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Sheridan B, Dinh T, Hendrick LE, Moran L, Zhao J, Leesley H, Ng T. Critical analysis of outcomes after surgical management of Zenker diverticulum. J Gastrointest Surg 2024:S1091-255X(24)00588-2. [PMID: 39179020 DOI: 10.1016/j.gassur.2024.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/28/2024] [Accepted: 08/18/2024] [Indexed: 08/26/2024]
Affiliation(s)
- Brenden Sheridan
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Theresa Dinh
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Leah E Hendrick
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Lindsey Moran
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI, United States
| | - Jane Zhao
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States; Division of Thoracic Surgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Haley Leesley
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI, United States
| | - Thomas Ng
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States; Division of Thoracic Surgery, University of Tennessee Health Science Center, Memphis, TN, United States.
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Norton B, Siggens K, Papaefthymiou A, Telese A, Duku M, Murino A, Johnson G, Murray C, Mohammadi B, Mughal M, Bisschops R, Bhandari P, Birchall M, Haidry R. The safety and efficacy of endoscopic approaches for the management of Zenker's diverticulum: a multicentre retrospective study. Surg Endosc 2024:10.1007/s00464-024-11164-4. [PMID: 39160304 DOI: 10.1007/s00464-024-11164-4] [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: 04/16/2024] [Accepted: 08/05/2024] [Indexed: 08/21/2024]
Abstract
INTRODUCTION Minimally invasive endoscopic options are safe and effective alternatives to surgery for the treatment of symptomatic Zenker's diverticulum (ZD). However, there is no consensus on the gold-standard approach. We compared the safety and efficacy of Zenker's peroral endoscopic myotomy (Z-POEM), flexible diverticulotomy (FD), and rigid diverticulotomy (RD) for the management of ZD. METHODS Patients undergoing treatment for ZD at three UK tertiary referral centres were identified and analysed between 2013 and 2023. Patient demographics, procedural details, clinical success, and 30-day adverse events (AE) were recorded. The primary outcomes were technical and clinical success defined as a fall in Dakkak and Bennett dysphagia score to ≤ 1 without re-intervention. RESULTS There was no difference in baseline characteristics amongst 126 patients undergoing intervention (50 RD, 31 FD, 45 Z-POEM). Technical success for RD, FD, and Z-POEM was 80%, 100%, and 100%, respectively (p < 0.001). Over a mean follow-up of 11.0 months (95% CI 8.2-13.9), clinical success amongst those treated was 85.3% (RD), 74.1% (FD), and 83.7% (Z-POEM; p = 0.48) with recurrence in 17.2% (RD), 20.0% (FD), and 8.3% (Z-POEM; p = 0.50). AEs were equivalent between groups (p = 0.98). During this time, 11 patients underwent surgical myotomy with low clinical success (36.4%) and high morbidity. CONCLUSION Endoscopic options for the treatment of ZD show equivalent rates of success, but failed RD often led to open myotomy with worse outcomes. Flexible endoscopic modalities are both safe and highly effective treatments that may be considered first-line in experienced centres and should be offered before surgery.
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Affiliation(s)
- Benjamin Norton
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK.
- Department of Gastroenterology, University College London Hospital, Euston Road, London, NW1 2BU, UK.
- Centre for Obesity Research, University College London, London, UK.
