1
|
Diehl DL, Mehta MJ, Khalid A, Shafqet MA, Khara HS, Confer B. Flexible endoscopic incisional therapy for Zenker's diverticulum (FEIT-Z) is an effective treatment for surgical failures or non-operative patients. Surg Endosc 2022; 36:8863-8868. [PMID: 35578048 DOI: 10.1007/s00464-022-09318-3] [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: 10/27/2021] [Accepted: 04/27/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Symptomatic Zenker's diverticulum (ZD) occurs mostly in the elderly, who often have significant comorbidities, and poor neck hyperextension, putting them at high risk for surgical management while also increasing the potential of technical failure. Flexible endoscopic incisional therapy for Zenker's diverticulum (FEIT-Z) offers a safe approach to this problem with high technical and clinical success rates. There are limited data on its use following a failed surgical approach or in patients unfit for a surgical approach. The aim of this study was to assess clinical and technical outcomes of FEIT-Z in patients who were non-operative candidates or refused or failed surgical management. METHODS Patients who underwent FEIT-Z from January 2015 to February 2019 at a tertiary referral center were included. Patient demographics, prior ZD surgical history, procedural data, dysphagia scores, clinical success, and adverse events (AE) were collected. Univariable analysis was performed to assess differences between pre- and post-FEIT-Z dysphagia scores. RESULTS 30 patients undergoing FEIT-Z were included. Seven had a prior failed ZD surgical approach, 6 refused surgical management, and 17 were deemed to be non-operative candidates based on medical comorbidities. Mean age was 78.4 (± 12.1) and 36.7% were male. Technical success of FEIT-Z was 96.7%. There was a significant improvement in dysphagia scores after FEIT-Z: 2.3 (± 0.64) vs. before, 0.4 (± 0.76) (p < 0.001). Long-term clinical success was achieved in 73.3% of patients. Adverse events were seen in 23.3% of patients; however, these were graded as mild in 85.7% of patients. One microperforation was managed with antibiotics. CONCLUSION FEIT-Z is a safe procedure with low adverse events and a high rate of technical and clinical success. FEIT-Z can be done in patients who fail previous surgical treatment, refuse a surgical approach, or are not surgical candidates due to medical comorbidity or other factors.
Collapse
Affiliation(s)
- David L Diehl
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, 100 North Academy Ave., MC 21-11, Danville, PA, 17822, USA.
| | - Minesh J Mehta
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, 100 North Academy Ave., MC 21-11, Danville, PA, 17822, USA
| | - Ammara Khalid
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, 100 North Academy Ave., MC 21-11, Danville, PA, 17822, USA
| | - Muhammad A Shafqet
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, 100 North Academy Ave., MC 21-11, Danville, PA, 17822, USA
| | - Harshit S Khara
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, 100 North Academy Ave., MC 21-11, Danville, PA, 17822, USA
| | - Bradley Confer
- Department of Gastroenterology and Nutrition, Geisinger Medical Center, 100 North Academy Ave., MC 21-11, Danville, PA, 17822, USA
| |
Collapse
|
2
|
Uoti S, Andersson SEM, Robinson E, Räsänen J, Kytö V, Ilonen I. Epidemiology and Management of Zenker Diverticulum in a Low-Threshold Single-payer Health Care System. JAMA Otolaryngol Head Neck Surg 2021; 148:235-242. [PMID: 34913965 DOI: 10.1001/jamaoto.2021.3671] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
Collapse
Affiliation(s)
- Sandra Uoti
- Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Saana E-M Andersson
- Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Eric Robinson
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jari Räsänen
- Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Ville Kytö
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland.,Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland.,Administrative Center, Hospital District of Southwest Finland, Turku, Finland
| | - Ilkka Ilonen
- Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
3
|
Provenzano L, Salvador R, Cutrone C, Capovilla G, Moletta L, Nicoletti L, Costantini M, Merigliano S, Valmasoni M. Traction on the septum during transoral septotomy for Zenker diverticulum improves the final outcome. Laryngoscope 2019; 130:637-640. [PMID: 31021435 DOI: 10.1002/lary.28030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/25/2019] [Accepted: 04/02/2019] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Transoral diverticulostomy/septotomy has become a popular treatment for patients with Zenker diverticulum (ZD). To improve the results of transoral stapler-assisted septotomy, a modification of the technique has been introduced. In this study, we aimed to compare the final outcome of such a modified transoral septotomy (MTS) with the results of traditional transoral septotomy (TTS) in patients with ZD. METHODS Fifty-two consecutive patients with ZD underwent transoral stapler-assisted septotomy between 2010 and 2018. Symptoms were recorded and scored using a detailed questionnaire. Barium swallow, endoscopy, and manometry were performed before and after the procedure. RESULTS Of the 52 patients forming the study population (male:female = 35:17), 25 had TTS and 27 had MTS. The patients' demographic and clinical parameters were similar in the two groups. No intraoperative mucosal lesions were detected, and the mortality was nil. The median time taken to complete the procedure was 25 minutes (interquartile range [IQR]: 22-35) for TTS, and 30 minutes (IQR: 25-36) for MTS (P < 0.07). The median follow-up was 69 months (IQR: 46-95) in the TTS group and 30 months (IQR: 25-35) in the MTS group. All patients in both groups had an improvement in their symptom score after the procedure, but the failure rates were 32% (8 of 25) after TTS and 3.7% (1 of 27) after MTS (P < 0.02). At univariate and multivariate analyses, the procedure was the only predictor of a positive final outcome. CONCLUSION Albeit with the intrinsic limitations of the study (retrospective, different time window, and different follow-up), traction on the septum during transoral septotomy improves the final outcome of this treatment in patients with ZD. LEVEL OF EVIDENCE 4 Laryngoscope, 130:637-640, 2020.
