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Krekeler BN, Howell RJ. Cricopharyngeus muscle dysfunction: a poorly defined disorder from diagnosis to treatment. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08644-7. [PMID: 38714548 DOI: 10.1007/s00405-024-08644-7] [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: 01/17/2024] [Accepted: 03/26/2024] [Indexed: 05/10/2024]
Abstract
PURPOSE Cricopharyngeus muscle dysfunction (CPMD) is a common clinical occurrence with very few clear diagnostic criteria and multiple pathways for treatment. Incidence of CPMD is not known, but some data suggest around 25% of people with dysphagia experience some degree of CPMD, which negatively impacts swallowing safety and efficiency. Workup and treatment of CPMD can require multidisciplinary collaboration across laryngologists, speech-language pathologists with training in dysphagia management, and gastroenterologists. The purpose of this paper is to review what is known about CPMD and identify areas of future research in CPMD diagnosis and treatment. METHODS An overview of CPMD, relative treatments and disorders, and a discussion of future areas of research needed to improve clinical care of CPMD. RESULTS Details regarding historical background, pathophysiology and treatment practiced for CPMD are included. CONCLUSION In summary, CPMD is a poorly defined disease due to a lack of understanding of its pathophysiology and the lack of consensus diagnostic criteria. Well-designed, prospective clinical trials are necessary to develop a better understanding of clinical incidence of CPMD, impact of the disorder on oropharyngeal swallowing, and how to approach treatment of the disorder surgically or in conjunction with therapy directed by a specialized speech-language pathologist.
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Affiliation(s)
- Brittany N Krekeler
- Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, USA
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, USA
- Department of Communication Sciences and Disorders, University of Cincinnati College of Allied Health Sciences, Cincinnati, USA
| | - Rebecca J Howell
- Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, USA.
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2
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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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Mandarino FV, Vespa E, Barchi A, Fasulo E, Sinagra E, Azzolini F, Danese S. Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review. Life (Basel) 2023; 13:2143. [PMID: 38004283 PMCID: PMC10672509 DOI: 10.3390/life13112143] [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: 09/25/2023] [Revised: 10/28/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
Our review delves into the realm of peroral endoscopic myotomies (POEMs) in the upper gastrointestinal tract (UGT). In recent years, POEMs have brought about a revolution in the treatment of UGT motility disorders. Esophageal POEM, the first to be introduced, has now been validated as the primary treatment for achalasia. Subsequently developed, G-POEM displays promising results in addressing refractory gastroparesis. Over time, multiple endoscopic myotomy techniques have emerged for the treatment of Zenker's diverticulum, including Z-POEM, POES, and hybrid approaches. Despite the well-established efficacy outcomes, new challenges arise in the realm of POEMs in the UGT. For esophageal POEM, the future scenario lies in customizing the myotomy extent to the minimum necessary, while for G-POEM, it involves identifying patients who can optimally benefit from the treatment. For ZD, it is crucial to validate an algorithm that considers various myotomy options according to the diverticulum's size and in relation to individual patients. These challenges align with the concept of precision endoscopy, personalizing the technique for each subject. Within our text, we comprehensively examine each myotomy technique, analyzing indications, outcomes, and adverse events. Additionally, we explore the emerging challenges posed by myotomies within the context of the evolving field of precision endoscopy.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Edoardo Vespa
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Ernesto Fasulo
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele Giglio, 90015 Cefalù, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
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Guo TT, Dong YB, Liu YH, Lu C, Li WX. Diagnosis and Open Surgical Management of Laimer's Diverticulum: Case Series and Review of the Literature. EAR, NOSE & THROAT JOURNAL 2023:1455613231202245. [PMID: 37752849 DOI: 10.1177/01455613231202245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
Objectives: Laimer's diverticulum (LD) is a very rare clinical entity originating between the cricopharyngeus muscle (CPM) and circular muscular fibers of the esophagus. Its diagnosis and management remain to be elucidated. This article summarizes our experience in its diagnosis and open surgical management.Methods: A retrospective review of LD cases treated at our tertiary medical institution was conducted between July 2018 and May 2023. The clinical and demographic data were retrieved from case notes.Results: Three cases were included in this review. There were 2 male patients and 1 female patient. The average and median ages were 47.3 and 54 years, respectively. Presenting symptoms included hoarseness, pharyngeal foreign body sensation, and neck mass. All 3 diverticula were on the left side, with the first 2 cases discovered accidentally on gastric endoscopic or cervical MRI examinations. After evaluating esophageal swallowing with barium sulfate or urografin contrast media, all the patients consented to undergo an open surgical procedure. During surgical exploration, the diverticula were found to be on the posterior part of the cervical esophagus, below CPM, and away from the recurrent laryngeal nerve, and only then, could the diagnosis of LD be established. Then, diverticulectomy and manual suturing of the esophagus was performed. Recovery of all 3 patients was uneventful. Nasogastric tube feeding lasted 7 to 12 days until esophageal examinations demonstrated no leak, and then, oral liquid feeding resumed. The median duration of follow-up was 50 months. No recurrence of symptoms or diverticulum was observed, and the swallowing function of all 3 patients was excellent.Conclusions: An open surgical approach is not only important for the diagnosis of LD, but can also be utilized as a safe and effective treatment.
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Affiliation(s)
- Ting-Ting Guo
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yan-Bo Dong
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yu-He Liu
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Cheng Lu
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Wan-Xin Li
- Department of Otolaryngology Head and Neck Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Tikka T, Hall MA, de Blieck SM, Buchanan MA. Swallowing outcomes following division of pseudo-epiglottis resulting from vertical pharyngeal closure in laryngectomy. Head Neck 2023; 45:952-962. [PMID: 36811257 DOI: 10.1002/hed.27311] [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: 06/09/2022] [Revised: 01/24/2023] [Accepted: 01/31/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Vertical closure of the pharynx after laryngectomy can result in an outpouch of the anterior wall of the neopharynx below the tongue base, called a pseudo-diverticulum. The prolapsed mucosa that separates the rest of the neopharynx from the pseudo-diverticulum is termed a pseudo-epiglottis. METHODS Prospective study of patients with pseudo-epiglottis. M. D. Anderson Dysphagia Inventory (MDADI) scores were used to assess swallowing outcomes pre- and post-pseudo-epiglottis division, including minimally clinically important difference (MCID) assessment. RESULTS Of 16 patients with a pseudo-epiglottis, 12 had dysphagia (75%). Symptomatic patients had significantly worse global MDADI and subscale scores. After division, the mean composite MDADI increased from 48.3 to 64.7 (p = 0.035), including a high MCID (16.4) with a similar improvement in the global question rating findings (31.1 vs. 60, p = 0.021). The MCID was significant for all MDADI subscales. CONCLUSIONS Pseudo-epiglottis formation is associated with significantly worse global and subscale MDADI scores. A clinically- and statistically-significant improvement in the MDADI scores was found following surgical division.
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Affiliation(s)
- Theofano Tikka
- ENT Department, Queen Elizabeth University Hospital, Glasgow, UK
| | - Mark Andrew Hall
- Radiology Department, Queen Elizabeth University Hospital, Glasgow, UK
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Andrási L, Ábrahám S, Simonka Z, Paszt A, Erdős M, Rovó L, Rosztóczy A, Ollé G, Lázár G. [Minimally invasive surgery for motility disorders of the oesophagus]. Magy Seb 2022; 75:121-132. [PMID: 35895537 DOI: 10.1556/1046.2022.20006] [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: 03/29/2022] [Accepted: 04/04/2022] [Indexed: 01/06/2023]
Abstract
Introduction and aims. We present our experience with minimally invasive surgery for pharyngoesophageal (Zenker) diverticulums, epiphrenic diverticulums and achalasia cardiae focusing on the perioperative features and patients’ quality of life. Patients and methods. Between 1 January 2003 and 31 December 2020, patients were selected with a symptom-causing Zenker diverticulum, epiphrenic diverticulum and achalasia cardiae. In 17 cases, transoral stapler diverticulostomy, in 23 cases transcervical diverticulectomy and cricomyotomy were done because of Zenker diverticulum, in 14 cases, laparoscopic transhiatal surgery was performed because of epiphrenic diverticula, while in 63 cases, laparoscopic Heller–Dor operation were carried out because of achalasia cardiae. Perioperative results, the quality of life outcomes of various surgeries were evaluated in mid- and long-term. Results/conclusions. The surgeries were performed with minimal blood loss, zero mortality and low morbidity. According to our result, the two different surgical approaches in the therapy of Zenker’s diverticulum, the laparoscopic Heller–Dor procedure applied in the management of epiphrenic diverticulas and achalasia cardiae are safe and effective operations. In the long term, the symptom control in patients after minimally invasive surgeries is sufficient and only a small percentage of the patients may require additional medication therapy and/or reintervention due to persistent complaints.