| | - Katie Siggens
- Department of Gastroenterology, Portsmouth University Hospitals, Portsmouth, UK
| | | | - Andrea Telese
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Margaret Duku
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Alberto Murino
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Gavin Johnson
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Charles Murray
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Borzoueh Mohammadi
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Muntzer Mughal
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, UZ Leuven. TARGID, Louvain, KU, Belgium
| | - Pradeep Bhandari
- Department of Gastroenterology, Portsmouth University Hospitals, Portsmouth, UK
| | - Martin Birchall
- Royal National Ear Nose and Throat and Eastman Dental Hospitals, University College London Hospital, London, UK
- The Ear Institute University College London, London, UK
| | - Rehan Haidry
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
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Howell R, Johnson C, Allen J, Altaye M, Amin M, Bayan S, Belafsky P, Cervenka B, Desilva B, Dion GR, Ekbom D, Friedman A, Fritz M, Giliberto JP, Guardiani E, Kasperbauer J, Kim B, Krekeler BN, Kuhn M, Kwak P, Ma Y, Madden LL, Matrka L, Mayerhoff R, McKeon M, Piraka C, Rosen CA, Tabangin M, Wahab SA, Wilson K, Wright C, Young VN, Postma G. Surgical Outcomes in Zenker Diverticula: A Multicenter, Prospective, Longitudinal Study. Laryngoscope 2024; 134:97-102. [PMID: 37191092 DOI: 10.1002/lary.30753] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/19/2023] [Accepted: 05/03/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To compare improvement in patient-reported outcomes (PROM) in persons undergoing endoscopic and open surgical management of Zenker diverticula (ZD). METHODOLOGY Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgery for ZD. Patient survey, radiography reports, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were abstracted from a REDCap database, which summarized means, medians, percentages, and frequencies of. Outcome based on operative intervention (endoscopic vs. open) was compared using t-test, Wilcoxon rank sum test or chi-square test, as appropriate. RESULTS One hundred and forty-seven persons were prospectively followed. The mean age (SD) of the cohort was 68.7 (11.0). Overall, 66% of patients reported 100% improvement in EAT-10; 81% of patients had greater than 75% improvement; and 88% had greater than 50% improvement. Endoscopic was used for n = 109 patients, and open surgical intervention was used for n = 38. The median [interquartile range, IQR] EAT-10 percent improvement for endoscopic treatment was 93.3% [72, 100], and open was 100% [92.3, 100] (p = 0.05). The incidence of intraoperative complications was 3.7% for endoscopic and 7.9% for open surgical management. The median [IQR] in follow-up was 86 and 97.5 days, respectively. CONCLUSION Both endoscopic and open surgical management of ZD provide significant improvement in patient-reported outcomes. The data suggest that open diverticulectomy may provide a modest advantage in symptomatic improvement compared to endoscopic management. The data suggest that the postoperative complication rate is higher in the open surgical group. LEVEL OF EVIDENCE 3 Laryngoscope, 134:97-102, 2024.
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Affiliation(s)
- Rebecca Howell
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Christopher Johnson
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
| | - Jacqui Allen
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Mekibib Altaye
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Milan Amin
- Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, New York, New York, U.S.A
| | - Semirra Bayan
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Peter Belafsky
- Department of Otolaryngology-Head and Neck Surgery, University of California-Davis, Davis, California, U.S.A
| | - Brian Cervenka
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Brad Desilva
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, U.S.A
| | - Gregory R Dion
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Dale Ekbom
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron Friedman
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Mark Fritz
- Department of Otolaryngology-Head and Neck Surgery, University of Kentucky, Lexington, Kentucky, U.S.A
| | - John Paul Giliberto
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Elizabeth Guardiani
- Department of Otolaryngology-Head and Neck Surgery, University of Maryland, Baltimore, Maryland, U.S.A
| | - Jan Kasperbauer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Brandon Kim
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, U.S.A
| | - Brittany N Krekeler
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
- Department of Communication Sciences and Disorders, University of Cincinnati College of Allied Health Sciences, Cincinnati, Ohio, U.S.A
| | - Maggie Kuhn
- Department of Otolaryngology-Head and Neck Surgery, University of California-Davis, Davis, California, U.S.A
| | - Paul Kwak
- Department of Otolaryngology-Head and Neck Surgery, New York University Grossman School of Medicine, New York, New York, U.S.A
| | - Yue Ma
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Lyndsay L Madden
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest University, Winston-Salem, North Carolina, U.S.A
| | - Laura Matrka
- Department of Otolaryngology-Head and Neck Surgery, Ohio State University, Columbus, Ohio, U.S.A
| | - Ross Mayerhoff
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan, U.S.A
| | - Mallory McKeon
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Cyrus Piraka
- Department of Gastroenterology/Hepatology, Henry Ford Health System, Detroit, Michigan, U.S.A
| | - Clark A Rosen
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Meredith Tabangin