Collapse
Affiliation(s)
- Luca Provenzano
- Department of Surgical, Oncological and Gastrointestinal Sciences, University of Padova, Clinica Chirurgica 3, Padova, Italy
| | - Renato Salvador
- Department of Surgical, Oncological and Gastrointestinal Sciences, University of Padova, Clinica Chirurgica 3, Padova, Italy
| | - Cesare Cutrone
- Department of Surgical, Oncological and Gastrointestinal Sciences, University of Padova, Clinica Chirurgica 3, Padova, Italy
| | - Giovanni Capovilla
- Department of Surgical, Oncological and Gastrointestinal Sciences, University of Padova, Clinica Chirurgica 3, Padova, Italy
| | - Lucia Moletta
- Department of Surgical, Oncological and Gastrointestinal Sciences, University of Padova, Clinica Chirurgica 3, Padova, Italy
| | - Loredana Nicoletti
- Department of Surgical, Oncological and Gastrointestinal Sciences, University of Padova, Clinica Chirurgica 3, Padova, Italy
| | - Mario Costantini
- Department of Surgical, Oncological and Gastrointestinal Sciences, University of Padova, Clinica Chirurgica 3, Padova, Italy
| | - Stefano Merigliano
- Department of Surgical, Oncological and Gastrointestinal Sciences, University of Padova, Clinica Chirurgica 3, Padova, Italy
| | - Michele Valmasoni
- Department of Surgical, Oncological and Gastrointestinal Sciences, University of Padova, Clinica Chirurgica 3, Padova, Italy
| |
Collapse
|
4
|
Outcomes in modified transoral resection of diverticula for Zenker’s diverticulum. Eur Arch Otorhinolaryngol 2019; 276:1423-1429. [DOI: 10.1007/s00405-019-05374-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 03/09/2019] [Indexed: 01/28/2023]
|
5
|
Desbeaux A, Gronnier C, Piessen G, Vanderbeken M, Ruolt N, Triboulet JP, Mariette C. Same-day discharge in benign esophageal surgery: a prospective cohort study. Dis Esophagus 2017; 30:1-7. [PMID: 28375480 DOI: 10.1093/dote/dow036] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Indexed: 12/11/2022]
Abstract
Day-case esophageal surgery has been demonstrated to be safe in small prospective cohorts and only for laparoscopic fundoplication. The aims of this study are to assess the feasibility and safety of a large series of esophageal day-case surgeries, including laparoscopic Nissen fundoplication (LNF), Zenker diverticulectomy (ZD), and laparoscopic Heller myotomy (LHM) and to compare the outcomes among three procedures.This was a prospective, observational study of selected patients who underwent day-case LNF, ZD, and LHM between 2003 and 2013. Postoperative outcomes, the patients' satisfaction, and functional results were evaluated with dedicated scores and compared.Of the 427 patients who underwent surgery for those indications during the study period, 168 (39.3%) eligible patients underwent day-case procedures (134 LNF, 14 LHM, and 20 ZD). The overnight unplanned admission rate was 16.2% and was similar among the groups (P = 0.681). Ten patients were readmitted during the first postoperative week because of dysphagia (n = 6, all in the LNF group), flu-like syndrome (n = 1), and secondary perforation (n = 3, all in the LHM group). The unplanned seven-day readmission rate was significantly higher in the LHM group than in the ZD and LNF groups (P = 0.042). The 30-day rates of unplanned readmission and consultation were 8.9% (P = 0.300) and 4.8%, respectively. At follow-up, 87.5% of the patients were satisfied with day-case treatment, and the functional results were good for 81.4% of the patients.Day-case esophageal surgery is feasible for LNF and seems to be feasible for ZD. Safety criteria have not yet been met for LHM, requiring further adaptations.