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Affiliation(s)
- László Andrási
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Szabolcs Ábrahám
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Zsolt Simonka
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Attila Paszt
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - Márton Erdős
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
| | - László Rovó
- 2 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Fül-Orr-Gégészeti és Fej-Nyaksebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Rovó László)
| | - András Rosztóczy
- 3 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Belgyógyászati Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lengyel Csaba)
| | - Georgina Ollé
- 3 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Belgyógyászati Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lengyel Csaba)
| | - György Lázár
- 1 Szegedi Tudományegyetem Szent-Györgyi Albert Orvostudományi Kar, Sebészeti Klinika, Szeged, Magyarország (tanszékvezető: Prof. Dr. Lázár György)
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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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Endoscopic septotomy of Zenker's diverticulum with Stag-Beetle Knife™: A descriptive observational study and literature review. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 45:432-439. [PMID: 34129902 DOI: 10.1016/j.gastrohep.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/20/2021] [Accepted: 06/04/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Zenker's diverticulum (ZD) is a protrusion of the hypopharyngeal mucosa with a prevalence of 2/100,000 inhabitants. The symptoms of the patients determine the need for treatment, which can be surgical or endoscopic. The latter, known as endoscopic septotomy or diverticulotomy (ED), this involves dissecting the diverticular septum, which can be performed with different dissection devices. AIM The aim of our study was to evaluate the efficacy and safety of ED with Stag-Beetle-Knife™ device, as well as to conduct a literature review to assess the position of the technique in the current scientific panorama. MATERIAL AND METHODS Descriptive retrospective study that includes patients who underwent ED with SB-Knife™ between June 2017 and February 2020. Literature review of the available evidence between January 2013 and April 2020 of ED with SB-Knife™ technique and its variants. RESULTS Twelve patients (66% male) with a median age of 70.5 years were collected. The median size of diverticular was 32.5mm and complete remission was observed in 75% of the cases. Fourteen interventions were performed with a technical success of 92.8. There were no serious complications. A literature review was carried out, finding 13 papers, of which 8 were finally included (6 retrospective studies, a series of cases and a clinical case). CONCLUSION Based on our experience and the reviewed literature, we consider ED with SB-Knife™ is a safe, effective and reproducible technique, and may be a better alternative to surgery in patients with ZD.
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Levy RM, Luketich JD, Brynien D, Mpamaugo C, Shende MR, Gooding WE, Pennathur A. Transoral endoscopic repair of Zenker diverticulum by a thoracic surgical service. J Thorac Cardiovasc Surg 2021; 163:1965-1974.e1. [PMID: 34148637 DOI: 10.1016/j.jtcvs.2020.12.151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 11/20/2020] [Accepted: 12/08/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Zenker diverticulum (ZD), a pulsion diverticulum of the esophagus, has been traditionally managed with an open surgical approach, but endoscopic transoral stapling has been reported with increasing frequency. The objective of this study was to evaluate the results of endoscopic repair of ZD by a thoracic surgery service. METHODS We conducted a retrospective review of patients who underwent transoral stapling repair of ZD at our institution by the thoracic surgery service. We evaluated perioperative outcomes including dysphagia (1, no dysphagia to 5, unable to swallow saliva) and failure of repair requiring surgical intervention. RESULTS A total of 151 patients (median age, 78 years; 75 men, 76 women) underwent evaluation for endoscopic repair of ZD. Endoscopic stapled repair of the ZD was completed in 135. Sixteen patients underwent conversion to open repair. The perioperative mortality was 0.6% (1 patient). The median hospital stay was 2 days (range, 0-18 days). Complications occurred in 5 patients who underwent endoscopic repair. The mean preoperative dysphagia score was 2.8 and improved to 1.2 during follow-up (median, 16 months; P < .001). During further follow-up (median, 52 months), 8 patients (5.3%) had failure of the endoscopic repair requiring open surgery (n = 5) or redo transoral stapling (n = 3). CONCLUSIONS Endoscopic stapling repair of ZD can be performed safely with good results in experienced centers by thoracic surgeons with significant esophageal experience. Long-term follow-up is required to evaluate the durability of endoscopic repair of ZD.
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Affiliation(s)
- Ryan M Levy
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pa
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pa
| | - Daniel Brynien
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pa
| | - Chinenyenwa Mpamaugo
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pa
| | - Manisha R Shende
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pa
| | | | - Arjun Pennathur
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pa.
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10
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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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11
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Hampton T, Allan J, Pearson D, Emerson H, Jones GH, Junaid M, Kanzara T, Lau AS, Siau R, Williams SP, Wilkie MD. A multi-centre analysis of a decade of endoscopic pharyngeal pouch surgery in Cheshire and Merseyside. J Laryngol Otol 2020; 134:1-6. [PMID: 33138870 DOI: 10.1017/s0022215120002224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND There are sparse data on the outcomes of endoscopic stapling of pharyngeal pouches. The Mersey ENT Trainee Collaborative compared regional practice against published benchmarks. METHODS A 10-year retrospective analysis of endoscopic pharyngeal pouch surgery was conducted and practice was assessed against eight standards. Comparisons were made between results from the tertiary centre and other sites. RESULTS A total of 225 procedures were performed (range of 1.2-9.2 cases per centre per year). All centres achieved 90 per cent resumption of oral intake within 2 days. All centres achieved less than 2-day hospital stays. Primary success (84 per cent (i.e. abandonment of endoscopic stapling in 16 per cent)), symptom resolution (83 per cent) and recurrence rates (13 per cent) failed to meet the standard across the non-tertiary centres. CONCLUSION Endoscopic pharyngeal pouch stapling is a procedure with a low mortality and brief in-patient stay. There was significant variance in outcomes across the region. This raises the question of whether this service should become centralised and the preserve of either tertiary centres or sub-specialist practitioners.
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Affiliation(s)
- T Hampton
- Mersey ENT Trainee Research Collaborative, Liverpool University Hospitals NHS Foundation Trust, UK
- Department of ENT Surgery, Liverpool University Hospitals NHS Foundation Trust, UK
| | - J Allan
- Mersey ENT Trainee Research Collaborative, Liverpool University Hospitals NHS Foundation Trust, UK
- Department of ENT Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, UK
| | - D Pearson
- Mersey ENT Trainee Research Collaborative, Liverpool University Hospitals NHS Foundation Trust, UK
- Department of ENT Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, UK
| | - H Emerson
- Mersey ENT Trainee Research Collaborative, Liverpool University Hospitals NHS Foundation Trust, UK
- Department of ENT Surgery, Warrington and Halton Teaching Hospitals NHS Foundation Trust, Warrington, UK
| | - G H Jones
- Mersey ENT Trainee Research Collaborative, Liverpool University Hospitals NHS Foundation Trust, UK
- Department of ENT Surgery, Liverpool University Hospitals NHS Foundation Trust, UK
| | - M Junaid
- Mersey ENT Trainee Research Collaborative, Liverpool University Hospitals NHS Foundation Trust, UK
- Department of ENT Surgery, Warrington and Halton Teaching Hospitals NHS Foundation Trust, Warrington, UK
| | - T Kanzara
- Mersey ENT Trainee Research Collaborative, Liverpool University Hospitals NHS Foundation Trust, UK
- Department of ENT Surgery, Mid Cheshire Hospitals NHS Trust, Crewe, UK
| | - A S Lau
- Mersey ENT Trainee Research Collaborative, Liverpool University Hospitals NHS Foundation Trust, UK
- Department of ENT Surgery, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, UK
| | - R Siau
- Mersey ENT Trainee Research Collaborative, Liverpool University Hospitals NHS Foundation Trust, UK
- Department of ENT Surgery, Liverpool University Hospitals NHS Foundation Trust, UK
| | - S P Williams
- Mersey ENT Trainee Research Collaborative, Liverpool University Hospitals NHS Foundation Trust, UK
- Department of ENT Surgery, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - M D Wilkie
- Mersey ENT Trainee Research Collaborative, Liverpool University Hospitals NHS Foundation Trust, UK
- Department of ENT Surgery, Liverpool University Hospitals NHS Foundation Trust, UK
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12
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Dadhich A, Saluja H, Shah S, Nilesh K. Zenker's diverticulum: a rare clinical condition with unusual oral manifestation. BMJ Case Rep 2020; 13:13/10/e239248. [PMID: 33130589 DOI: 10.1136/bcr-2020-239248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Oral mucosa exhibit clinical manifestations of a variety of systemic conditions and can serve as an indicator of overall health of an individual. Various systemic conditions like autoimmune, endocrine and haematological disorders can present with oral mucosal lesions, which can serve as an important diagnostic feature. These oral lesions can vary from oral ulceration, bleeding gums, xerostomia, chronic glossitis, to erosion and sensitivity of teeth. It is important that a clinician must be aware of the oral presentations of systemic conditions, so that timely diagnosis can be made and the necessary treatment is executed. This paper presents an unusual case of severe oral mucosal ulcerations and dysphagia in an elderly patient diagnosed with Zenker's diverticulum. Patient was relieved of all oral symptoms once the underlying gastrointestinal tract pathology was diagnosed and surgically corrected.
