 10.1001/jamaoto.2020.4091] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Neel K Bhatt
- Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle
| | - Joshua Mendoza
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Dorina Kallogjeri
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri.,Statistics Editor, JAMA Otolaryngology-Head & Neck Surgery
| | - Angela C Hardi
- Bernard Becker Medical Library, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Joseph P Bradley
- Department of Otolaryngology-Head and Neck Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri
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Menéndez Del Castro M, Fernández Morais R, Martínez P, Fernández Pello M, Carreño M, Álvarez JC. Results of laser surgery in the treatment of Zenker's diverticulum. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2021; 72:S0001-6519(20)30203-X. [PMID: 33483092 DOI: 10.1016/j.otorri.2020.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/16/2020] [Accepted: 11/21/2020] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
| | | | - Patricia Martínez
- Servicio de Otorrinolaringología, Hospital Universitario de Cabueñes, Gijón, España
| | | | - Marcos Carreño
- Servicio de Otorrinolaringología, Hospital Universitario de Cabueñes, Gijón, España
| | - Juan Carlos Álvarez
- Servicio de Otorrinolaringología, Hospital Universitario de Cabueñes, Gijón, España
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Crawley B, Dehom S, Tamares S, Marghalani A, Ongkasuwan J, Reder L, Ivey C, Amin M, Fritz M, Pitman M, Tulunay-Ugur O, Weissbrod P. Adverse Events after Rigid and Flexible Endoscopic Repair of Zenker’s Diverticula: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2019; 161:388-400. [DOI: 10.1177/0194599819839991] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective To determine adverse events after endoscopic flexible vs endoscopic rigid cricopharyngeal myotomy for treatment of Zenker’s diverticulum (ZD). Data Sources Systematic review of MEDLINE, Web of Science, CINAHL, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials for all years according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional studies were identified from review citations and a by hand search of manuscripts referencing ZD. Review Methods A structured literature search was conducted to identify studies for this systematic review. Methodological Index for Non-randomized Studies (MINORS) criteria were applied to assess study quality. For inclusion, each study had to provide data for at least 10 adult patients who had undergone endoscopic ZD repair reporting clear association with the postprocedure course in each case. Data extracted included all reported adverse events, recurrences, follow-up, and operative times. Results In total, 115 studies were included. All but 8 were retrospective case series. Sixty-one reported series of patients after rigid endoscopic stapler repair, 31 after rigid laser repair, and 13 with other rigid endoscopic instruments. Twenty-nine flexible endoscopic studies were included. Mortality, infection, and perforation were not significantly more likely in either the rigid or the flexible group, but bleeding and recurrence were more likely after flexible endoscopic techniques (20% vs <10% and 4% vs 0%, respectively). Dental injury and vocal fold palsy were reported rarely in the rigid endoscopic groups. Conclusions Adverse events are rare after endoscopic Zenker’s repair. The flexible approach minimizes exposure limitations and can be completed in some patients without general anesthesia. Transoral rigid approaches result in fewer revision surgeries compared with flexible diverticulotomy.
