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Wang NK, Molin NL, Soliman AMS. Postoperative management of Zenker's diverticulum: Results of the American Bronchoesophagological Association survey. Am J Otolaryngol 2022; 43:103602. [PMID: 35981430 DOI: 10.1016/j.amjoto.2022.103602] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/07/2022] [Accepted: 08/08/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Although treatment of Zenker's diverticulum (ZD) is commonly performed by otolaryngologists using a variety of surgical techniques, there is little published data on the postoperative management of patients. We sought to determine practice patterns among members of the American Bronchoesophagological Association (ABEA) after surgery for ZD. METHODS An online questionnaire was designed via JotForm™ and subsequently sent to active members of the ABEA. Responses were analyzed using descriptive statistics. RESULTS Twenty-three members (6.6 %) completed the survey. Most (73.9 %) were fellowship trained in laryngology and reported performing >5 procedures per year. Most laryngologists reported employing multiple techniques including transcervical (TC) (73.9 %), endoscopic stapling (ES) (65.2 %), endoscopic CO2 laser (EL) (56.5 %), and endoscopic harmonic scalpel (EH) (4.3 %). Postoperatively, 52.3 % of respondents placed patients in 23-hour observation after TC, 66.7 % after ES, 69.2 % after EL, and 100 % after EH. 47.1 % of respondents used standard overnight admission after TC, as compared to 13.3 % after ES, 23.1 % after EL and 0 % after EH. Postoperative esophagography was utilized by 70.6 % of respondents after TC, 20 % after ES, 38.5 % after EL, and 100 % after EH. A peroral diet was started postoperatively on the day of surgery by 26.7 % respondents after ES but not after any of the other techniques. CONCLUSION Most laryngology trained respondents employ multiple techniques for the treatment of ZD including at least 1 endoscopic technique. Respondents were more likely to hospitalize patients after a transcervical than endoscopic approach. Postoperative esophagography was utilized in most patients after TC, but not after ES or EL. Most respondents admit patients for 23-hour observation and start a peroral diet on postoperative day 1 regardless of technique.
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Affiliation(s)
- Nigel K Wang
- Department of Otolaryngology-Head & Neck Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America
| | - Nicole L Molin
- Department of Otolaryngology-Head & Neck Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America
| | - Ahmed M S Soliman
- Department of Otolaryngology-Head & Neck Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America.
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Kaaki S, Hartwig MG. Commentary: Zenker's diverticulum: One size does not fit all. J Thorac Cardiovasc Surg 2021; 163:1977-1978. [PMID: 33551074 DOI: 10.1016/j.jtcvs.2020.12.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 12/28/2020] [Accepted: 12/28/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Suha Kaaki
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC.
| | - Matthew G Hartwig
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC
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Bommakanti KK, Moss WJ, Weisman RA, Weissbrod PA. Zenker's diverticulotomy with bipolar tissue sealer: Retrospective review of safety and short-term outcomes. Am J Otolaryngol 2020; 41:102325. [PMID: 31727337 DOI: 10.1016/j.amjoto.2019.102325] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 10/25/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The objective of this study is to analyze and report the institution's experience using the Enseal bipolar tissue sealing device to perform endoscopic Zenker's diverticulotomy. Safety and early functional outcomes are presented as primary endpoints of the study. MATERIALS & METHODS This is a retrospective study of consecutive patients with Zenker's diverticulum (ZD) treated via a transoral approach using a rigid endoscope and a bipolar tissue sealer between 2011 and 2019. Demographic data, ZD size, complications and preoperative versus postoperative symptoms were assessed. The Eating Assessment Tool-10 (EAT-10) questionnaire was used to evaluate functional outcomes, and statistical comparisons were made using the student's t-test. RESULTS Nineteen ZD patients were identified who underwent rigid endoscopic diverticulotomy using a bipolar tissue sealer. The mean age was 71 years and 74% were male. The mean diverticulum size was 3.1 cm. There were no intraoperative or postoperative complications identified. Average pre-operative EAT-10 score was 21 and post-operative EAT-10 score was 12 at one to two weeks after surgery (p = .05). CONCLUSIONS Evidence from this preliminary study of endoscopic Zenker's diverticulotomy using the Enseal device indicates that it is both safe and effective. Several features of the device, including its narrow profile, articulation and rotation capability, rapid repeatable activation, and low risk of collateral thermal injury, make it an appealing option for endoscopic Zenker's diverticulotomy.