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Affiliation(s)
- Anuj Dadhich
- Department of Oral and Maxillofacial Surgery, Pravara Institute of Medical Sciences, Loni, India
| | - Harish Saluja
- OMFS, Pravara Rural Dental College, Ahmednagar, India
| | - Seemit Shah
- Department of Oral and Maxillofacial Surgery, Pravara Institute of Medical Sciences, Loni, India
| | - Kumar Nilesh
- Oral and Maxillofacial Surgery, Krishna Institute of Medical Sciences Deemed University, Karad, India
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13
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Podgaetz E, Konda V. Experience and Technique for Zenker's Diverticulum Per Oral Endoscopic Myotomy: Z-POEM. Thorac Cardiovasc Surg 2020; 69:228-230. [PMID: 33086405 PMCID: PMC8041486 DOI: 10.1055/s-0040-1717127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Objective
With the advent of minimally invasive surgery, incisionless surgery, and third-space endoscopy, the treatment for Zenker's diverticulum has also moved toward less invasive techniques
Methods
New incisionless per oral techniques can be applied for cricopharyngeal myotomy in Zenker's diverticulum.
Results
Five patients underwent Zenker's diverticulum per oral endoscopic myotomy (Z-POEM) without complications, minimal discomfort, and narcotic consumption, with complete resolution of their symptoms by history and Eckardt scores.
Conclusions
Z-POEM is performed entirely endoscopically with very little associated pain or complication rates, with short-term follow-up having excellent functional and symptomatic results.
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Affiliation(s)
- Eitan Podgaetz
- Center for Thoracic Surgery, Baylor Scott & White North Texas, Dallas, Texas, United States
| | - Vani Konda
- Center for Esophageal Diseases, Baylor University Medical Center at Dallas, Dallas, Texas, United States
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14
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Peroral Endoscopic Diverticulotomy (POED) for Zenker Diverticulum Using Submucosal Injection to Perform a Complete Myotomy. Surg Laparosc Endosc Percutan Tech 2020; 30:e30-e32. [PMID: 33021771 DOI: 10.1097/sle.0000000000000814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Endoscopic diverticulotomy associated with cricopharyngeal myotomy is a well-known and safe treatment for Zenker diverticulum. We describe our first 5 consecutive cases treated by a new variant of the technique that allows a deeper and longer myotomy than the standard one. Technical success was achieved in all the cases. All patients showed a significant improvement and relevant disappearance of preoperative dysphagia. Tips for the technique are described in the paper. This variant of peroral endoscopic diverticulotomy for Zenker diverticulum is feasible, effective, and guarantees a complete myotomy in selected patients.
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15
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Zanghì S, Siboni S, Asti E, Bonavina L. Endoscopic stapling versus laser for Zenker diverticulum: a retrospective cohort study. Eur Arch Otorhinolaryngol 2020; 278:2625-2630. [PMID: 32895798 DOI: 10.1007/s00405-020-06346-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/29/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Despite the evolution of the endoscopic techniques for the treatment of symptomatic Zenker diverticulum, comparative studies are lacking. Aim of this observational study was to compare safety, efficacy, and outcomes of endoscopic stapling (ES) versus Laser (EL). METHODS A prospectively collected database of patients who underwent treatment for Zenker diverticulum at a single institution was reviewed. Consecutive patients treated by ES or EL were included in the study. Demographic data, presenting symptoms, diverticulum characteristics, and intra- and postoperative data were analyzed. The Functional Outcome Swallowing Scale (FOSS) and MD Anderson Dysphagia Inventory (MDADI) questionnaires were administered to assess severity of dysphagia and quality of life before and after treatment. RESULTS Between March 2017 and September 2018, 36 patients underwent ES or EL. In the TL group (n = 19), the diverticulum size was smaller compared to the EL group (n = 17) (p = 0.002). Two perforations occurred in the EL group, one treated conservatively and the other requiring drainage of a mediastinal abscess. At a median follow-up of 16 months, symptoms improved in both groups but the number of patients with a postoperative FOSS score ≥ 2 significantly decreased only after EL (p < 0.001). The scores of all items of the MDADI questionnaire significantly increased in both groups, but the average delta values were greater in the EL patients (p < 0.001). CONCLUSIONS Both TL and ES are effective treatment options for Zenker diverticulum. Postoperative quality of life was significantly higher in patients undergoing EL compared to ES.
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Affiliation(s)
- Simone Zanghì
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy
| | - Stefano Siboni
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy
| | - Emanuele Asti
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy
| | - Luigi Bonavina
- Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy.
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16
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Nitschke P, Kemper M, König P, Zahnert T, Weitz J, Reissfelder C, Distler M. Interdisciplinary Comparison of Endoscopic Laser-Assisted Diverticulotomy vs. Transcervical Myotomy as a Treatment for Zenker's Diverticulum. J Gastrointest Surg 2020; 24:1955-1961. [PMID: 31482409 DOI: 10.1007/s11605-019-04381-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 08/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Currently, there are different competing techniques for the treatment of Zenker's diverticulum (ZD). To improve patient selection, we compared endoscopic laser-assisted diverticulotomy (ELAD) with transcervical myotomy (TCM) with regard to possible risk factors for treatment failure. METHODS Data of ZD patients (n = 104) treated between 2004 and 2016 with either TCM (38%) or ELAD (62%) were analyzed retrospectively. Univariate and multivariate analyses were performed. RESULTS TCM is associated with a higher morbidity (27.8% vs. 10.2%; p = 0.095) but lower recurrence rate (7.3% vs. 19.3%; p = 0.095). Preoperative reflux disease (OR 8.755; p = 0.021) was identified as an independent risk factor for complications. CONCLUSIONS Although short-term outcome and symptom relief are similar, TCM tends to have a higher complication rate but better long-term results. Preoperative reflux disease is an independent risk factor for postoperative complications.
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Affiliation(s)
- Philipp Nitschke
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Max Kemper
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Patricia König
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Thomas Zahnert
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Christoph Reissfelder
- Department of Surgery, Medical Faculty Heidelberg, University Hospital Mannheim, Mannheim, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
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17
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Exteriorized Giant Zenker’s Diverticulum: Case Report. ARS MEDICA TOMITANA 2020. [DOI: 10.2478/arsm-2019-0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Zenker’s diverticulum (ZD) also known as cricopharyngeal (CP), pharyngoesophageal or hypopharyngeal diverticulum is an outpouching of mucosal and submucosal layers originated from the pharyngoesophageal junction. Radiological evaluation of deglutition, modified barium swallow radiography may reveal the retentive character of the diverticular sac and confirm the diagnosis. Many different types of surgical approaches have been developed over the decades with modifications focusing on the need to reduce intra-operative or post-operative complications and overall morbidity. The authors present the case of a 76-years-old woman with spontaneous apparition of an exteriorised tumor in the oral cavity after an excessive cough effort. Surgical treatment is elective, preventing the occurence of complications that may endanger the patients life and improve the quality of life. Surgical therapy was open neck resection of the Zenker’s diverticulum with esophageal myotomy and pharynx reconstruction.
