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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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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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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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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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Leong SC, Wilkie MD, Webb CJ. Endoscopic stapling of Zenker’s diverticulum: establishing national baselines for auditing clinical outcomes in the United Kingdom. Eur Arch Otorhinolaryngol 2012; 269:1877-84. [DOI: 10.1007/s00405-012-1945-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 01/20/2012] [Indexed: 11/29/2022]
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Affiliation(s)
- Thomas J Watson
- University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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Vogelsang A, Schumacher B, Neuhaus H. Therapy of Zenker's diverticulum. DEUTSCHES ARZTEBLATT INTERNATIONAL 2008; 105:120-6. [PMID: 19633762 DOI: 10.3238/arztebl.2008.0120] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2006] [Accepted: 10/30/2007] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Zenker's diverticulum is a rare disease, which can cause considerable suffering. The classic presentation is worsening dysphagia. Anatomically there is a loose bulge of the dorsal wall of the hypopharynx. A septum between the diverticulum and the lumen of the esophagus can develop and hamper the passage of food. Therapeutic options include the open diverticular resection in combination with myotomy of the cricopharyngeus muscle, or endoluminal or transoral approaches which merely split the septum by means of rigid or flexible endoscopy. METHODS Selective review of literature found in Medline. RESULTS Significant relief is achievable in more than 90% of cases by one or another approach. Endoluminal methods have lower complication rates but higher recurrence rates. DISCUSSION Treatment planning should be interdisciplinary, and take into account individual anatomy and risk factors, as well as local expertise.
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Affiliation(s)
- Arnd Vogelsang
- Evangelisches Krankenhaus Düsseldorf, Kirchfeldstrasse 40, Düsseldorf, Germany.
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Palmer AD, Herrington HC, Rad IC, Cohen JI. Dysphagia After Endoscopic Repair of Zenker's Diverticulum. Laryngoscope 2007; 117:617-22. [PMID: 17325609 DOI: 10.1097/mlg.0b013e3180305061] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine whether patient outcomes after endoscopic staple-assisted diverticulectomy(ESD) were correlated with demographic or disease-specific patient characteristics. STUDY DESIGN Retrospective chart review with followup. METHODS A survey was sent to all eligible subjects who had undergone ESD from February 1995 to June 2004 to gather information about their postoperative weight, diet, dysphagia symptoms, distress, and overall satisfaction. RESULTS Thirty-five individuals responded(49% response rate) at a mean of 29 (range,3-83) months postoperative. There was a significant reduction in the following symptoms: food avoidance,regurgitation, dysphagia for pills, choking, coughing,difficulty finishing a meal, heartburn/reflux, and halitosis. There was no significant difference for dysphonia.Swallow-related distress had decreased from a preoperative level of 7.86 to 2.23 at follow-up (P <.001). Overall satisfaction with the surgery was high. There were no significant differences in outcome by any demographic characteristic, duration of preoperative symptoms, presence of gastroesophageal reflux disease, Zenker's diverticulum size, time since surgery,or number of surgeries. Ninety-one percent of subjects reported improvement in their swallowing after surgery, but 22% reported some decline since that time. Symptomatic subjects reported significantly higher swallow-related distress and lower satisfaction(P < .01). Preoperative variables were not correlated with a return of symptoms. Individuals who underwent multiple procedures had similar levels of benefit and satisfaction as those who underwent a single ESD procedure. CONCLUSION ESD results in high levels of patient satisfaction, significant reduction in postoperative symptoms, low levels of complications,and the opportunity to safely and successfully repeat the procedure if necessary.