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Affiliation(s)
- K K Bommakanti
- University of California San Diego, School of Medicine, La Jolla, CA, United States of America
| | - W J Moss
- Division of Otolaryngology, Department of Surgery, University of California San Diego, La Jolla, CA, United States of America
| | - R A Weisman
- Division of Otolaryngology, Department of Surgery, University of California San Diego, La Jolla, CA, United States of America
| | - P A Weissbrod
- Division of Otolaryngology, Department of Surgery, University of California San Diego, La Jolla, CA, United States of America.
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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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Li LY, Yang YT, Qu CM, Liang SW, Zhong CQ, Wang XY, Chen Y, Spandorfer RM, Christofaro S, Cai Q. Endoscopic needle-knife treatment for symptomatic esophageal Zenker's diverticulum: A meta-analysis and systematic review. J Dig Dis 2018; 19:204-214. [PMID: 29675866 DOI: 10.1111/1751-2980.12588] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/29/2018] [Accepted: 03/06/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study was to assess the efficacy and safety following endoscopic management of Zenker's diverticulum (ZD) using a needle-knife technique. METHODS A systematic search of PubMed, Embase and Cochrane library databases was performed. All original studies reporting efficacy and safety of needle-knife technique for treatment of ZD were included. Pooled event rates across studies were expressed with summative statistics. Main outcomes, such as rates of immediate symptomatic response (ISR), adverse events and recurrence, were extracted, pooled and analyzed. Heterogeneity among studies was assessed using the R statistic. The random effects model was used and results were expressed with forest plots and summative statistics. RESULTS Thirteen studies included 589 patients were enrolled. Pooled event rates for ISR, overall complication, bleeding and perforation were 88% (95% confidence interval [CI] 79-94%), 13% (95% CI 8-22%), 5% (95% CI 3-10%) and 7% (95% CI 4-12%), respectively. The pooled data demonstrated an overall recurrence rate of 14% (95% CI 9-21%). Diverticulum size of at least 4 cm and less than 4 cm demonstrated pooled adverse event rates of 17% (95% CI 10-27%) and 7% (95% CI 2-18%), respectively. When using diverticuloscope as an accessory, pooled ISR and adverse events rates were 84% (95% CI 58-95%) and 10% (95% CI 3-26%), respectively. CONCLUSION Flexible endoscopic procedures using needle-knife offers a relatively safe and effective treatment of symptomatic ZD, especially for ZD of <4 cm in diameter.
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Affiliation(s)
- Lian Yong Li
- Department of Gastroenterology, The 306th Hospital of PLA, Beijing, China
| | - Yong Tao Yang
- Department of Gastroenterology, The 306th Hospital of PLA, Beijing, China
| | - Chang Min Qu
- Department of Gastroenterology, The 306th Hospital of PLA, Beijing, China
| | - Shu Wen Liang
- Department of Gastroenterology, The 306th Hospital of PLA, Beijing, China
| | - Chang Qing Zhong
- Department of Gastroenterology, The 306th Hospital of PLA, Beijing, China
| | - Xiao Ying Wang
- Department of Gastroenterology, The 306th Hospital of PLA, Beijing, China
| | - Yan Chen
- Department of Gastroenterology, The 306th Hospital of PLA, Beijing, China
| | | | - Sarah Christofaro
- Division of Digestive Diseases, Emory University, Atlanta, Georgia, USA
| | - Qiang Cai
- Division of Digestive Diseases, Emory University, Atlanta, Georgia, USA
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Pharyngoesophageal diverticuli: diagnosis, incidence and management. Curr Opin Otolaryngol Head Neck Surg 2018; 24:500-504. [PMID: 27636983 DOI: 10.1097/moo.0000000000000309] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Pharyngoesophageal diverticuli such as Zenker's diverticulum are relatively rare diseases that may have a significant impact on a patient's quality of life. Open surgical techniques have historically been the mainstay of treatment for Zenker's diverticuli and remain the preferred approach for many surgeons operating on Killian-Jamieson diverticuli (KJD) and pharyngoceles. However, advances in technology in recent decades have allowed for the development of successful endoscopic surgical techniques for the management of these conditions. RECENT FINDINGS Endoscopic management of Zenker's diverticulum with carbon dioxide laser-assisted diverticulotomy or endoscopic stapler-assisted diverticulostomy has gained wide acceptance in recent years. This is based on studies showing high rates of successful outcomes, low rates of complications and shorter operative time with an associated impact on overall cost and patient recovery. Endoscopic management of KJD and pharyngoceles has recently been described, but remains controversial with many surgeons preferring open surgical approaches for the ability to identify and protect the recurrent laryngeal nerve. SUMMARY Open and endoscopic techniques are accepted for the treatment of Zenker's diverticulum with open approaches remaining the traditional technique for management of non-Zenker's diverticulum. Further investigation of endoscopic approaches for management of KJD is necessary to assess safety and efficacy.