Collapse
Affiliation(s)
- A Desbeaux
- Univ. Lille, Department of Digestive and Oncological Surgery, University Hospital Claude Huriez, Lille, France.,Univ. Lille, Ambulatory Department, University Hospital Claude Huriez, Lille, France
| | - C Gronnier
- Univ. Lille, Department of Digestive and Oncological Surgery, University Hospital Claude Huriez, Lille, France.,Univ. Lille, Ambulatory Department, University Hospital Claude Huriez, Lille, France.,Univ. Lille, UMR-S 1172 - JPARC - Centre de Recherche Jean Pierre Aubert Neuroscience et Cancer, F-59000 Lille, France
| | - G Piessen
- Univ. Lille, Department of Digestive and Oncological Surgery, University Hospital Claude Huriez, Lille, France.,Univ. Lille, Ambulatory Department, University Hospital Claude Huriez, Lille, France.,Univ. Lille, UMR-S 1172 - JPARC - Centre de Recherche Jean Pierre Aubert Neuroscience et Cancer, F-59000 Lille, France
| | - M Vanderbeken
- Univ. Lille, Department of Digestive and Oncological Surgery, University Hospital Claude Huriez, Lille, France.,Univ. Lille, Ambulatory Department, University Hospital Claude Huriez, Lille, France
| | - N Ruolt
- Univ. Lille, Ambulatory Department, University Hospital Claude Huriez, Lille, France
| | - J-P Triboulet
- Univ. Lille, Department of Digestive and Oncological Surgery, University Hospital Claude Huriez, Lille, France.,Univ. Lille, Ambulatory Department, University Hospital Claude Huriez, Lille, France
| | - C Mariette
- Univ. Lille, Department of Digestive and Oncological Surgery, University Hospital Claude Huriez, Lille, France.,Univ. Lille, Ambulatory Department, University Hospital Claude Huriez, Lille, France.,Univ. Lille, UMR-S 1172 - JPARC - Centre de Recherche Jean Pierre Aubert Neuroscience et Cancer, F-59000 Lille, France
| |
Collapse
|
6
|
Costamagna G, Iacopini F, Bizzotto A, Familiari P, Tringali A, Perri V, Bella A. Prognostic variables for the clinical success of flexible endoscopic septotomy of Zenker's diverticulum. Gastrointest Endosc 2016; 83:765-73. [PMID: 26344886 DOI: 10.1016/j.gie.2015.08.044] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 08/26/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Flexible endoscopy septotomy for Zenker's diverticulum (ZD) is an alternative to endostapling; however, long-term data are sparse and studies are heterogeneous. The aim of this study was to assess the clinical success of flexible endoscopy diverticuloscope-assisted septotomy according to all ZD-related symptoms and to identify potential prognostic variables. METHODS A prospective database of all patients with ZD undergoing septotomy and followed up for 24 months or longer was analyzed. Septotomy was conducted by using a diverticuloscope-assisted technique. Dysphagia, regurgitation, and respiratory symptoms (during the day and at night) were scored by their weekly frequency from 0 to 3 when on a solid food diet. Clinical success (asymptomatic state) was defined as a maximum of 2 symptoms with a score of 1 (once per week). Prognostic variables of clinical success included age, sex, pretreatment total symptom score, pre- and posttreatment ZD size, and septotomy length. The Kaplan-Meier method and Cox proportional hazards model were used to calculate the crude and adjusted hazard ratio (HR). RESULTS Septotomy was attempted and achieved in a single session in 89 patients. Clinical success at the intention-to-treat analysis was 69%, 64%, and 46% at 6, 24, and 48 months, respectively. Adverse events occurred in 3 patients: perforation in 2 (2%) and postprocedural bleeding in 1 (1%). Independent variables for failure at 6 months were a septotomy length ≤25 mm (HR 6.34) and pretreatment ZD size ≥50 mm (HR 11.08), whereas at 48 months, they were septotomy length ≤25 (HR 2.20) and posttreatment ZD size ≥10 mm (HR 2.03). Success rates for ZD ranging in size from 30 mm to 49 mm with a septotomy >25 mm were 100% and 71% at 6 months and 48 months, respectively. CONCLUSION Flexible endoscopic septotomy for ZD is feasible and safe. Treatment success correlates with the length of the septotomy and the size of ZD, which should ultimately determine the appropriate approach.
Collapse
Affiliation(s)
- Guido Costamagna
- Surgical Digestive Endoscopy, Policlinico Gemelli, Università Cattolica, Rome, Italy
| | - Federico Iacopini
- Gastroenterology and Digestive Endoscopy, Ospedale San Giuseppe, Albano L., Rome, Italy
| | - Alessandra Bizzotto
- Surgical Digestive Endoscopy, Policlinico Gemelli, Università Cattolica, Rome, Italy; Fondazione Poliambulanza, Istituto Ospedaliero, Brescia, Italy
| | - Pietro Familiari
- Surgical Digestive Endoscopy, Policlinico Gemelli, Università Cattolica, Rome, Italy
| | - Andrea Tringali
- Surgical Digestive Endoscopy, Policlinico Gemelli, Università Cattolica, Rome, Italy
| | - Vincenzo Perri
- Surgical Digestive Endoscopy, Policlinico Gemelli, Università Cattolica, Rome, Italy
| | - Antonino Bella
- National Center for Epidemiology, Surveillance, and Health Promotion, Istituto Superiore di Sanità, Rome, Italy
| |
Collapse
|
7
|
Bobkiewicz A, Banasiewicz T, Krokowicz Ł, Dryjas A, Wykrętowicz M, Katulska K, Borejsza-Wysocki M, Malinger S, Drews M. Assessment of the Results of Surgical Treatment of Zenker'S Diverticulum in Own Material. POLISH JOURNAL OF SURGERY 2015; 87:109-15. [PMID: 26146104 DOI: 10.1515/pjs-2015-0028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Indexed: 11/15/2022]
Abstract
UNLABELLED Zenker diverticulum (ZD) is the most common type of diverticula of the esophagus. Most often refers to men with a peak incidence in the seventh and eighth decade of life. In the majority diverticula remains asymptomatic and in patients with symptomatic course of the disease symptoms are often nonspecific. Aim of the study was to present the authors' own experience in surgical treatment of Zenker diverticulum. MATERIAL AND METHODS In this paper we present an analysis of 31 patients with confirmed ZD treated surgically at the Clinic in 2004-2014. Patients were analyzed in terms of age, gender, clinical symptoms, diverticulum size, type of surgery, the time to return to the oral intake, hospital stay and perioperative complications. RESULTS 22 men and 9 women were enrolled it this study. The mean age of the patients was 64.8 (SD, 10.7; in the range of 28 to 82 years). 29 patients (93.5%) underwent resection of the diverticulum, while diverticulopexy was performed in two patients. In 25 (80.6%) cases stapler device was used, while in 4 (12.9%) resection was performed manually. The average size of resected diverticulum was 4.9 cm (SD, 1.5). Following the surgery in four patients (12.9%) complications were present. The average operating time was 118.7 minutes (SD, 42.2, in the range of 50 to 240 minutes). The mean length of hospital stay was 9.3 (SD, 3.3). CONCLUSIONS Surgical treatment of ZD is associated with high effectiveness and low recurrence rate. Despite the advantages of endoscopic techniques, surgical treatment is characterized by one- stage procedure. The use of mechanical suture (stapler) significantly improves the operation, although on the basis of our own analysis there was no superiority revealed over hand sewn. Unquestionable adventage of classical technique is the opportunity to histopathological evaluation of resected diverticulum what is impossible to achieve in endoscopic techniques.