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Affiliation(s)
- Brianna Crawley
- Department of Otolaryngology–Head and Neck Surgery, Loma Linda University Voice and Swallowing Center, Loma Linda, California, USA
| | - Salem Dehom
- School of Nursing, Loma Linda University, Loma Linda, California, USA
| | - Shanalee Tamares
- School of Medicine and School of Behavioral Sciences, Loma Linda University, Loma Linda, California, USA
| | - Abdullah Marghalani
- Preventive Dentistry Department, Umm Al-Qura University, Mecca, Saudi Arabia
| | - Julina Ongkasuwan
- Department of Otolaryngology–Head and Neck Surgery, Baylor College of Medicine/Texas Children’s Hospital, Houston, Texas, USA
| | - Lindsay Reder
- Department of Otolaryngology–Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Chandra Ivey
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine Mount Sinai, New York, New York, USA
| | - Milan Amin
- Department of Otolaryngology–Head and Neck Surgery, New York University School of Medicine, New York, New York, USA
| | - Mark Fritz
- Department of Otolaryngology–Head and Neck Surgery, University of Kentucky, Lexington, Kentucky
| | - Michael Pitman
- Division of Laryngology, Department of Otolaryngology–Head and Neck Surgery, Columbia University, New York, New York, USA
| | - Ozlem Tulunay-Ugur
- Division of Laryngology, Department of Otolaryngology–Head and Neck Surgery, University of Arkansas, Little Rock, Arkansas
| | - Philip Weissbrod
- San Diego Division of Laryngology, Department of Otolaryngology–Head and Neck Surgery, University of California, San Diego, California, USA
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Akturk Z, Ulas AB, Eroglu A. Delayed diagnosis of a case of Zenker's diverticulum. What may happen when a family physician does not visit his family physician. Eur J Gen Pract 2018; 24:151-154. [PMID: 29726737 PMCID: PMC5944372 DOI: 10.1080/13814788.2018.1464556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/29/2018] [Accepted: 04/04/2018] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Zenker's diverticulum is a diverticulum of the mucosa of the pharynx, just above the cricopharyngeal muscle. It occurs commonly in elderly patients (over 70 years) and the typical symptoms include dysphagia, regurgitation, chronic cough, aspiration and weight loss. CASE We are reporting dysphagia in a 49-years old man who was treated as having Helicobacter Pylori gastritis for three years. Being a family physician himself, the patient applied to specialists in gastroenterology, bypassing primary care. During a casual interview on his symptoms, a family physician referred him to undergo a repeated endoscopy with suspected Zenker's diverticulum. After being diagnosed with Zenker's diverticulum, the patient underwent surgical intervention at the department of thoracic surgery and made a full recovery. He regained five kilograms at the end of five weeks after the operation. CONCLUSION This case demonstrates once more the importance of history taking and follow-up in medical care. Attentive listening by a family physician could have probably prevented the delay of service in this case.
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Affiliation(s)
| | - Ali Bilal Ulas
- Department of Thoracic Surgery, Ataturk University Medical Faculty, Erzurum, Turkey
| | - Atila Eroglu
- Department of Thoracic Surgery, Ataturk University Medical Faculty, Erzurum, Turkey
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Jackson AS, Aye RW. Endoscopic Approaches to Cricopharyngeal Myotomy and Pyloromyotomy. Thorac Surg Clin 2018; 28:507-520. [DOI: 10.1016/j.thorsurg.2018.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Tabola R, Lewandowski A, Cirocchi R, Augoff K, Kozminska U, Strzelec B, Grabowski K. Zenker diverticulum: Experience in surgical treatment of large diverticula. Medicine (Baltimore) 2018; 97:e0557. [PMID: 29742690 PMCID: PMC5959430 DOI: 10.1097/md.0000000000010557] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The purpose of this retrospective study is to show that transcervical diverticulectomy (TD) in treatment of Zenker diverticulum (ZD) can still be a first choice procedure in selected patients and in experienced hands its safety might be compared to the minimally invasive endoscopic diverticulostomy.The study cohort consisted of 44 patients (18 male, 26 female) operated for (ZD). All the patients underwent open diverticulectomy. The decision to choose open surgical repair depended on surgical risk, age of the patient, size of the diverticular septum (the distance between the top of the diverticulum and its bottom on barium study), and patient's preference.Mean age of patients was 64.6 ± 11.9 years; range: 26 to 88 years. A total of 36.4% out of them finished 70 years. Postoperative mortality was nil. Two major complications (4.5%) requiring surgical intervention occurred: leak and hematoma.Data were analyzed by t test for independent samples using Statistica 12.5 software. P value <0.05 was considered statistically significant.Surgical treatment of patients with ZD should be individualized. Large Zenker diverticula with the septum longer than 6 cm should preferably be resected through an open approach because it is not possible to remove the septum completely during one-step endoscopic procedure and diverticulostomy creates a weak and large common cavity in the esophagus. Surgical repair is effective for all sizes of diverticula, but its most serious complications such as leakage or laryngeal nerve injury should be considered, especially in elderly patients with comorbidities. However, age alone should not be the main criterion if choosing the treatment option.