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18
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Howell RJ, Edelmayer LW, Postma GN. The Utility of Flexible Esophagoscopy During Open Hypopharyngeal (Zenker's) Diverticulum Surgery. Laryngoscope 2019; 130:E764-E766. [PMID: 31854455 DOI: 10.1002/lary.28485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/18/2019] [Accepted: 11/28/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Rebecca J Howell
- Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Luke W Edelmayer
- Department of Otolaryngology-Head & Neck Surgery, Medical College of Georgia at Augusta University, Augusta, GA, U.S.A
| | - Gregory N Postma
- Department of Otolaryngology-Head & Neck Surgery, Medical College of Georgia at Augusta University, Augusta, GA, U.S.A
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19
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Bloom JD, Bleier BS, Mirza N, Chalian AA, Thaler ER. Factors Predicting Endoscopic Exposure of Zenker's Diverticulum. Ann Otol Rhinol Laryngol 2019. [DOI: 10.1177/000348941011901116] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives The objectives of this study were 1) to understand which anatomic variables are associated with failed endoscopic exposure of Zenker's diverticulum and 2) to enable preoperative selection of patients suitable for endoscopic repair of Zenker's diverticulum on the basis of anatomic variables. Methods We performed a prospective, Institutional Review Board-approved study of 30 patients undergoing attempted endoscopic repair of Zenker's diverticulum. Three categorical variables (sex, presence of maxillary dentition, and Mallampati score) and 6 continuous variables (age, neck circumference, hyomental distance, neck length, neck extension, and body mass index [BMI]) were collected before operation and then correlated to successful endoscopic exposure of the Zenker's pouch by use of a Fisher's exact test and Student's t-test, respectively. Results Exposure was unsuccessful in 9 of 30 patients (30%). Factors that correlated significantly with exposure failure included a shorter neck length (7.2 ± 1.2 cm; p = 0.047), a shorter hyomental distance (5.0 ± 1.1 cm; p = 0.004), and a higher BMI (27.2 ±4.0 kg/m2; p = 0.05). The presence of maxillary dentition did not reach significance in exposure failure, but did show a trend toward an association. Conclusions Surgical exposure in endoscopic repair of Zenker's diverticulum tends to be significantly less successful in patients with short necks, decreased hyomental distance, and/or a high BMI. An open approach should be considered in this patient population.
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Affiliation(s)
- Jason D. Bloom
- Department of Otorhinolaryngology-Head and Neck
Surgery, University of Pennsylvania School of Medicine, Philadelphia,
Pennsylvania
| | - Benjamin S. Bleier
- Department of Otorhinolaryngology-Head and Neck
Surgery, University of Pennsylvania School of Medicine, Philadelphia,
Pennsylvania
| | - Natasha Mirza
- Department of Otorhinolaryngology-Head and Neck
Surgery, University of Pennsylvania School of Medicine, Philadelphia,
Pennsylvania
| | - Ara A. Chalian
- Department of Otorhinolaryngology-Head and Neck
Surgery, University of Pennsylvania School of Medicine, Philadelphia,
Pennsylvania
| | - Erica R. Thaler
- Department of Otorhinolaryngology-Head and Neck
Surgery, University of Pennsylvania School of Medicine, Philadelphia,
Pennsylvania
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20
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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.
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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
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21
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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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22
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Hering S, Wiegand S. Systemic inflammatory response after endoscopic surgery of Zenker's diverticulum. ACTA OTORHINOLARYNGOLOGICA ITALICA 2019; 39:230-234. [PMID: 30745590 PMCID: PMC6734204 DOI: 10.14639/0392-100x-1576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 12/01/2017] [Indexed: 11/23/2022]
Abstract
Zenker’s diverticulum can be treated with a carbon dioxide laser or linear stapling device. A retrospective study on patients undergoing elective surgery for Zenker`s diverticulum with carbon dioxide laser or stapler was performed to analyse possible differences in inflammatory responses during the postoperative period. Leucocyte counts and C-reactive protein levels in peripheral blood were measured before and on days 1, 2, 3 and 5 after the operation. Statistical analysis was performed using the Mann-Whitney U-test. Of 34 patients, 16 were treated by laser and 18 by stapler. Age, sex ratio and ASA grade did not differ between the groups. Postoperative leukocytosis was significantly milder in the stapler group compared with patients who were treated by carbon dioxide laser. The mean C-reactive protein (CRP) level on day 1, 2 and 3 after surgery was significantly higher in the CO2 laser group than in the stapler group. Leukocyte counts recovered on day 3 after surgery in both groups while CRP levels did not decline to preoperative levels at day 5 after the operation in either group. No inflammatory complications such as mediastinitis or pneumonia occurred. In conclusion, the inflammatory response in the early period after carbon dioxide laser diverticulotomy of Zenker’s diverticulum is higher than after stapler-assisted surgery of Zenker’s diverticulum.
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Affiliation(s)
- S Hering
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Giessen and Marburg GmbH, Marburg, Germany
| | - S Wiegand
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Leipzig, Leipzig, Germany
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23
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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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24
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Ishaq S, Sultan H, Siau K, Kuwai T, Mulder CJ, Neumann H. New and emerging techniques for endoscopic treatment of Zenker's diverticulum: State-of-the-art review. Dig Endosc 2018; 30:449-460. [PMID: 29423955 DOI: 10.1111/den.13035] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 02/04/2018] [Indexed: 02/06/2023]
Abstract
Zenker's diverticulum (ZD), or pharyngeal pouch, is an anatomical defect characterized by herniation of the posterior pharyngeal wall through Killian's dehiscence, and may result in dysphagia and regurgitation. Multiple therapeutic modalities including surgery, rigid and flexible endoscopy have been developed to manage ZD. Although surgical management with open and endoscopically assisted techniques have historically been the mainstay of ZD treatment, minimally invasive flexible endoscopic techniques, carried out under conscious sedation, are increasingly favored. Over the last two decades, the advent of new accessories and techniques have changed the landscape of endotherapy for ZD, with the current armamentarium including, but not limited to, endoscopic stapling, CO2 laser, argon plasma coagulation, needle knife, bipolar forceps, hook knife, clutch cutter, stag beetle knife, and submucosal tunneling endoscopic septum division. We hereby review the latest evidence to support the endoscopic management of ZD.
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Affiliation(s)
- Sauid Ishaq
- Department of Gastroenterology, Russell Hall Hospital, Dudley, UK.,Birmingham City University, Birmingham, UK.,St George's University, Grenada, West Indies
| | - Haleema Sultan
- Department of Gastroenterology, Russell Hall Hospital, Dudley, UK
| | - Keith Siau
- Department of Gastroenterology, Russell Hall Hospital, Dudley, UK.,Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
| | - Toshio Kuwai
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure, Japan
| | - Chris J Mulder
- Department of Gastroenterology and Hepatology, VU Medical Center, Amsterdam, Netherlands
| | - Helmut Neumann
- Department of Interdisciplinary Endoscopy, University Hospital Mainz, Mainz, Germany
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25
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Pugliese F, Dioscoridi L, Forgione A, Forti E, Cintolo M, Mutignani M. Cricopharyngeal myotomy with flexible endoscope for Zenker's diverticulum using hook knife and endoclips (with video describing an objective measurement of the cutting length). Esophagus 2018; 15:122-126. [PMID: 29892938 DOI: 10.1007/s10388-018-0606-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 02/20/2018] [Indexed: 02/03/2023]
Abstract
Cricopharyngeal myotomy with flexible endoscope is a well-known and safe treatment for Zenker's diverticulum. We describe hereafter how we perform this flexible endotherapy. From January 2011 to January 2017, we treated 28 patients with this endotherapy. Our technique is described step-by-step in the paper: the main principle is to perform an endoscopic cut of the diverticular septum and cricopharyngeal muscle's fibers (see the video). We describe an objective measurement of the cutting length and depth of the myotomy. Technical success was achieved in all the patients. As to clinical success, 76.2% of patients showed a significant improvement and relevant disappearance of preoperative dysphagia. The present follow-up ranges from 6 months to 5 years. This flexible endoscopic technique can overcome some limitations of rigid endoscopic technique (i.e., upper teeth protrusion, inadequate jaw opening, or limited neck mobility). The main indication was based on clinical presentation and referred to the diverticular dimensions between 2 and 5 cm. Tips for the technique are described in the paper. This variant of cricopharyngeal myotomy with flexible endoscopy is feasible and effective for the treatment of Zenker's diverticulum in selected patients.