Collapse
|
8
|
Abstract
Esophageal disease and dysfunction of the lower esophageal sphincter (LES) manifesting as gastroesophageal reflux disease (GERD) particularly, is the most common of all gastrointestinal conditions impacting patients on a day-to-day basis. LES dysfunction can lead to anatomic changes to the distal esophagus, with GERD-mediated changes being benign stricture or progression of GERD to Barrett's esophagus and even esophageal cancer, and LES hypertension impairing esophageal emptying with subsequent development of pulsion esophageal diverticulum. This article details the causes, clinical presentation, workup, and treatment of esophageal stricture and epiphrenic esophageal diverticulum. Other types of esophageal diverticula (Zenker's and midesophageal) are also covered.
Collapse
|
9
|
Murray IA, Grimes DR, Wilde AD, Palmer J, Waters C, Dalton HR. Incidence and predictive features of pharyngeal pouch in a dysphagic population. Dysphagia 2014; 29:305-9. [PMID: 24385219 DOI: 10.1007/s00455-013-9507-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 12/12/2013] [Indexed: 12/17/2022]
Abstract
Pharyngeal pouch patients often present with dysphagia and risk perforation when undergoing gastroscopy. Knowledge of pharyngeal pouch incidence and predictive demographic features in patients referred for dysphagia would help determine those patients who should have barium swallow as an initial investigation. The prospectively collected data of 2,797 consecutive referrals were analysed. Logistic regression determined significant variables for predicting pharyngeal pouches. Of the 2,430 patients investigated [mean age = 67.7 years, range 17-103; 48.2 % male], 49 (2.0 %) had a pharyngeal pouch [mean age = 79.8 years (range 58-93); 53.1 % male]. Significant predictors of pharyngeal pouch were pharyngeal level dysphagia (odds ratio [OR] 3.8-19.2), age over 65 years (OR 2.2-14.1), symptom duration over 12 weeks (OR 1.1-3.9), and no weight loss (OR 1.1-5.5). Only 18 patients (36.7 %) underwent surgery for their pouch. Midsternal dysphagia alone occurred in 16 % of all patients with pouches. From our results we conclude that pharyngeal pouches in a dysphagic population are more common than previously recognised. Patients aged over 65 years with pharyngeal level dysphagia for more than 12 weeks should have a barium swallow as their initial investigation.
Collapse
Affiliation(s)
- Iain Alexander Murray
- Department of Gastroenterology, Royal Cornwall Hospital, Truro, Cornwall, TR1 3LJ, UK,
| | | | | | | | | | | |
Collapse
|
10
|
Patient reported outcomes in endoscopic and open transcervical treatment for Zenker's diverticulum. Laryngoscope 2013; 124:119-25. [DOI: 10.1002/lary.24152] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2013] [Indexed: 12/15/2022]
|
11
|
Lavin JM, Tieu D, Maddalozzo J. Complementary and integrative treatments: swallowing disorders. Otolaryngol Clin North Am 2013; 46:447-60. [PMID: 23764821 DOI: 10.1016/j.otc.2013.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Swallowing disorders are associated with many disease processes and are associated with significant morbidity and mortality. This article provides information regarding the various causes of swallowing disorders as well as medical, surgical, and integrative approaches to their management.
Collapse
Affiliation(s)
- Jennifer M Lavin
- Department of Otolaryngology-Head and Neck Surgery, Northwestern, University Feinberg School of Medicine, Chicago, IL 60611, USA.
| | | | | |
Collapse
|
12
|
Dzeletovic I, Ekbom DC, Baron TH. Flexible endoscopic and surgical management of Zenker's diverticulum. Expert Rev Gastroenterol Hepatol 2012; 6:449-65; quiz 466. [PMID: 22928898 DOI: 10.1586/egh.12.25] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Zenker's diverticulum is an outpouching of the mucosa through the Killian's triangle. The etiology of Zenker's diverticulum is not well understood. It is thought to be due to the incoordination or incomplete relaxation of the cricopharyngeal muscle. Most patients are men who present with symptoms of dysphagia between the seventh and eighth decades of life. The diagnosis is made with a dynamic contrast swallowing study. Treatment options include open surgical diverticulectomy and diverticulopexy with myotomy or myotomy alone using flexible or rigid endoscopes. Rigid endoscopic treatment is currently the preferred initial choice for Zenker's diverticulum of any size. The flexible endoscopic technique is used when there is a high risk of general anesthesia, or neck extension is contraindicated. Some centers use flexible endoscopy as the initial treatment option. Due to a lack of prospective studies, the treatment choice should be tailored to the individual patient and local expertise.
