Pharyngoesophageal diverticulum: evaluation of treatment results

Cost-Effectiveness of Open vs. Endoscopic Repair of Zenker's Diverticulum

OBJECTIVE

To evaluate the cost-effectiveness of open versus endoscopic surgical repair of Zenker's diverticulum.

METHODS

In this study, an economic decision tree was utilized to compare the cost-effectiveness of open surgery compared to endoscopic surgery. The primary outcome in this analysis was the incremental cost-effectiveness ratio (ICER) that was calculated based on the economic decision tree. The probability of post-operative esophageal perforation complications, revision rates, and effectiveness of each procedure along with associated costs were extracted to construct the decision tree. Univariate sensitivity analysis was then utilized to determine how changes in esophageal perforation rate affect the cost-effectiveness of each surgical approach.

RESULTS

The ICER of open surgery for Zenker's diverticulum was $67 877, above most acceptable willingness to pay (WTP) thresholds. Additionally, if the probability of esophageal perforation with endoscopic surgery is above 5%, then open surgery becomes a more cost-effective option. Probabilistic sensitivity analysis using Monte Carlo simulations also showed that at the WTP thresholds of $30 000 and $50 000, endoscopic surgery is the most cost-effective method with 83.9% and 67.6% certainty, respectively.

CONCLUSION

Open surgery and endoscopic surgery are 2 treatment strategies for Zenker's diverticulum that each have their own advantages and disadvantages that can complicate the decision-making process. With no previous cost-effectiveness analysis of open versus endoscopic surgery for Zenker's diverticulum, our results support the endoscopic approach at most common WTP thresholds. Particularly with the current focus on rising healthcare costs, our results can serve as an important adjunct to medical decision-making for patients undergoing treatment for 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.

Adverse Events after Rigid and Flexible Endoscopic Repair of Zenker’s Diverticula: A Systematic Review and Meta-analysis

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.

Endoscopic versus surgical approach in the treatment of Zenker's diverticulum: systematic review and meta-analysis

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.