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Affiliation(s)
- Francesco Pugliese
- Digestive and Operative Endoscopy Unit, Niguarda-Ca' Granda Hospital, Piazza dell'Ospedale Maggiore, Milan, Italy
| | - Lorenzo Dioscoridi
- Digestive and Operative Endoscopy Unit, Niguarda-Ca' Granda Hospital, Piazza dell'Ospedale Maggiore, Milan, Italy.
| | - Antonello Forgione
- Mininvasive and Oncological Surgery, Niguarda-Ca' Granda Hospital, Milan, Italy.,AIMS-Advance International Mininvasive Surgery Academy, Milan, Italy
| | - Edoardo Forti
- Digestive and Operative Endoscopy Unit, Niguarda-Ca' Granda Hospital, Piazza dell'Ospedale Maggiore, Milan, Italy
| | - Marcello Cintolo
- Digestive and Operative Endoscopy Unit, Niguarda-Ca' Granda Hospital, Piazza dell'Ospedale Maggiore, Milan, Italy
| | - Massimiliano Mutignani
- Digestive and Operative Endoscopy Unit, Niguarda-Ca' Granda Hospital, Piazza dell'Ospedale Maggiore, Milan, Italy
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Surgical Aspects of Pharyngeal Dysfunction, Dysphagia, and Aspiration. Dysphagia 2018. [DOI: 10.1007/174_2017_141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Siboni S, Asti E, Sozzi M, Bonitta G, Melloni M, Bonavina L. Respiratory Symptoms and Complications of Zenker Diverticulum: Effect of Trans-Oral Septum Stapling. J Gastrointest Surg 2017; 21:1391-1395. [PMID: 28470561 DOI: 10.1007/s11605-017-3435-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 04/24/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Zenker diverticulum is a rare condition commonly associated with dysphagia and respiratory symptoms/complications, which are alarming especially in the elderly population. Aim of this study was to investigate the prevalence of respiratory symptoms/complications and the effects of minimally invasive trans-oral surgery in these patients. METHODS Consecutive adult patients who underwent trans-oral septum stapling for Zenker diverticulum were included in a retrospective, observational cohort study. Pre- and postoperative symptoms, including chronic cough and aspiration pneumonia, were evaluated using a dedicated foregut questionnaire and were recorded on a prospectively maintained database. The operation was performed under general anesthesia. A barium swallow study and an upper gastrointestinal endoscopy were performed 6 months after the operation, and the foregut questionnaire was administered yearly. RESULTS A total of 139 patients were finally included in the study. The median age was 72 years. In 62 (44.6%, CI 36.2-53.3) patients, there was a history of chronic cough and/or aspiration pneumonia. Chronic cough was associated with pneumonia (p < 0.001), while pneumonia was associated with severe regurgitation (p < 0.042) and weight loss (p = 0.001). The overall postoperative morbidity rate was 2.2% and there was no mortality. The median postoperative hospital stay was 2 days (range 0-22). The median follow-up was 38 months (range 2-105). At 3 years, a statistically significant reduction in the rate of chronic cough (36.8 vs. 7.9%, p < 0.001), recurrent episodes of pneumonia (6.6 vs. 0.0%, p = 0.031), dysphagia (78.9 vs. 6.6%, p < 0.001), and regurgitation (67.1 vs. 6.6%, p < 0.001) was recorded. The probability of remaining symptom-free at 90 months of follow-up was 0.818 (CI: 0.745-0.899). CONCLUSIONS Trans-oral septum stapling is safe and can effectively reduce the burden of respiratory symptoms and complications associated with Zenker diverticulum.
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Affiliation(s)
- Stefano Siboni
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Emanuele Asti
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Marco Sozzi
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Matteo Melloni
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy.
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Hussain T, Maurer JT, Lang S, Stuck BA. [Pathophysiology, diagnosis and treatment of Zenker's diverticulum]. HNO 2017; 65:167-176. [PMID: 27933354 DOI: 10.1007/s00106-016-0302-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Zenker's diverticulum occurs at the dorsal pharyngoesophageal junction through Killian's dehiscence and is caused by increased intrabolus pressure. Symptomatic disease most frequently affects male elderly patients. Primary symptom is oropharyngeal dysphagia, as well as regurgitation of undigested food, halitosis, and chronic aspiration. A barium swallow study is performed to confirm diagnosis. Treatment options for symptomatic patients include open surgery, as well as transoral rigid or flexible endoscopic procedures. Transoral procedures have become the main treatment approach over the past year thanks to reduced intraoperative complication rates compared to open surgery. The septum dividing the diverticulum from the esophagus is most commonly divided by a stapler device, papillotome, or laser. For high-risk patients who are poor candidates for general anesthesia, the procedure can be performed via flexible endoscopy in awake patients, albeit at an increased risk of recurrence.
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Affiliation(s)
- T Hussain
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - J T Maurer
- Universitäts-Hals-Nasen-Ohren-Klinik Mannheim, Mannheim, Deutschland
| | - S Lang
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - B A Stuck
- Klinik für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
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Abstract
Over the last 20-30 years, treatment of pharyngoesophageal diverticula was subject to a number of fundamental changes. Considering the classical open transcervical approaches, the necessity for myotomy of the upper esophageal sphincter with the goal of interrupting the pathogenesis of the disease has become a standard component of the operation. On the other hand, with the growing popularity of rigid and flexible endoscopic techniques, pharyngoesophageal diverticula are increasingly being treated by gastroenterologists and otorhinolaryngologists, often with the argument of a technically easier and less invasive procedure; however, it remains unclear whether this shift towards endoscopic techniques truly translates into better outcome quality. This aim of this CME article is to summarize the available scientific evidence on the complex pathophysiology, diagnostics and treatment of pharyngoesophageal diverticula and to provide the reader with an updated guide to best clinical practice for diagnostics and treatment.
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Abstract
Zenker's diverticula (ZDs) are a relatively common cause of cervical dysphagia. Diagnosis is best by a good upper GI exam though upper endoscopy should be performed as well. Treatment is either by open, transcervical approaches or trans-oral. Over the past 20 years, transoral approach has mostly replace transcervical approaches due to less pain, no scarring and a rapid recovery. Transoral approaches are either using rigid access or flexible endoscopy. Today, the most common approach is transoral stapling using a 12 mm laparoscopic linear cutting stapler. This has the drawbacks of requiring extreme neck extension, the massive size of the stapler making visualization mostly impossible and the current staple design that does not cut/staple all the way to the end of the blades-resulting in a residual pouch. Flexible endoscopy allows a more tailored approach under direct vision, the myotomy can even be extended beyond the diverticulum and onto the esophageal wall to minimize the risk of incomplete myotomy. Experienced endoscopists report high technical success and low complication. Success rates are similar but maybe slightly higher than with ridged transoral approaches or open surgery. Today, flexible endoscopic Zenkers is our preferred initial approach-with open or ridged being reserved for special indications.