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Affiliation(s)
- Renata Tabola
- Department of Gastrointestinal and General Surgery, Medical University of Wroclaw, Wroclaw, Poland
| | - Andrzej Lewandowski
- Department of Gastrointestinal and General Surgery, Medical University of Wroclaw, Wroclaw, Poland
| | - Roberto Cirocchi
- Department of General and Oncological Surgery, University of Perugia, Perugia, Italy
| | - Katarzyna Augoff
- Department of Gastrointestinal and General Surgery, Medical University of Wroclaw, Wroclaw, Poland
| | | | | | - Krzysztof Grabowski
- Department of Gastrointestinal and General Surgery, Medical University of Wroclaw, Wroclaw, Poland
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Nauschuetz KK, Ogden LL, Starling CE, Saleh MJ, Golding AC, Traweek ST. Pharyngoesophageal diverticula simulating thyroid nodules: An unusual occurrence with unique features. Diagn Cytopathol 2017; 46:193-197. [PMID: 28925594 DOI: 10.1002/dc.23817] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 08/31/2017] [Accepted: 09/01/2017] [Indexed: 12/18/2022]
Abstract
Pharyngoesophageal diverticula (PED) of the Zenker's and Killian-Jamieson types arise in close proximity to the thyroid gland, and may rarely be confused with a thyroid nodule on ultrasonography. In this brief report, we detail the cytologic, clinical, and radiologic findings of three PED that were thought to be thyroid nodules, and were subjected to fine-needle aspiration (FNA). The patients were females with an age range of 51-64 years. All three patients had multiple thyroid nodules, and two patients reported symptoms attributable to the diverticulum. Nodule sizes ranged from 1.0 to 2.7 cm, and either the right or left thyroid lobe could be involved. Microcalcifications were present by ultrasonography in all three cases. FNA of these thyroid nodule mimics showed squamous cells with granular or amorphous debris, bacterial and/or fungal colonies, inflammation, and food particles. These cytologic features, particularly the presence of vegetable or meat fragments, are characteristic, and have also been reported in the few previous reports of PED. The presence of a diverticulum was confirmed with imaging studies in all our patients. Although a rare occurrence, the inadvertent FNA of a PED masquerading as a thyroid nodule is important to recognize, as a recommendation for appropriate radiologic studies could potentially avoid inappropriate therapy for thyroid disease.
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Affiliation(s)
| | | | | | | | - Allan C Golding
- The Memorial Center for Integrative Endocrine Surgery, Hollywood, Florida
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Verdonck J, Morton R. Remarks on the Rotterdam experience. Eur Arch Otorhinolaryngol 2016; 274:3539. [PMID: 27942893 DOI: 10.1007/s00405-016-4409-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 11/24/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Jan Verdonck
- AZ St. Rembertziekenhuis Torhout, Rembertlaan 21, 8820, Torhout, West-Vlaanderen, Belgium.
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Hoffmann M, Fazel A, Mews KG, Ambrosch P. 32 years of experience with CO2
-LASER-assisted treatment for Zenker's Diverticulum - an update of 227 patients treated in Kiel. Clin Otolaryngol 2016; 42:592-596. [DOI: 10.1111/coa.12777] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2016] [Indexed: 11/30/2022]
Affiliation(s)
- M. Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery; Christian-Albrechts-University of Kiel; Kiel Germany
| | - A. Fazel
- Department of Otorhinolaryngology, Head and Neck Surgery; Christian-Albrechts-University of Kiel; Kiel Germany
| | - K.-G. Mews
- Department of Otorhinolaryngology, Head and Neck Surgery; Christian-Albrechts-University of Kiel; Kiel Germany
| | - P. Ambrosch
- Department of Otorhinolaryngology, Head and Neck Surgery; Christian-Albrechts-University of Kiel; Kiel Germany
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