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A
| | - Shaun A Wahab
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Keith Wilson
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Carter Wright
- Department of Otolaryngology-Head and Neck Surgery, Wake Forest University, Winston-Salem, North Carolina, U.S.A
| | - VyVy N Young
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, U.S.A
| | - Gregory Postma
- Department of Otolaryngology-Head and Neck Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, U.S.A
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Søfteland EØ, Aasebøstøl AK, Johnsen G, Bringeland EA. Endoluminal treatment for Zenker's diverticulum - a population-based observational study. Scand J Gastroenterol 2024; 59:218-224. [PMID: 37728323 DOI: 10.1080/00365521.2023.2260036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/12/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Zenker's diverticulum is a false diverticulum arising in the oesophago-pharyngeal junction. It may cause symptoms like dysphagia and regurgitation. In Central Norway, treatment is centralized to St. Olavs hospital, either as an endoscopic stapled oesophago-diverticulostomy procedure at the Department of Gastrointestinal Surgery or as laser diverticulostomy at the Department of Ear, Nose and Throat Surgery, depending on diverticulum size. METHODS Retrospective, population-based, study from 2001-2020 on patients treated for Zenker's diverticulum, at the time with a rigid endoscopic approach. Patients were identified through the in-hospital register for operations. The two treatment groups were compared on relevant pre-, intra-, and postoperative variables by review of the individual patient records. RESULTS 78 consecutive patients, 36 at Dept. of Ear, Nose and Throat Surgery and 42 at Dept. of Gastrointestinal Surgery, were treated with a total of 104 interventions. Crude incidence for a surgery-demanding Zenker's diverticulum was 0.57 per 100 000 per year. The Dept. of Ear, Nose and Throat Surgery administered significantly less often prophylactic antibiotics than the Dept. of Gastrointestinal Surgery (p < 0.001), administered more frequently intraoperative dexamethasone (p < 0.001), and had significantly more postoperative infections (19.6% vs 3.4%, p = 0.01). No procedure-related mortality was registered. Although no standardized follow-up took place, at a median of 119 months elapsed, observed clinical recurrence was 35% for the endostapler treatment and 51% for the laser treatment procedure. CONCLUSION Both rigid endoscopic stapled oesophago-diverticulostomy and laser diverticulostomy are safe treatments for Zenker's diverticulum, however with a substantial risk of recurrence.
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Affiliation(s)
- Eirik Østensen Søfteland
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Anne Kristin Aasebøstøl
- Department of Ear, Nose and Throat Surgery, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Gjermund Johnsen
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Gastrointestinal Surgery, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Erling Audun Bringeland
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Gastrointestinal Surgery, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
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5
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Swei E, Pokala SK, Menard-Katcher P, Wagh MS. Comparison of Zenker's per-oral endoscopic myotomy (Z-POEM) with standard flexible endoscopic septotomy for Zenker's diverticulum: a prospective study with 2-year follow-up. Surg Endosc 2023; 37:6818-6823. [PMID: 37277515 PMCID: PMC10241386 DOI: 10.1007/s00464-023-10136-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/09/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Flexible endoscopic therapy of Zenker's diverticulum using submucosal tunneling (Z-POEM) similar to esophageal Per-Oral Endoscopic Myotomy (POEM) is becoming increasingly common. However, data comparing Z-POEM with traditional flexible endoscopic septotomy (FES) are sparse. The aim of this study was to compare outcomes of Z-POEM with traditional FES over a medium-term follow-up period. METHODS This was a prospective study of patients who underwent Z-POEM for treatment of Zenker's diverticulum between 2018 and 2020 at a tertiary academic medical center compared to prior patients who had FES (between 2015 and 2018). Procedural characteristics and clinical outcomes (technical and clinical success, and adverse events) were compared between patients who underwent each treatment. RESULTS A total of 28 patients underwent ZD therapy during the study period. 13 patients (mean age 70 years; 77% male) underwent Z-POEM and 15 patients (mean age 72 years; 73% male) underwent traditional FES. The mean Zenker's diverticulum size was 2.4 ± 0.6 cm in the ZPOEM group vs 2.5 ± 0.8 cm in the FES group. The mean procedure time was similar between groups: 43.9 min (range 26-66) in the Z-POEM group and 60.2 min (range 25-92) in the traditional FES group (t = 1.74 p = 0.19). Overall technical success was seen in 100% of patients. There was one adverse event in the FES group (dehydration resulting in near-syncope) (1/28, 3.6%). Overall clinical success was seen in 92.8% (26/28) of patients and was not significantly different between groups (Z-POEM; 13/13, 100% vs FES; 13/15, 86.7%, t = - 1.36 p = 0.18). CONCLUSION This prospective study suggests that ZPOEM is an effective technique for the treatment of Zenker's diverticulum with no significant differences in clinical outcomes or adverse event rates when compared to traditional FES.
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Affiliation(s)
- Eric Swei
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sridevi K Pokala
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Paul Menard-Katcher
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Mihir S Wagh
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO, USA.