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Affiliation(s)
- Andrew D Palmer
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, PV-01, Portland, OR 97239-3098, USA
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Miller FR, Bartley J, Otto RA. The endoscopic management of Zenker diverticulum: CO2 laser versus endoscopic stapling. Laryngoscope 2006; 116:1608-11. [PMID: 16954989 DOI: 10.1097/01.mlg.0000233508.06499.41] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The purpose of this project was to analyze the endoscopic management of Zenker diverticulum (ZD) using both the CO2 laser and endoscopic stapling techniques. This study compares the two techniques in terms of diverticulum size, onset to oral intake, hospital stay, resolution of symptoms (dysphagia and regurgitation), and complications. STUDY DESIGN A retrospective consecutive case series was performed at an academic medical center. METHODS Forty patients underwent an attempted endoscopic resection of the ZD using either the CO2 laser or the endoscopic stapling technique. The two techniques were compared on a variety of parameters, including diverticulum size, hospital stay, onset to oral intake, resolution of symptoms, and complications. Symptom scores were obtained before and after surgery with a patient self-reported scoring report (scale 0-3 for both dysphagia and regurgitation with 0 indicating asymptomatic and 3 severe symptoms). RESULTS Forty patients underwent an attempted endoscopic management of ZD. Five patients (12.5%) failed endoscopic exposure (four converted to open, one observed). Sixteen patients underwent CO2 laser management and 19 underwent endoscopic stapling. The mean diverticulum size (3.8 cm CO2 laser versus 4.4 cm stapling) was not significantly different for the two groups. Both groups demonstrated a significant decrease in preoperative versus postoperative dysphagia and regurgitation symptoms scores, respectively, CO2 laser dysphagia scores decreasing from 2.75 to 1.38 and the regurgitation score dropping from 1.51 to 0.68, whereas endoscopic stapling dysphagia score decreased from 2.74 to 1.21 and the regurgitation score dropped from 1.37 to 0.53. Overall, 86% of patients demonstrated an onset of liquid intake on postoperative day 1 and the average length of stay was 3.4 days in the CO2 laser group and 1.5 days in the endoscopic stapling (P < .0015). Complications included dental trauma in four patients (two CO2 laser and two stapling) and subcutaneous air in three patients (all three CO2 laser). There were no cases of mediastinitis, recurrent laryngeal nerve injury, fistula, or perioperative death. CONCLUSIONS The endoscopic management of ZD is a safe and effective technique. The endoscopic stapling technique appears to have an improved efficacy and safety when compared with the CO2 laser technique. The two techniques are compared and contrasted.
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Affiliation(s)
- Frank R Miller
- Department of Otolaryngology-Head Neck Surgery, University of Texas Health Science Center, San Antonio, Texas, USA.
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Van Daele DJ. Conservative management of stapler failure in Zenker's endoscopic diverticulotomy. Ann Otol Rhinol Laryngol 2006; 114:946-8. [PMID: 16425562 DOI: 10.1177/000348940511401210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The endoscopic stapler has achieved widespread use in the management of Zenker's diverticulum owing to its ease of use and safety. However, complications associated with its use can and do occur. This study details the treatment course of 2 patients who underwent an endoscopic stapler approach to their Zenker's diverticulum complicated by the stapler's not sealing the mucosal edges. Although the patients' hospital stays were extended as a result, they suffered no long-term morbidity as a result of the complication.
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Affiliation(s)
- Douglas J Van Daele
- Department of Otolaryngology-Head and Neck Surgery, Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa 52242, USA
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Aly A, Devitt PG, Jamieson GG. Author's reply: Evolution of surgical treatment for pharyngeal pouch ( Br J Surg 2004; 91: 657–664). Br J Surg 2005. [DOI: 10.1002/bjs.4920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- A Aly
- University of Adelaide Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - P G Devitt
- University of Adelaide Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - G G Jamieson
- University of Adelaide Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
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Lerut T. Letter: Evolution of surgical treatment for pharyngeal pouch (Br J Surg 2004; 91: 657–664). Br J Surg 2005; 92:119; author reply 119-20. [PMID: 15635612 DOI: 10.1002/bjs.4919] [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] [Indexed: 11/10/2022]
Abstract
Abstract
The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses can be sent electronically via the BJS website (www.bjs.co.uk) or by post. All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length. Letters submitted by post should be typed on A4-sized paper in double spacing and should be accompanied by a disk.