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Affiliation(s)
- Kristen Beard
- Providence Portland Comprehensive Cancer Center, Portland, OR, USA
| | - Lee L Swanström
- Division of GI and MIS Surgery, The Oregon Clinic, Portland, OR, USA.,Institute for Image Guided Surgery, IHU-Strasbourg, Strasbourg, France
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Friedrich DT, Scheithauer MO, Greve J, Rotter N, Doescher J, Hoffmann TK, Schuler PJ. Application of a computer-assisted flexible endoscope system for transoral surgery of the hypopharynx and upper esophagus. Eur Arch Otorhinolaryngol 2017; 274:2287-2293. [DOI: 10.1007/s00405-017-4498-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 02/04/2017] [Indexed: 12/21/2022]
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Evolving Management of Zenker's Diverticulum in the Endoscopic Era: A North American Experience. World J Surg 2017; 40:1390-6. [PMID: 26956900 DOI: 10.1007/s00268-016-3442-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Open surgical cricopharyngeal myotomy(CM) is considered standard of care for Zenker's diverticulum(ZD). Trans-oral CM has been described using a rigid stapling device for two decades; however, this remains problematic for severely kyphotic patients. This problem can be overcome with flexible endoscopy utilizing an electrosurgical needle knife. We sought to compare clinical outcomes between these techniques to stratify patient selection. METHODS Patients undergoing ZD treatment from 1992 to 2015 were reviewed. Demographics, diverticulum size, post-operative complications, and length of stay (LOS) were compared between open cricopharyngeal myotomy (OpenCM), rigid trans-oral stapling myotomy (RigidCM), and flexible endoscopic myotomy (FlexCM). Dysphagia scores (DS, 0:best-4:worst) and pneumonia incidence were assessed pre-operatively and post-operatively. RESULTS 62 patients underwent OpenCM (39/62(63 %)) or endoscopic CM (23/62(37 %) (8 RigidCM/15 FlexCM)). CM significantly reduced dysphagia for all approaches [OpenCM:2(2-3)-0(0-0); RigidCM:2(2-2)-0(0-0); FlexCM:3(3-3)-0(0-0)]. FlexCM patients had significantly worse pre-operative DS. Endoscopic CM was attempted and completed in 23/35(66 %) patients. Reasons for OpenCM conversion included inability to position the diverticular retractor due to patient body habitus (RigidCM), and the inability to position the overtube due to small ZD (FlexCM). Major post-operative complications were rare and similar in all groups. Medium-to-long-term post-myotomy pneumonia was comparable between groups. LOS (days) was reduced for FlexCM (1(1-2)) versus RigidCM (3(2-6)) and OpenCM (4(3-7)). CONCLUSIONS CM is highly effective for treating ZD. Open and endoscopic approaches offer comparable outcomes and dysphagia resolution. FlexCM is efficacious for large ZD and can be performed in most patients irrespective of body habitus. FlexCM represents an excellent approach for large ZD, while OpenCM should be reserved for small ZD for which an overtube cannot be positioned.
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Feußner H, Hüser N, Wilhelm D, Fingerle A, Jell A, Friess H, Bajbouj M. [Surgical treatment of esophageal diverticula : Endoscopic or open approach?]. Chirurg 2017; 88:196-203. [PMID: 28054111 DOI: 10.1007/s00104-016-0344-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Esophageal diverticula are comparatively rare. The majority are Zenker's diverticula but parabronchial and epiphrenic diverticula can also occur. Parabronchial diverticula are of low clinical relevance, whereas Zenker's and epiphrenic diverticula both belong to the group of pulsion diverticula and can become clinically apparent by dysphagia and regurgitation. Approximately 100 years after the first surgical treatment, peroral approaches (e.g. stapler dissection and flexible endoscopic diverticulotomy) have now achieved a certain level of importance. Both approaches are less invasive than the open approach but are evidently more prone to recurrences. Accordingly, traditional open diverticulectomy with cervical myotomy should be recommended to patients with a reasonable life expectancy and an acceptable operative risk. This holds particularly true for Brombart stages I-III of the disease, as complete myotomy cannot be achieved via the peroral access. The classical surgical treatment of epiphrenic diverticula is open or laparoscopic/thoracoscopic diverticulectomy with distal myotomy, mostly combined with an anterior partial fundoplication; however, the leakage rate is high and several alternative options are currently being evaluated.
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Affiliation(s)
- H Feußner
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland.
| | - N Hüser
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - D Wilhelm
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - A Fingerle
- Institut für Diagnostische und Interventionelle Radiologie, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland
| | - A Jell
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - H Friess
- Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland
| | - M Bajbouj
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland
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Venkatesan NN, Evangelista LM, Kuhn MA, Belafsky PC. Normal fluoroscopic appearance status post-successful endoscopic Zenker diverticulotomy. Laryngoscope 2017; 127:1762-1766. [PMID: 28052332 DOI: 10.1002/lary.26446] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 09/22/2016] [Accepted: 11/04/2016] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Endoscopic Zenker diverticulotomy (EZD) is a primary treatment for Zenker diverticulum (ZD). During EZD, the diverticulum is not excised, and interpretation of postoperative videofluoroscopic swallow study (VFSS) is challenging. The purpose of this investigation was to describe normal VFSS findings status post-successful EZD. METHODS The charts of all patients with ZD treated at our center between October 01, 2011, and May 30, 2014, were abstracted. Outcome measures included recidivistic diverticulum size, Eating Assessment Tool-10 (EAT-10), penetration aspiration scale, pharyngeal constriction ratio (PCR), and pharyngoesophageal segment (PES) opening. RESULTS Twenty patients met inclusion criteria. The mean age was 70.5 (± 13) years. Seventy percent of the patients were male. Mean EAT-10 decreased 72.1% from 17.9 (± 8.2) to 5 (± 6.9) (P < 0.0001), and diverticulum size decreased 50.9% from 1.96 cm (± 0.68) to 0.96 cm (± 0.57) (P < 0.001). The PCR improved 33.6% from 0.17 (± 0.13) to 0.11 (± 0.11) (P < 0.001). Mean PES opening increased 61.6% from 0.53 cm (± 0.3544) to 0.86 cm (± 0.29) in lateral view and increased 40.0% from 1.00 cm (± 0.54) to 1.39 cm (± 0.46) in anteroposterior view (P < 0.001). CONCLUSION VFSS following successful EZD demonstrates an approximate 50% reduction in diverticulum size and significant improvement in PCR and PES opening. These data provide a framework for the expected fluoroscopic outcomes of successful diverticulotomy. LEVEL OF EVIDENCE 4. Laryngoscope, 127:1762-1766, 2017.
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Affiliation(s)
- Naren N Venkatesan
- Department of General Surgery, University of North Texas-Health Sciences Center, Fort Worth, Texas, U.S.A
| | - Lisa M Evangelista
- 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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Altman JI, Genden EM, Moche J. Fiberoptic Endoscopic–Assisted Diverticulotomy: A Novel Technique for the Management of Zenker's Diverticulum. Ann Otol Rhinol Laryngol 2016; 114:347-51. [PMID: 15966520 DOI: 10.1177/000348940511400503] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Endoscopic diverticulotomy is rapidly becoming the procedure of choice for treatment of Zenker's diverticulum. The endoscopic approach has resulted in significant decreases in patient morbidity, time to resumption of oral intake, and overall cost as compared with open treatment. However, a small but significant patient population is unable to accommodate the rigid laryngoscope and therefore requires open treatment. We present a novel technique, flexible fiberoptic endoscopic–assisted diverticulotomy, for the management of patients who are unable to undergo rigid endoscopy.
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Affiliation(s)
- Jason I Altman
- Department of Otolaryngology-Head and Neck Surgery, The Mount Sinai School of Medicine, New York, New York 10029, USA
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Albers DV, Kondo A, Bernardo WM, Sakai P, Moura RN, Silva GLR, Ide E, Tomishige T, de Moura EGH. Endoscopic versus surgical approach in the treatment of Zenker's diverticulum: systematic review and meta-analysis. Endosc Int Open 2016; 4:E678-86. [PMID: 27556078 PMCID: PMC4993875 DOI: 10.1055/s-0042-106203] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 03/29/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Zenker's diverticulum is a rare disease in the general population. Its treatment can be carried out by either an endoscopic or surgical approach. The objective of this study was to systematically identify all reports that compare both treatment modalities and to assess the outcomes in terms of length of procedure, length of hospitalization, time until diet introduction, complication rates, and recurrence rates. METHODS A search of Medline and Embase selected all studies that compared different methods of surgical and endoscopic treatment for Zenker's diverticulum published in the English, Portuguese, and Spanish languages between 1975 and 2014. The meta-analysis was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Data were extracted and analyzed for five different outcomes. RESULTS Eleven studies met the inclusion criteria, describing outcomes of endoscopic versus surgical treatment for 596 patients with Zenker's diverticulum. A meta-analysis of the studies suggested a statistically significant reduction in operating time and length of hospitalization, favoring endoscopic treatment (standardized mean difference (SMD) - 78.06, 95 %CI - 90.63, - 65.48 and SMD - 3.72, 95 %CI - 4.49, - 2.95, respectively), just as with the reduction in the fasting period (SMD - 4.30, 95 %CI - 5.18, - 3.42) and risk of complications (SMD - 0.09, 95 %CI 0.03, 0.43) for patients who had undergone the endoscopic approach in comparison with the surgical group. Also, a statistically significant reduction in the risk of symptom recurrence was seen when the treatment of Zenker's diverticulum was carried out by a surgical approach compared with endoscopic treatment (SMD 0.08, 95 %CI 0.03, 0.13). CONCLUSION Compared with a surgical approach, endoscopic treatment appeared to result in a shorter length of procedure and hospitalization, earlier diet introduction, and lower rates of complications, but in higher rates of symptom recurrence.