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6
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Constantin A, Constantinoiu S, Achim F, Socea B, Costea DO, Predescu D. Esophageal diverticula: from diagnosis to therapeutic management-narrative review. J Thorac Dis 2023; 15:759-779. [PMID: 36910058 PMCID: PMC9992562 DOI: 10.21037/jtd-22-861] [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: 06/20/2022] [Accepted: 12/12/2022] [Indexed: 02/04/2023]
Abstract
Background and Objective Esophageal diverticulum (ED) is a relatively rare condition, characterized by high etio- and pathophysiological versatility, with an uncommon clinical impact, consequently requiring a complete and complex diagnostic evaluation, so that the therapeutic decision is "appropriate" to a specific case. The aim of the paper is, therefore, a reassessment of the diagnostic possibilities underlying the establishment of the therapeutic protocol and the available therapeutic resources, making a review of the literature, and a non-statistical retrospective analysis of cases hospitalized and operated in a tertiary center. Methods Thus, classical investigations (upper digestive endoscopy, barium swallow) need to be correlated with complex, manometric, and imaging evaluations with direct implications in therapeutic management. Moreover, in the absence of a precise etiology, the operative indication needs to be established sparingly, with the imposition of the identification and interception of the pathophysiological mechanisms through the therapeutic gesture. Key Content and Findings The identification of the pathophysiological mechanisms is mandatory for the management of diverticular disease, the result obtained-restoring swallowing and comfort/good quality of life in the postoperative period-is directly related to the chosen therapeutic procedure. In addition, management appears to be a difficult goal in the context of the low incidence of ED but also of the results that emphasize important differences in the reports in the medical literature. Although ED is a benign condition, surgical techniques are demanding, impacted by significant morbidity and mortality. The causes of these results are multiple: possible localizations anywhere in the esophagus, diverticulum size/volume from a few millimeters to an impressive one, over 10-12 cm, metabolic impact in direct relation to the alteration swallowing, numerous diverticular complications but, perhaps most importantly, alteration of the quality of the diverticular wall by inflammatory phenomena, with an impact on the quality of the suture. Conclusions The accumulation of cases in a tertiary profile center, with volume/hospital, respectively volume/surgeon + gastroenterologist could be a solution in improving the results. One consequence would be the identification of alternative solutions to open surgical techniques, a series of minimally invasive or endoscopic variants can refine these results.
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Affiliation(s)
- Adrian Constantin
- General and Esophageal Clinic, Sf. Maria Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Silviu Constantinoiu
- General and Esophageal Clinic, Sf. Maria Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Florin Achim
- General and Esophageal Clinic, Sf. Maria Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Bogdan Socea
- Department of Surgery, Sf. Pantelimon Emergency Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Daniel Ovidiu Costea
- Department II of Surgery, Emergency Hospital, Ovidius University of Medicine, Constanta, Romania
| | - Dragos Predescu
- General and Esophageal Clinic, Sf. Maria Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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Anthropometric Variables Predict Feasibility and Long-term Outcomes of Trans-oral Septum Stapling for Zenker Diverticulum. J Gastrointest Surg 2022; 27:590-593. [PMID: 35970953 DOI: 10.1007/s11605-022-05432-8] [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: 05/03/2022] [Accepted: 07/29/2022] [Indexed: 01/31/2023]
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Martinez Paredes JF, Al Fakir R, Rutt AL. Clinical Symptoms Contributing to Zenker's Diverticulum Repair: A Retrospective Review. Cureus 2022; 14:e22369. [PMID: 35371686 PMCID: PMC8940557 DOI: 10.7759/cureus.22369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 11/05/2022] Open
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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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Affiliation(s)
- Mihir S Wagh
- Division of Gastroenterology, University of Colorado-Denver, Aurora, Colorado.
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
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11
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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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12
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Mansour M, Badara FA, Ahmed LT, Babacar N, Maria F, Khodia F, Moustapha F, Bakary B, Seynabou D, Niakhaleen K, Aw BM, Ameth D, Modou N, Abou S, Fary KEH, Boucar D. [Zenker´s diverticulum in a hemodialysis patient]. Pan Afr Med J 2020; 37:121. [PMID: 33425154 PMCID: PMC7755364 DOI: 10.11604/pamj.2020.37.121.24932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 07/20/2020] [Indexed: 11/11/2022] Open
Abstract
Le diverticule de Zenker est une pathologie rare et généralement bénigne. Sa présence chez le malade en hémodialyse a des implications thérapeutiques et pronostiques et constitue un facteur de risque de morbi-mortalité du fait de ses complications comme la dénutrition protéino-énergétique et la pneumopathie. Nous rapportons le cas d´un diverticule de Zenker diagnostiqué chez une patiente hémodialysée chronique. Il s´agissait d´une patiente âgée de 61 ans, qui était reçue pour une hémorragie digestive haute accompagnée d´une dysphagie. L´examen physique trouvait une altération de l´état général avec une perte de poids estimée à 5 kg en 3 mois. Le transit œsogastroduodénal objectivait un refoulement de la portion cervicale de l´œsophage par une volumineuse image d´addition hétérogène dont le pôle supérieur se situe au niveau de la jonction pharyngo-œsophagienne. Le diagnostic d´un diverticule de Zenker avait été retenu. Une diverticulectomie par voie cervicale externe avait été réalisé. La patiente est décédée dans les suites postopératoires précoces d´une pneumopathie d´inhalation. Le diverticule de Zenker est une pathologie rare qui est généralement bénigne mais sa présence chez le malade hémodialysé chronique augmente sa morbi-mortalité.
