Stapled diverticulectomy and myotomy for symptomatic Zenker's diverticulum

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

Importance

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

Objective

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

Data Sources

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

Study Selection

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

Data Extraction and Synthesis

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

Main Outcome and Measure

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

Results

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

Conclusions and Relevance

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

Divertículo de Zenker: tratamento endoscópico versus cirúrgico

OBJETIVO: Revisar a evidência da segurança e efetividade dos tratamentos endoscópico e cirúrgico do divertículo de Zenker. MÉTODOS: pesquisa no MEDLINE, LILACS e SciELO por "Zenker's diverticulum or pharyngoesophageal diverticulum", e seleção de estudos para avaliação da qualidade e extração dos dados para uma metanálise. RESULTADOS: a pesquisa não localizou nenhum ensaio clínico randomizado. Encontramos cinco estudos comparativos não randomizados com grupo controle, com um total de 630 pacientes, 339 no braço endoscópico e 291 no cirúrgico. Os valores para segurança foram uma mortalidade de 0,29% e morbidade 7% para o tratamento endoscópico, e mortalidade 0,34% e morbidade 5% para o tratamento cirúrgico. O valor para efetividade foi 84% e 85%, respectivamente. O efeito das abordagens endoscópica e cirúrgica para o tratamento do divertículo de Zenker foi comparável, a odds ratio para morbidade foi 1,24 (0,56-2,74), e a odds ratio para o sucesso foi 0,66 (0,41-1,05). CONCLUSÃO: os estudos sobre o tratamento do divertículo de Zenker têm baixo nível de evidência e não são capazes de definir qual o melhor tratamento em termos de segurança e efetividade.

Surgical treatment of hypopharyngeal diverticulum (Zenker's diverticulum)

The goal of this study was to evaluate the outcome of various modalities in the treatment of hypopharyngeal diverticulum (Zenker's diverticulum, HD) as performed in the ENT department, University of Ulm. A retrospective analysis of 40 consecutive patients with the diagnosis of a HD was conducted. The three different modalities of surgery applied had been endoscopic laser diverticulotomy (ELD), conventional endoscopic esophagodiverticulotomy (CEE) and transcervical open technique involving diverticulectomy and cricopharyngeal myotomy. Medical records had been reviewed to determine preoperative symptoms and diagnostic findings, operative time, length of hospital stay, time of oral intake, postoperative laboratory parameters, and postoperative complications. Significant differences (P < 0.05) could be observed between the three surgical groups concerning the postoperative time to oral intake, the length of the hospital stay, and the length of time with a nasogastric tube. Patients after ELD had statistically significantly less thoracic pain than patients after CEE. In conclusion, the comparison of three different surgical approaches in the treatment of HD showed that endoscopic techniques versus open-neck technique result in statistically significant shorter operative times and shorter hospital stays. Conventional endoscopic diverticulotomy is not safer than ELD or transcollar open technique.

[Zenker's diverticulum as a cause of aspiration pneumonia and dysphagia in nonagenarian with moderate dementia]

The association between aspiration pneumonias and digestive symptoms is frequent in geriatric patients and is usually attributed to comorbidity, being the most frequent causes cerebrovascular disease or dementia. We present the case of a 90-year-old woman, with malnutrition associated with progressive dysphagia and episodes of aspiration pneumonia, due to Zenker's diverticulum, which was treated surgically. We provide a review of this disease and analyze the criteria that can be applied when considering surgical indication in the oldest-old with dementia.