Collapse
Affiliation(s)
- Ivana Dzeletovic
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | | | | |
Collapse
|
13
|
Zaninotto G. [Modern treatment of cricopharyngeal (Zenker's) diverticula]. Cir Esp 2012; 90:213-4. [PMID: 22480769 DOI: 10.1016/j.ciresp.2012.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Accepted: 02/14/2012] [Indexed: 11/16/2022]
|
14
|
Pomerri F, Costantini M, Dal Bosco C, Battaglia G, Bottin R, Zanatta L, Ancona E, Muzzio PC. Comparison of preoperative and surgical measurements of Zenker’s diverticulum. Surg Endosc 2012; 26:2010-5. [DOI: 10.1007/s00464-012-2146-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Accepted: 01/03/2012] [Indexed: 11/28/2022]
|
15
|
Repici A, Pagano N, Fumagalli U, Peracchia A, Narne S, Malesci A, Rosati R. Transoral treatment of Zenker diverticulum: flexible endoscopy versus endoscopic stapling. A retrospective comparison of outcomes. Dis Esophagus 2011; 24:235-9. [PMID: 21143692 DOI: 10.1111/j.1442-2050.2010.01143.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Transoral stapled diverticulo-esophagostomy (TSDE) has gained increased popularity in surgical treatment of Zenker diverticulum (ZD). One of the advantages of this approach is early rehabilitation with significant decrease in patient morbidity and time to resumption of oral intake as compared with open treatment. The section of the septum between the diverticulum and the esophagus with a flexible endoscopic (ES) approach has also been proposed since mid-90s as an alternative for treatment of ZD. Both these approaches are a minimally invasive approach to treat ZD. We compared the TSDE management of ZD versus the ES treatment in a retrospective consecutive series of patients who were referred to either the ES or surgical unit of our Institute. Fifty-eight consecutive patients underwent treatment for ZD either by TSDE or ES. The two techniques were evaluated for length of hospital stay, diverticulum size, resumption of oral intake, resolution of dysphagia, and complications. Clinical outcome was evaluated throughout a symptom score from 0 to 3, calculated before and after the procedure. The two groups were compared on the various parameters using a Mann--Whitney test. Twenty-eight patients underwent ES and 30 TSDE for ZD. In both groups, a significant decrease in postoperative versus preoperative dysphagia was reported. The average length of hospital stay wasn't significantly different in the two groups (3.38 days for TSDE vs. 2.42 days for ES). The overall complication rate was similar in the two groups. There were two cases in the ES group and three cases in the TDSE group that required an ES revision to take down a residual diverticular wall that produced a mild but persistent dysphagia. Minimally invasive treatment of ZD both with ES and with TSDE is a valuable option for this disease: both techniques are safe and effective, with similar outcome in terms of hospital stay, symptom reduction, and complication rate. Long-term results have to be evaluated.
Collapse
Affiliation(s)
- A Repici
- Gastroenterology Unit, IRCCS Istituto Clinico Humanitas, Rozzano, Italy.
| | | | | | | | | | | | | |
Collapse
|
16
|
Kopelman Y, Triadafilopoulos G. Endoscopy in the diagnosis and management of motility disorders. Dig Dis Sci 2011; 56:635-54. [PMID: 21286936 DOI: 10.1007/s10620-011-1584-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 01/14/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gastrointestinal illness may result from either an underlying structural abnormality (e.g. neoplastic obstruction), or a functional disorder (e.g. motor diarrhea), or both (e.g. achalasia with squamous esophageal cancer). AIMS The purpose of this study was to highlight the potential value and role of endoscopy in the recognition and management of patients with functional and motility disorders. METHODS We performed a literature review in PubMed. RESULTS Diagnostic and therapeutic endoscopy may be under-used by motility-oriented gastroenterologists; in contrast, motility and other functional studies may be under-used by endoscopists. Yet, many areas of cross-exchange exist. CONCLUSIONS This review aims to guide the appropriate indications for the use of endoscopy in diagnosing and treating functional GI and motility disorders and serve as a bridge and a forum of exchange between endoscopists and motility specialists.
Collapse
Affiliation(s)
- Yael Kopelman
- Stanford University School of Medicine, Stanford, CA, USA
| | | |
Collapse
|
17
|
Surgical experience of the national institution in the treatment of Zenker's diverticula. ACTA ACUST UNITED AC 2009; 56:25-33. [PMID: 19504986 DOI: 10.2298/aci0901025s] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIM To review the 8-year experience of the Department of Esophagogastric Surgery, First Surgical University Hospital in Belgrade in the surgical management of Zenker's diverticula (ZD). METHODS Between January 2000 and January 2009, 52 patients underwent surgical procedure for the treatment of ZD. Complete preoperative workup including the symptom evaluation and large variety of structural and functional diagnostic procedures were conducted before the surgery. After the operative treatment patients underwent detailed follow-up in regular intervals up to 3 years. RESULTS Preoperative evaluation marked higher incidence of hiatal hernia and pathologic gastroesophageal reflux (GER) among the patients with ZD then in normal population. According to the preoperative evaluation and size of diverticula, as well as due to the intraopertive findings, a variety of surgical procedures were performed, including myotomy alone (n = 2), diverticulopexy and myotomy (n = 36) and diverticulectomy and myotomy (n = 14). Regardless of the operative treatment no salivary cervical fistulas were observed. Late and early postoperative results revealed low incidence in postoperative transitory dysphagia or regurgitation. CONCLUSION The results of this study show that the open surgical procedures are safe and effective in the treatment of ZD. Cricopharyngeal myotomy remains the essential focus of treatment, while the choice of resecting or suspending the diverticulum is brought upon its size. Complete preoperative investigation must be conducted in ZD patients, and the role of pathologic GER must be taken into account when we discuss the origin of this disorder.