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Affiliation(s)
- Débora V. Albers
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | - André Kondo
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | | | - Paulo Sakai
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | - Renata Nobre Moura
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | - Gustavo Luis Rodela Silva
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | - Edson Ide
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | - Toshiro Tomishige
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
| | - Eduardo G. H. de Moura
- Gastrointestinal Endoscopy Unit, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
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Shah RN, Slaughter KA, Fedore LW, Huang BY, Deal AM, Buckmire RA. Does residual wall size or technique matter in the treatment of Zenker's diverticulum? Laryngoscope 2016; 126:2475-2479. [PMID: 27010588 DOI: 10.1002/lary.25975] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 01/23/2016] [Accepted: 02/22/2016] [Indexed: 11/12/2022]
Abstract
OBJECTIVES/HYPOTHESIS We aimed to compare three surgical techniques (open approach for diverticulectomy with cricopharyngeal myotomy [OA], endoscopic laser-assisted diverticulotomy [ELD], and endoscopic stapler-assisted diverticulotomy [ESD]) for treatment of Zenker's diverticulum with regard to validated swallowing outcomes, radiographic outcomes, complications, and revision rates. We statistically analyzed whether the size of residual postoperative party wall or the specific surgical technique correlates with swallowing outcomes. STUDY DESIGN Retrospective chart review and radiographic study analysis. METHODS A retrospective chart review and radiographic analysis of preoperative and postoperative contrast swallow studies were conducted on patients undergoing surgery for Zenker's diverticulum between 2002 and 2014 at our institution. A follow-up validated swallowing outcome questionnaire, the Eating Assessment Tool-10, was administered to measure and compare patients' symptomatic outcomes. RESULTS Seventy-three patients were reviewed and grouped according to technique. Median follow-up was 1.6 years. ESD resulted in a significantly larger residual party wall than ELD and OA but yielded comparative swallowing outcomes. OA had the highest complication rate and ESD had the highest revision rate. There were no revisions after ELD nor OA. CONCLUSIONS Despite the predictably larger residual postoperative party wall following ESD, this technique produced statistically comparable swallowing outcomes. Given its low complication rate and comparable results, ESD should be considered first line therapy for medically high-risk patients with Zenker's diverticulum, while acknowledging a higher risk of symptom recurrence. ELD, with its slightly greater risk profile but low recurrence rate, is well suited for most in revision cases. OA may best be reserved for those patients in whom endoscopic approach is not feasible. LEVEL OF EVIDENCE 4 Laryngoscope, 126:2475-2479, 2016.
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Affiliation(s)
- Rupali N Shah
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina Hospitals, Chapel Hill, North Carolina, U.S.A
| | - Keimun A Slaughter
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina Hospitals, Chapel Hill, North Carolina, U.S.A
| | - Lauren W Fedore
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina Hospitals, Chapel Hill, North Carolina, U.S.A
| | - Benjamin Y Huang
- Department of Radiology, University of North Carolina Hospitals, Chapel Hill, North Carolina, U.S.A
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center Biostatistics Core, University of North Carolina Hospitals, Chapel Hill, North Carolina, U.S.A
| | - Robert A Buckmire
- Department of Otolaryngology-Head and Neck Surgery, University of North Carolina Hospitals, Chapel Hill, North Carolina, U.S.A..
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de la Morena Madrigal EJ, Pérez Arellano E, Rodríguez García I. Flexible endoscopic treatment of Zenkers diverticulum: thirteen years experience in Spain. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 108:297-303. [DOI: 10.17235/reed.2016.4030/2015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
BACKGROUND Management of the pharyngeal pouch has evolved enormously since the first description by Ludlow in 1764 and the first case series by Zenker and Von Ziemssen in 1877. With the introduction of antibiotics, and the advancement of surgical technique with the advent of endoscopic surgery and lasers, current management is vastly different to that in the nineteenth century. OBJECTIVES This paper traces the history of pharyngeal pouch management, and discusses the various treatment options and opinions recorded during the nineteenth and twentieth centuries, comparing these with techniques popular today. RESULTS AND CONCLUSION Pharyngeal pouch surgery has been associated with significant morbidity, both because of the elderly age of patients typically affected by the condition and because of the surgery itself and potential post-operative complications encountered. The historical development of pharyngeal pouch management and the understanding of pharyngeal pouch pathophysiology are discussed.
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Revision endoscopic stapler Zenker's diverticulotomy. Surg Endosc 2015; 30:2022-5. [PMID: 26194259 DOI: 10.1007/s00464-015-4435-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 07/11/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Endoscopic stapler diverticulotomy (ESD) has become an accepted primary treatment for Zenker's diverticulum (ZD). Recurrence of symptoms after surgical treatment of ZD is not uncommon, and traditionally patients with recurrent symptomatic ZD were referred to revision surgery by the transcervical Zenker's diverticulectomy approach. Our objective was to evaluate the technical feasibility, safety and effectiveness of revision endoscopic stapler diverticulotomy (RESD) for recurrent ZD. METHODS A case series with chart review study conducted in a tertiary referral center. The records of all patients who underwent ESD at our institute between 2002 and 2013 were retrieved and those who underwent RESD were identified and screened for primary surgical history, symptoms of recurrent ZD, time to recurrence, intraoperative and postoperative RESD course, complications and symptom resolution. The surgical history and outcome results of RESD and primary ESD (PESD) patients were compared. RESULTS Eighty-nine ESDs were performed. Twenty were RESDs for recurrent ZD, and 69 were PESDs. Nine RESDs were performed for recurrent ZD after transcervical Zenker's diverticulectomy, 10 RESDs for recurrent ZD after ESD, and one initial surgical approach was unknown. The mean time from first operation for ZD to RESD was 4.7 years. The average RESD surgery time and hospital stay were 21.4 min and 2.8 days, respectively. Endoscopic stapling of the ZD was feasible in 19 of 20 RESDs. Relief of symptoms without recurrence was achieved after 18 RESDs. Four RESD patients experienced minor postoperative complications. There were no significant differences in operative time, technical feasibility, hospital stay and complication rate between the RESD and PESD groups (P > .05). CONCLUSION RESD for ZD is technically feasible, safe and effective. The results are comparable to those of PESD.
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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.
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Tang SJ, Wu R. Esophageal introitus (with videos). Gastrointest Endosc 2015; 81:270-81. [PMID: 25616751 DOI: 10.1016/j.gie.2014.09.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 09/29/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Shou-jiang Tang
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Ruonan Wu
- Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
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Systematic review on treatment of Zenker’s diverticulum. Eur Arch Otorhinolaryngol 2014; 272:3095-107. [DOI: 10.1007/s00405-014-3267-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 08/29/2014] [Indexed: 12/12/2022]
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Wilken R, Whited C, Scher RL. Endoscopic staple diverticulostomy for Zenker's diverticulum: review of experience in 337 cases. Ann Otol Rhinol Laryngol 2014; 124:21-9. [PMID: 25026961 DOI: 10.1177/0003489414542421] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Surgical treatment of Zenker's diverticulum (ZD) has evolved over the previous 2 decades to a predominantly endoscopic approach. In this study, we review our experience with endoscopic staple-assisted diverticulostomy (ESD) for treatment of ZD from 2002 to 2011. METHODS Retrospective chart review of 359 primary and revision ESD procedures performed on 337 unique patients between September 2002 and December 2011. Data were tabulated for age, sex, size of diverticulum, time to symptom recurrence, complications, and relief of symptoms. RESULTS Of 337 attempted primary ESD procedures, 3.9% (N = 13) were aborted due to inadequate exposure. Of 324 patients who underwent primary ESD, 93.8% (N = 304) reported postoperative improvement of dysphagia symptoms. There was a 4.0% (N = 13) major complication rate. Patient-reported recurrence of symptoms occurred in 7.1% (N = 23) of primary ESD patients but was not significantly associated with diverticulum size (P = .9765). Twenty-one patients underwent revision ESD, with 95% (N = 20) of patients reporting improvement and 4.8% (N = 1) developing recurrent symptoms. CONCLUSION Primary and revision ESD were shown to have similar success at relieving the symptoms of ZD, with low procedure abandonment and perioperative complication rates. Further patient follow-up is needed to determine the durability of symptom improvement and ZD recurrence rate following ESD.