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Affiliation(s)
- Mbengue Mansour
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Fall Alioune Badara
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Lemrabott Tall Ahmed
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Ndiaye Babacar
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Faye Maria
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Fall Khodia
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Faye Moustapha
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Ba Bakary
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Diagne Seynabou
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Keita Niakhaleen
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Ba Mamadou Aw
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Dieng Ameth
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Ndongo Modou
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Sy Abou
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Ka El Hadji Fary
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
| | - Diouf Boucar
- Service de Néphrologie de l´Hôpital Aristide Le Dantec, Université Cheikh Anta Diop de Dakar, Dakar, Sénégal
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Krutsri C, Phalanusitthepha C, Hiranyatheb P, Sumritpradit P, Leelakusolvong S, Methasate A, Singhatas P, Janbavonkij T. Successful advanced third-space endoscopic surgery by per-oral endoscopic myotomy (Z-POEM) for Zenker's diverticulum: A case report and review of literature. Int J Surg Case Rep 2020; 74:186-191. [PMID: 32890894 PMCID: PMC7481499 DOI: 10.1016/j.ijscr.2020.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/02/2020] [Accepted: 08/04/2020] [Indexed: 02/07/2023] Open
Abstract
Z-POEM is a minimal invasive surgery result in good outcomes. Z-POEM provide a precision of treatment for Zenker’s diverticulum which reduce recurrence rate. Z-POEM can reduce perforation due to complete view of septal muscle while perform myotomy.
Introduction Zenker’s diverticulum is a rare condition caused by herniation of the mucosa at the pharyngoesophageal junction, resulting in dysphagia. Third-space endoscopic surgery now plays an important role in its management, facilitating precise surgery with good outcomes. The aim of report is to demonstrate technical steps and outcomes of per-oral endoscopic myotomy (Z-POEM). Presentation of case We report two male patients presented with dysphagia. Esophagograms revealed Zenker’s diverticula of 2.1 and 2.0 cm, respectively, and diagnostic gastroscopy showed the diverticula to be 17 cm from the incisors, with tight, thick septal muscle. A 2-cm mucosal incision was made with a triangle-tipped knife, and submucosal tunneling was created by spray coagulation. The gastroscope was advanced into the submucosal space of the esophageal lumen and the diverticulum site until the bottom of the diverticulum could be clearly identified. The septal muscle was completely divided, immediately allowing the gastroscope to pass through easily, and the mucosal defect was reapproximated with hemoclips. Discussion As compared Z-POEM to previous technique; endoscopic septotomy, staple-assisted diverticulotomy, or open neck surgery, Z-POEM is less recurrent of symptoms and complications. Different types of endoscopic knife and lifting materials were used, but all provided the same outcomes. Most of the cases use though-the-scope clips to close the mucosal defect. Conclusion Z-POEM provided precise treatment and complete view of the entire septal muscle can helps to avoid inadequate myotomy.