Collapse
|
18
|
Brigand C, Bajcz K, Elamrani H, Dan S, Rohr S, Meyer C. [Suspension diverticulopexy for Zenker's diverticulum]. ACTA ACUST UNITED AC 2009; 145:341-5. [PMID: 18955924 DOI: 10.1016/s0021-7697(08)74313-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Zenker's diverticulum is an unusual condition. Its treatment requires surgery but there is no consensus regarding the various operative techniques. Through an open cervical approach, the diverticulum can be either resected or suspended with or without a concurrent myotomy of the cricopharyngeus muscle. An innovative option is endoscopic trans-oral stapled esophago-diverticulostomy. PATIENTS and method: We retrospectively reviewed a consecutive series of 36 patients operated on between 1988 and 2006. Median age was 77.5 years and M/F sex ratio was 1.4. Through an open neck approach, diverticulectomy without cricopharyngeal myotomy was performed in 7 patients, diverticulectomy with myotomy in 11, and diverticulopexy with myotomy in 18. RESULTS Morbidity rate was 13.8%. One fistula and one recurrence occurred in both diverticulectomy groups with and without myotomy. There was no morbidity after suspension diverticulopexy which also allowed earlier oral feeding (1 vs. 6 days) and shortened hospitalization (6 vs. 13.5 days). CONCLUSION Diverticulopexy with cricopharyngeus myotomy is an effective, reliable, and reproducible technique for the correction of Zenker's diverticula smaller than 5 cm. Diverticulectomy should be reserved for larger diverticula. Technical improvements of transoral stapled diverticulostomy are still required before it can be promoted as an alternative therapy.
Collapse
Affiliation(s)
- C Brigand
- Service de chirurgie générale et digestive, pôle des pathologies digestives, hépatiques et de la transplantation, hôpital de Hautepierre Strasbourg.
| | | | | | | | | | | |
Collapse
|
19
|
Rizzetto C, Zaninotto G, Costantini M, Bottin R, Finotti E, Zanatta L, Guirroli E, Ceolin M, Nicoletti L, Ruol A, Ancona E. Zenker's diverticula: feasibility of a tailored approach based on diverticulum size. J Gastrointest Surg 2008; 12:2057-64; discussion 2064-5. [PMID: 18810559 DOI: 10.1007/s11605-008-0684-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2008] [Accepted: 08/20/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND Zenker's diverticula (ZD) can be treated by transoral diverticulostomy or open surgery (upper esophageal sphincter myotomy and diverticulectomy or diverticulopexy). The aim of this study was to compare the effectiveness of a minimally invasive (group A) versus a traditional open surgical approach (group B) in the treatment of ZD. MATERIAL AND METHODS Between 1993 and September 2007, 128 ZD patients underwent transoral diverticulostomy (n = 51) or cricopharyngeal myotomy and diverticulectomy or diverticulopexy (n = 77). All patients were evaluated for symptoms using a detailed questionnaire. Manometry recorded upper esophageal sphincter (UES) pressure, relaxations, and intrabolus pharyngeal pressure. The size of the pouch was measured on the barium swallow. The choice of treatment was based on the size of the diverticulum and the patients' preference. Long-term follow-up data were available for 121/128 (94.5%) patients with a median follow-up of 40 months (interquartile range, 17-83). RESULTS Mortality was nil. Three patients in group A (5.8%) and ten in group B (13%) had postoperative complications (p = n.s.). Hospital stays were markedly shorter for patients after diverticulostomy (p < 0.01). Postoperative manometry showed a reduction in UES pressure, improved UES relaxation, and lower intrabolus pressure in both groups (p < 0.05). Four patients in the open surgery group (5.2%) complained of severe dysphagia after surgery (three of them required endoscopic dilations). In the transoral diverticulostomy group, 11 patients (21.5%) required additional septal reduction (n = 8) or a surgical myotomy (n = 3) for persistent symptoms (p < 0.01); nine of these 11 patients had a ZD < or = 3 cm in size. After primary and complementary treatments, symptoms disappeared or improved significantly at long-term follow-up in 93.5% of patients in group A and 96% of those in group B. CONCLUSION Diverticulostomy is safe, quick, and effective for most patients with medium-sized ZD, but open surgery offers better long-term results as a primary treatment and should be recommended for younger, healthy patients, especially those with small diverticula. Small ZD may represent a formal contraindication to the transoral approach because an excessively short septum prevents a complete division of the sphincter fibers.
Collapse
|
20
|
Videothoracoscopic management of middle esophageal diverticulum with secondary bronchoesophageal fistula: Report of a case. Surg Today 2008; 38:1124-8. [DOI: 10.1007/s00595-008-3797-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2007] [Accepted: 02/14/2008] [Indexed: 10/21/2022]
|
21
|
Flexible endoscopic clip-assisted Zenker's diverticulotomy: the first case series (with videos). Laryngoscope 2008; 118:1199-205. [PMID: 18401278 DOI: 10.1097/mlg.0b013e31816e2eee] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In treating Zenker's diverticulum (ZD), there are potential risks associated with performing flexible endoscopic diverticulotomy without suturing or stapling. We recently introduced flexible endoscopic clip-assisted diverticulotomy (ECD) in treating ZD by securing the septum prior to dissection. OBJECTIVE To evaluate the feasibility and safety of ECD for complete septum dissection. STUDY DESIGN Case series at an academic center. Seven consecutive patients (mean age 71 y; range 48-91 y) with symptomatic ZD of various craniocaudal sizes based on radiographic measurements (mean 2.6 cm; range 0.8 cm-4.5 cm) were included. The mean depth of the septum was 1.73 cm (range 0.3 cm-3.1 cm). The mean duration of symptoms was 4.8 years (range 0.5-10 y). METHODS After endoclips were placed on either side of the cricopharyngeal bar, the septum was dissected between these two clips down to the inferior end of the diverticulum with a needle-knife. Procedures including "one-step ECD" (n = 1), "stepwise ECD" (n = 3), and "bottom ECD" (n = 2) were performed based on the septum depth of the ZD during endoscopy. ECD was not performed on one patient due to severe mucosal fragility of the esophageal inlet. Iatrogenic blunt dissection of the septum by the endoscopic hood occurred secondary to patient retching during the procedure. Main outcome measurements were symptom resolution and complications. RESULTS All patients (n = 6) who underwent ECD had complete resolution of esophageal symptoms at a minimum 6-month follow-up. There were no procedural complications. The patient who did not undergo ECD developed an esophageal perforation. She was managed conservatively without surgical intervention. On follow-up, her dysphagia was completely resolved. CONCLUSIONS ECD is feasible, safe, and effective for complete septum dissection. ECD and endoscopic stapler-assisted diverticulotomy are complimentary rather than competing strategies in approaching ZD. Study limitations include the case series design and limited follow-up period.