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Abstract
OBJECTIVES/HYPOTHESIS Staple-assisted, endoscopic Zenker diverticulotomy has been shown to decrease both cost of treatment and length of convalescence when compared with the standard open approach. Although the endoscopic technique is generally considered to be safe, the feasibility of outpatient endoscopic Zenker diverticulotomy has never been reported. STUDY DESIGN Retrospective cohort study. METHODS All endoscopic Zenker diverticulotomy procedures performed at Oregon Health and Science University (Portland, OR) between 1998 and 2002 were reviewed. The study group was limited to patients whose surgeries were planned on an outpatient basis. Medical charts were reviewed for indications, demographics, operative findings, complications, and resolution of symptoms. RESULTS Of the 51 patients who underwent endoscopic, staple-assisted Zenker diverticulotomy, 40 were treated with the intent of outpatient management. Thirty-two cases were primary surgeries, and eight cases were revision treatments. The average patient age was 68 years (age range, 35-91 y), and the mean follow-up period was 5.9 months (range, 1-37 mo). Eight (20%) complications were noted in the study group. Intraoperative complications included 3 patients (7.5%) with mucosal disruptions. These patients underwent uneventful suture repair of small hypopharyngeal mucosal tears encountered intraoperatively and were temporarily observed in the hospital. One patient was admitted for postoperative urinary retention and another for fever and tachycardia 48 hours after surgery. One patient sustained a myocardial infarction. The remainder of patients were fed immediately and discharged home on the day of surgery. Two patients (5%) had iatrogenic tooth fracture. CONCLUSION Appropriately selected patients undergoing endoscopic, staple-assisted Zenker diverticulotomy can be managed safely on an outpatient basis. Intraoperative complications, such as a mucosal disruption, warrant conversion to inpatient monitoring.
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Affiliation(s)
- Neil D Gross
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, PV01, Portland, OR 97201, USA
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Thorne M, Harris P, Marcus K, Teknos TN. Bilateral vocal fold paresis after endoscopic stapling diverticulotomy for zenker's diverticulum. Head Neck 2004; 26:294-7. [PMID: 14999806 DOI: 10.1002/hed.10357] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Zenker's diverticulum may be treated with a variety of surgical techniques. Endoscopic methods, specifically endoscopic stapling diverticulotomy, have gained increasing acceptance because of shorter operative times, decreased morbidity, with shorter hospital stays and time to resumption of oral feedings. METHODS AND RESULTS We report the occurrence of bilateral vocal fold paresis after endoscopic stapling diverticulotomy for Zenker's diverticulum, previously unreported in the literature. This complication likely resulted from traction on the recurrent laryngeal nerves secondary to unfavorable patient anatomy. CONCLUSIONS Endoscopic stapling diverticulotomy is a safe and effective treatment method for Zenker's diverticulum and remains our procedure of choice for most patients. However, inability to safely expose the diverticulum endoscopically results in a significant abandonment rate for attempted procedures and may result in significant postoperative complications.
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Affiliation(s)
- Marc Thorne
- Department of Otolaryngology, University of Michigan Health System, A. Alfred Taubman Health Care Center, 1500 East Medical Center Drive Room 1904, Ann Arbor, Michigan 48109-0312, USA
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Abstract
Cricopharyngeal spasm and Zenker's diverticulum represent disorders of the pharyngoesophageal junction for which a unifying theory of etiology has yet to be established. There is, however, a large body of evidence that supports an association with gastroesophageal reflux. Cricopharyngeal myotomy is the key to successful management of both disorders. Newer transoral endoscopic techniques of management have a lower overall morbidity than traditional open approaches in appropriately selected patients and are therefore gaining popularity as the preferred method of treatment.
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Affiliation(s)
- Elizabeth A Veenker
- Oregon Health and Sciences University, Department of Otolaryngology/Head and Neck Surgery, 3181 SW Sam Jackson Park Rd, Portland, Oregon 97201-3098, USA
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Abstract
Motor dysfunction is an important cause of oropharyngeal dysphagia and distal esophageal symptoms. Minimally invasive surgical methods of managing Zenker diverticula and achalasia, important disorders associated with these presentations, continue to take center stage in the literature. Detection and characterization of hypomotility before antireflux surgery may be less important than systematically excluding achalasia, as the vague and variable presentations of this motor disorder become appreciated. The many processes that can mimic idiopathic achalasia continue to be exposed.
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Affiliation(s)
- Chandra Prakash
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
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