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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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Abstract
AbstractBackground:Pharyngeal pouches have been recognised as a cause of dysphagia for centuries and have been treated in a variety of ways over that time.Objective:This article aimed to analyse the results of surgery by a variety of techniques, as performed by one surgeon.Method:A retrospective analysis of a case series was conducted, analysing the variables of patient age, sex, type of surgery, length of hospital stay, leak, recurrence and other complications.Results:A total of 121 patients were treated by 135 operations. There were no leaks in the group treated by endoscopic stapling and this group also had a significantly shorter hospital stay. As for recurrence, the lowest rate appeared to be in the group treated by excision of the pouch.Conclusion:The techniques used by the author all still seem to have a role in the management of pharyngeal pouch, with the endoscopic stapling approach associated with a low rate of complications and short hospital stay.
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Zhang X, Cheng S, Xu Y, Wang S. Treatment of giant pharyngoesophageal diverticulum by video-assisted thoracoscopy. Ann Thorac Surg 2014; 97:2184-6. [PMID: 24882303 DOI: 10.1016/j.athoracsur.2013.08.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 08/26/2013] [Accepted: 08/28/2013] [Indexed: 11/29/2022]
Abstract
A 67-year-old woman presented with a giant pharyngoesophageal diverticulum (Zenker's diverticulum) that extended deep into the chest. Surgery, using either an open or endoscopic approach, was difficult. We stapled the common wall between the diverticulum and the esophagus using video-assisted thoracoscopic surgery. The patient exhibited good anatomic and functional results at 6 months' follow-up.
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Affiliation(s)
- Xun Zhang
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin, China.
| | - Shizhao Cheng
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Yijun Xu
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Shunhua Wang
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin, China
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Buchanan MA, Riffat F, Mahrous AK, Fish BM, Jani P. Endoscopic or external approach revision surgery for pharyngeal pouch following primary endoscopic stapling: which is the favoured approach? Eur Arch Otorhinolaryngol 2012; 270:1707-10. [PMID: 23015198 DOI: 10.1007/s00405-012-2186-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Accepted: 09/07/2012] [Indexed: 12/11/2022]
Abstract
This study aimed to assess outcomes of revision endoscopic stapling and external excision of pharyngeal pouch. A 5-year prospective study was performed on all patients requiring revision pouch surgery following primary endoscopic stapling. Data were collected retrospectively. Eighteen patients underwent revision pouch surgery. In seven patients, pouch size was down-graded from 3 to 2, and these were stapled endoscopically. Two leaks resulted. Eleven patients with grade 1 or 3 pouches underwent external excision of pouch, with no post-operative complications. As per results external excision of pouch is safe for grade 1 and 3 pouches. It avoids risking redundant mucosa and recurrence of symptoms which can complicate stapling and enables a myotomy to be performed to reduce cricopharyngeal hypertonicity. The highest predictable success is with grade 2 pouches, whose size is amenable to adequate endoscopic stapling. However, the "staple over staple" effect of revision stapling leads to unpredictable fibrosis, which can contribute to risk of perforation.
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Affiliation(s)
- Malcolm A Buchanan
- Department of Otorhinolaryngology and Head & Neck Surgery, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK.
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Optimising endoscopic stapling of pharyngeal pouches. The Journal of Laryngology & Otology 2012; 126:407-8. [PMID: 22284822 DOI: 10.1017/s0022215111003392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Endoscopic hypopharyngeal diverticulotomy is now largely performed using an endoscopic stapling device. A poorly applied endoscopic stapling device can result in incomplete division of the cricopharyngeal bar, necessitating the application of a second set of staples. Applying more than one set of staples is associated with an increased risk of complications and greater cost. Small pharyngeal pouches are difficult to staple because of difficulties engaging the stapling device over the cricopharyngeal bar. METHOD Two pairs of oesophageal forceps are used in conjunction with a 0 degree Hopkins rod to optimise the endoscopic stapling of small and large pharyngeal pouches. RESULTS AND CONCLUSION Applying grasping forceps to the cricopharyngeal bar improves the accuracy of the stapling procedure, thus reducing the morbidity and cost associated with multiple staple applications.
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