Collapse
|
22
|
Tang SJ, Lara LF. Flexible endoscopic clip-assisted Zenker's diverticulotomy (with videos). Gastrointest Endosc 2008; 67:704-8. [PMID: 18308312 DOI: 10.1016/j.gie.2007.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2007] [Accepted: 11/06/2007] [Indexed: 12/10/2022]
Abstract
BACKGROUND In treating Zenker's diverticulum (ZD), there are potential risks associated with flexible endoscopic diverticulotomy without suturing or stapling. Rigid endoscopic stapler-assisted diverticulotomy has limitations. The septum is usually not completely dissected with either technique. OBJECTIVE Our purpose was to evaluate the feasibility of flexible endoscopic clip-assisted diverticulotomy (ECD) for complete septum dissection. DESIGN Case report. SETTING Academic center. PATIENT An elderly male with symptomatic residual ZD. INTERVENTIONS After 1 endoclip (InScope multiclip applier, Ethicon Endo-Surgery) was placed on each side of the cricopharyngeal bar, the septum was easily and completely dissected between these 2 clips down to the bottom of the diverticulum into the esophageal mucosa with a needle-knife. MAIN OUTCOME MEASUREMENT Symptom resolution and complications. RESULTS Complete esophageal symptom resolution without complications. LIMITATION Case report. CONCLUSIONS ECD is feasible, easy, safe, and effective for complete septum dissection. This is the first reported case of ECD. ECD provides another option in managing ZD with flexible endoscopy.
Collapse
Affiliation(s)
- Shou-jiang Tang
- Division of Digestive Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas 75390-8887, USA
| | | |
Collapse
|
23
|
Esophagus Benign Diseases of the Esophagus. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
24
|
|
25
|
Yip HT, Leonard R, Kendall KA. Cricopharyngeal Myotomy Normalizes the Opening Size of the Upper Esophageal Sphincter in Cricopharyngeal Dysfunction. Laryngoscope 2006; 116:93-6. [PMID: 16481817 DOI: 10.1097/01.mlg.0000184526.89256.85] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The development of a cricopharyngeal dysfunction is associated with a hypertonic cricopharyngeus (CP) muscle. Therefore, CP myotomy has been advocated by some authors to be an essential part of repair of this condition. However, little objective data exists to show that there is improvement in the upper esophageal sphincter (UES) after CP myotomy. This study assesses the impact of CP myotomy on UES opening. STUDY DESIGN Prospective. METHODS Twenty patients treated at a university tertiary care center for cricopharyngeal dysfunction between 1998 and 2003 were identified. All patients underwent CP myotomy with or without Zenker's diverticulectomy. These patients had videofluoroscopic swallow studies before and after repair. The values of UES opening for 3 mL boluses from pre- and postrepair studies were compared with each other as well as with normal controls. Sixty percent (12/20) of the patients had a Zenker's diverticulum. Of these 12 patients, 5 had undergone previous attempts at surgical correction. Cricopharyngeal myotomy by way of an external approach, with or without Zenker's diverticulectomy, was performed in all patients by the senior author. RESULTS Before Zenker's diverticulectomy and CP myotomy, the mean UES opening (n = 20) for a 3 mL bolus was 0.30 cm +/- 0.17, which was 57% of the mean of 60 normal controls (0.52 cm +/- 0.15) (P < .001). After repair, the mean UES opening for the same bolus size improved to 0.51 cm +/- 0.16 (P < .0001). The UES opening size in patients who have undergone repair is comparable with that of the normal controls (P > .05). CONCLUSIONS UES opening size in patients with cricopharyngeal dysfunction is 57% of the size in normal controls. CP myotomy helps to normalize the UES opening in cricopharyngeal dysfunction repair.