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Affiliation(s)
- Reason Wilken
- Duke University Hospital, Durham, North Carolina, USA
| | - Chad Whited
- Duke University Hospital, Durham, North Carolina, USA
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Henry MACDA, Lerco MM, Tagliarini JV, Castilho EC, Novaes FT, Lamonica VC. Pharyngoesophageal diverticulum: evaluation of treatment results. Rev Col Bras Cir 2014; 40:104-9. [PMID: 23752635 DOI: 10.1590/s0100-69912013000200004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 08/09/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To evaluate the postoperative outcome of patients with pharyngoesophageal diverticulum submitted to surgical and endoscopic treatments. METHODS We retrospectively analyzed 36 patients with pharyngo-esophageal diverticulum treated at the Hospital of the Medical School of Botucatu - UNESP. Patients were divided into two groups, depending on the treatment: group 1 (n = 24): diverticulectomy associated myotomy through a left cervicotomy; group 2 (n = 12): endoscopic diverticulostomy with linear stapler. RESULTS Operative mortality was zero in both groups. Early complications: group 1 - two patients developed cervical fistula and two, hoarseness; group 2 - none. Late complications: group 1 - none; group 2: recurrence of dysphagia in four patients (p = .01). Mean follow-up was 33 months for group 1 and 28 months for group 2. CONCLUSION Both procedures were effective in remission of dysphagia. Surgical treatment showed superiority to endoscopy, with resolution of dysphagia with a single procedure. Endoscopic treatment should be reserved for the elderly and those with comorbidities.
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Leibowitz JM, Fundakowski CE, Abouyared M, Rivera A, Rudman J, Lo KM, Weed D, Civantos F. Surgical Techniques for Zenker's Diverticulum: A Comparative Analysis. Otolaryngol Head Neck Surg 2014; 151:52-8. [PMID: 24705225 DOI: 10.1177/0194599814529405] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 03/06/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To compare the different modalities for treatment of Zenker's diverticulum and the associated clinical outcomes. STUDY DESIGN Case series with chart review. SETTING Tertiary care hospital. SUBJECTS AND METHODS Between 1995 and 2011, 164 patients underwent surgery for Zenker's diverticulum (stapler, n = 69; laser, n = 68; open, n = 27). Patient sociodemographics, medical comorbidities, pre- and postoperative subjective dysphagia and regurgitation score, complications, length of stay, time to oral intake, and recurrence were reviewed for each surgical modality. RESULTS No statistically significant difference in diverticulum prevalence was associated with age, gender, or treatment group. Mean length of hospital stay was not significantly different between the 3 groups (P = .14). A significant difference in time to oral intake was observed in the laser group compared with the other 2 groups (P = .012). No significant difference in recurrence (P = .21) or complication (P = .12) rates was identified between the 3 groups. Although all 3 groups demonstrated a significant decrease between preoperative and postoperative dysphagia and regurgitation scores, the degree of improvement was not significant when the 3 groups were compared. CONCLUSION There is no single "best" approach to Zenker's diverticulum. The open, laser, and stapler methods are equally effective and have similar complication rates.
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Affiliation(s)
- Jason M Leibowitz
- Department of Otolaryngology-Head and Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, USA
| | - Christopher E Fundakowski
- Department of Otolaryngology-Head and Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, USA
| | - Marianne Abouyared
- Department of Otolaryngology-Head and Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, USA
| | - Andrew Rivera
- Department of Otolaryngology-Head and Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, USA
| | - Jason Rudman
- Department of Otolaryngology-Head and Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, USA
| | - Ka-Ming Lo
- Department of Epidemiology and Public Health, University of Miami-Miller School of Medicine, Miami, Florida, USA
| | - Donald Weed
- Department of Otolaryngology-Head and Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, USA
| | - Francisco Civantos
- Department of Otolaryngology-Head and Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, USA
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Zenker's diverticulum: outcome of endoscopic surgery is dependent on the intraoperative exposure. Eur Arch Otorhinolaryngol 2014; 272:167-73. [PMID: 24604681 DOI: 10.1007/s00405-014-2959-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 02/18/2014] [Indexed: 10/25/2022]
Abstract
The purpose of the present study is to evaluate long-term outcome and patients' satisfaction after endoscopic therapy of Zenker's diverticulum (ZD) and to analyze the results of the stapler technique in comparison with the application of the carbon dioxide (CO2) laser. A retrospective cohort study with outcome analysis of patients undergoing endoscopic cricopharyngeal myotomy with either stapler or CO2 laser between October 2000 and December 2010 by a single surgeon was performed. Patient's medical charts were reviewed with respect to symptoms before intervention, intra and post operative complications, reasons for the choice of endoscopic technique, and postoperative relief of symptoms. Long-term follow-up was acquired by a standardized self-assessment questionnaire. Seventy-four patients (51 men, 23 women) with a median age at operation of 74 years (range 45-93 years) were enrolled in this study. Forty-five patients underwent endoscopic repair of a ZD with stapler, 29 patients with CO2 laser. The mean follow-up was 4.7 years. We did not observe significant differences for intra and post operative complications, hospital stay, time until normal oral food intake, need for revision, and long-term subjective symptom relief between the two groups. Overall complication (12 %) and recurrence rate (11 %) for the endoscopic techniques were low. Endoscopic surgery had also a high success rate in recurrence cases (87.5 %). According to our study, the most important factor for the success rate of endoscopic treatment was the intraoperative exposure of the ZD. The endoscopic minimally invasive approach is a safe and effective treatment modality and can be considered as the treatment of choice for primary and recurrent ZD. The intraoperative exposure is decisive for the technique applied and the long-term success.
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Zenker's diverticulum: carbon dioxide laser endoscopic surgery. BIOMED RESEARCH INTERNATIONAL 2014; 2014:516231. [PMID: 24729975 PMCID: PMC3963375 DOI: 10.1155/2014/516231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 01/28/2014] [Indexed: 11/25/2022]
Abstract
Nowadays endoscopic diverticulotomy is the surgical approach of the first choice in treatment of Zenker's diverticulum. We report our experience with this procedure and try to sum up recent recommendations for management of surgery and postoperative care. Data of 34 patients with Zenker's diverticulum, treated by endoscopic carbon dioxide laser diverticulotomy at the Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University, University Hospital Motol, Prague, Czech Republic, were prospectively stored and followed in relatively short period from May 2009 to December 2013. The average length of diverticulum was 32 mm. The average duration of surgery was 32 min. The patients were fed via feeding tube for 6.1 days and antibiotics were administered for 7 days. Mean hospitalization time was 7.4 days. We observed one transient recurrent laryngeal nerve paralysis and no other serious complications. Recurrence rate was 3%. We recommend complete transection of the diverticular septum in one procedure, systemic antibiotic treatment and exclusion of transoral intake for minimally 5 days, and contrast oesophagogram before resumption of oral intake to exclude fistula. Open diverticulectomy should be reserved for cases with inadequate endoscopic exposure and for revision surgery for multiple recurrences from endoscopic diverticulotomies.
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Parker NP, Misono S. Carbon dioxide laser versus stapler-assisted endoscopic Zenker's diverticulotomy: a systematic review and meta-analysis. Otolaryngol Head Neck Surg 2014; 150:750-3. [PMID: 24496741 DOI: 10.1177/0194599814521554] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
To evaluate outcomes following endoscopic management of Zenker's diverticula using a carbon dioxide laser (CO2) or stapler-assisted technique, a systematic review and meta-analysis were conducted. Seven retrospective, uncontrolled case series including 391 procedures met selection criteria. No higher quality studies were identified. Outcomes favoring the stapler technique included a shorter duration of nil per os (NPO) status (2 studies), length of hospitalization (LOH, 2 studies), and fewer postoperative fevers and abnormal chest x-rays (1 study). Outcomes favoring the CO2 technique included greater improvement in postoperative dysphagia and regurgitation scores (2 studies) and a lower revision rate (1 study). Meta-analysis demonstrated increased nondental complications in the CO2 group (odds ratio 3.81; 95% confidence interval, 1.37-10.59; P = .01) but no difference in duration of NPO (P = .06), LOH (P = .07), overall complications (P = .08), dental complications (P = .57), major complications (P = .38), or revision surgery (P = .82). Implications are limited by the quality of studies identified.
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Affiliation(s)
- Noah P Parker
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
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