Collapse
Affiliation(s)
- Helena T Yip
- Department of Otolaryngology-Head and Neck Surgery, University of California at Davis, Sacramento, California 95817-2207, USA.
| | | | | |
Collapse
|
26
|
de la Morena E, Pérez-Arellano E, Carreño R, Tomás E, González-Lama Y. Tratamiento endoscópico del divertículo de Zenker. Cir Esp 2005; 78:256-9. [PMID: 16420835 DOI: 10.1016/s0009-739x(05)70928-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION We report our experience in the endoscopic (flexible) treatment of Zenker's diverticulum. PATIENTS AND METHOD Three patients with medium-sized Zenker's diverticula were treated by endoscopic cricopharyngeal myotomy with a modified needle-knife sphincterotome through a therapeutic gastroscope. The procedure was performed in the digestive endoscopy unit under conscious sedation without anesthetic support. RESULT Endoscopic cricopharyngeal myotomy was completed in a single session without immediate or late complications. In all three patients dysphagia disappeared and all were discharged at 48 hours with a solid diet. After 12, 18 and 17 months of follow-up there has been no recurrence of dysphagia or other symptoms attributable to Zenker's diverticulum. CONCLUSION Flexible endoscopic cricopharyngeal myotomy is a simple, effective and safe treatment of Zenker's diverticulum that avoids the need for open cervical surgery and general anesthesia.
Collapse
|
27
|
Abstract
BACKGROUND A pharyngeal pouch is an out-pouching or pocket that develops from the posterior wall of the pharynx just above the entrance to the oesophagus (gullet). Pouches may give rise to difficulty in swallowing, sensation of a lump in the throat or of food sticking in the throat and may lead to troublesome regurgitation of food. Food may enter the pouch rather than passing down the oesophagus and this and regurgitation may result in weight loss, hoarseness of voice and/or recurrent chest infections. The management of patients with a pharyngeal pouch may be either conservative or surgical. The surgical management can be further divided into two broad categories: endoscopic and open procedures. In the first half of the twentieth century an open surgical approach to the pouch was most frequently used, and remains common in some parts of the world. In recent decades endoscopic procedures (where the approach is made through the mouth) have become popular. The superiority of one approach over another has yet to be clearly demonstrated. OBJECTIVES To assess the effectiveness and safety of open and endoscopic surgical procedures for the management of a pharyngeal pouch. SEARCH STRATEGY We searched the Cochrane Ear, Nose and Throat Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 3, 2004, MEDLINE (1966 to 2004) and EMBASE (1974 to 2004). Reference lists of all identified trials and previous reviews were searched for additional trials. Further electronic searches for key authors identified were made. There were no language restrictions. The date of the last search was September 2004. SELECTION CRITERIA We sought to identify all randomised controlled trials (RCTs) comparing two or more interventions. DATA COLLECTION AND ANALYSIS Three reviewers assessed the eligibility of trials for inclusion in the review, based on pre-determined criteria. MAIN RESULTS No trials were identified which fulfilled the criteria. AUTHORS' CONCLUSIONS There is no evidence from high quality randomised controlled trials to demonstrate the effectiveness of endoscopic compared with open procedures for pharyngeal pouch. There is no good evidence to establish whether one endoscopic procedure is superior to another.
Collapse
Affiliation(s)
- P Sen
- ENT Department, Whipps Cross Hospital, Leytonstone, London, UK, E11 1NR.
| | | | | |
Collapse
|
28
|
Abstract
BACKGROUND The development of endoscopic techniques, particularly endoscopic stapling, has led to a re-evaluation of the treatment of pharyngeal pouch. The pathophysiology and treatment of the condition is reviewed. METHODS An electronic literature search was undertaken on the pathophysiology, history and surgery of pharyngeal pouch (Zenker's diverticulum). These last two terms were used to the search the Cochrane, Medline and Embase databases (from 1966 to date) and the bibliographies of extracted articles. RESULTS AND CONCLUSION With recognition of the central role of the cricopharyngeus muscle in the pathogenesis of pouch formation, the emphasis on treatment has shifted from diverticulectomy to cricopharyngeal myotomy. Minimally invasive techniques have become established since the advent of endoscopic stapling devices. Although randomized controlled data are lacking, the endoscopic approach appears to offer advantages in terms of a shorter duration of anaesthesia, more rapid resumption of oral intake, shorter hospital stay and quicker recovery. It is associated with excellent success rates and minimal morbidity.
Collapse
Affiliation(s)
- A Aly
- University of Adelaide Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | | | | |
Collapse
|
29
|
Costantini M, Zaninotto G, Rizzetto C, Narne S, Ancona E. Oesophageal diverticula. Best Pract Res Clin Gastroenterol 2004; 18:3-17. [PMID: 15123081 DOI: 10.1016/s1521-6918(03)00105-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2003] [Accepted: 06/01/2003] [Indexed: 01/31/2023]
Abstract
Oesophageal diverticula are rare. They are most commonly seen at the pharyngo-oesophageal junction (Zenker's diverticula) or at the distal oesophagus (epiphrenic diverticula). In both cases they are caused by altered motility which results in abnormal intraluminal pressure and the pushing of the oesophageal mucosa through focal weaknesses of the muscular wall (pulsion diverticula). The established surgical treatment for these diverticula therefore consists of eliminating the functional obstruction causing the disease (myotomy), associated with resection of the diverticulum (diverticulectomy) or its suspension (diverticulopexy). Recently, the spread of minimally invasive surgery has also led the application of such techniques to the treatment of oesophageal diverticula. Endoscopic diverticulostomy with stapler, laser or coagulation, through a rigid or flexible endoscope, has been demonstrated to be a valid treatment for Zenker's diverticula-as an alternative to surgery-especially in high-risk patients. On the other hand, laparoscopic treatment of epiphrenic diverticula has recently been introduced with encouraging results. However, because the disease is rare, more experience is required in order to allow definitive conclusions.
Collapse
Affiliation(s)
- Mario Costantini
- Clinica Chirugica IV, Department of Medical and Surgical Sciences, University of Padua, 2, via Giustiniani, Padua, Italy
| | | | | | | | | |
Collapse
|