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Affiliation(s)
- Chonlada Krutsri
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Pitichote Hiranyatheb
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Preeda Sumritpradit
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Somchai Leelakusolvong
- Department of Internal Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Asada Methasate
- Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pongsasit Singhatas
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thanida Janbavonkij
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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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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Patel J, Spiegel J, Topf MC, Boon M, Huntley C. Feasibility of Early Discharge after Open Hypopharyngeal Surgery for Dysphagia. Ann Otol Rhinol Laryngol 2020; 129:894-900. [DOI: 10.1177/0003489420916216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective: To determine the rate of surgical complications, unplanned readmission, and functional status after open hypopharyngeal surgery for dysphagia with early return to oral diet and hospital discharge. Methods: Retrospective chart review of patients who underwent open hypopharyngeal surgery for management of dysphagia from March 2013 to June 2018 at a single academic institution. A clear liquid diet is restarted the day of surgery and is advanced to a soft diet on postoperative day one. Univariate and multivariate logistic regression was performed to identify risk factors for postoperative complications and unplanned readmission. Results: Ninety patients met eligibility criteria; 62 patients underwent open cricopharyngeal myotomy, 13 underwent Zenker’s diverticulectomy, 15 had a Zenker’s diverticulopexy. Mean inpatient length of stay was 2.0 ± 2.0 days (range 0-11 days); 57 patients (63.3%) were discharged on the same day as surgery or on postoperative day one. Seven patients (7.8%) had postoperative complications; the most common complication was esophageal leak (n = 6). Six patients (6.7%) had unplanned readmissions within 30 days. Mean time to unplanned readmission was 12 days (range 2-19 days). Open diverticulectomy was associated with an increased risk of unplanned readmission with an OR = 7.63 (95% CI 1.29, 45.45, P = .025). At last follow-up, 70% of patients had an increased functional oral intake by at least one scale score (FOIS) after surgery (mean follow-up 0.8 ± 1.1 years, range 0.02-5.1 years). Conclusion: An early diet and discharge may be safe for patients undergoing open surgery without a mechanical or suture closure of their esophageal mucosa, whereas in those undergoing diverticulectomy, NPO status and a radiological check before resuming drinking and eating are advised. Level of Evidence: 4
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Affiliation(s)
- Jena Patel
- Department of Otolaryngology—Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joseph Spiegel
- Department of Otolaryngology—Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael C. Topf
- Department of Otolaryngology—Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Maurits Boon
- Department of Otolaryngology—Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Colin Huntley
- Department of Otolaryngology—Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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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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Open Versus Endoscopic Surgery of Zenker’s Diverticula: A Systematic Review and Meta-analysis. Dysphagia 2019; 34:930-938. [DOI: 10.1007/s00455-019-09994-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 02/23/2019] [Indexed: 10/27/2022]
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Is Myotomy Plus Diverticulopexy Suitable for Symptomatic Zenker's Diverticula? Dysphagia 2018; 34:240-247. [PMID: 30120546 DOI: 10.1007/s00455-018-9936-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 08/11/2018] [Indexed: 12/27/2022]
Abstract
The aim of the study was to prospectively evaluate the outcome of myotomy plus diverticulopexy over short and long-terms. A prospectively collected consecutive series (2007-2017) of 37 patients undergoing myotomy plus diverticulopexy was analyzed for clinical condition, operative information, peri-operative events, and follow-up by means of interview and physical examination. Diverticulopexy was scheduled regardless of the diverticulum's features and patient condition, other than operability. There was no choice or selection between possible treatment options. Patients were evaluated pre-operatively, at post-operative day 30 and after 1 year. Follow-up aimed at assessing the subjective condition following treatment. During the interview, patients were asked to self-assess their ability to swallow before and after surgery. No patient had peri-operative events, complications associated with the procedure, wound infection or impaired swallowing. All patients could start drinking the day after operation, could return to solid diet on post-operative day 2 and be discharged on post-operative days 3-4. Barium swallowing was not necessary before discharge. Full solid diet was resumed according to patient's compliance from post-operative day 2 (some patients refused solid diet soon after the operation even if asymptomatic). Follow-up ranged between 1 and 8 years. No patient was lost at follow-up. No disease recurrence was observed. Finally, no patient needed or sought for a clinical examination between the follow-up calls. Patients reported at least 50% improvement of symptomatology after 1 year. Diverticulopexy appears to be clinically safe, methodologically reproducible, and an effective procedure; it avoids suturing and offers good outcome results along with high patient satisfaction.
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Abstract
PURPOSE OF REVIEW The purpose of the review is to examine current research focused on upper oesophageal sphincter (UES) and cricopharyngeus muscle function, and how better understanding UES physiology will translate to improved management. RECENT FINDINGS Although much is known about UES function, new information describing the dynamics of the UES and cricopharyngeus is being identified through manometry, combined fluoromanometry, and anatomic study. Response of the UES to injury, reflux, and surgical interventions is reported. Direct surgical treatment of cricopharyngeus noncompliance with or without diverticuli continues to show benefit and long-term results support a sustained improvement in three-quarters of patients. SUMMARY UES and cricopharyngeus function is complex and dynamic. It is affected by internal signals such as posture and constitution of refluxate, aging, and interventions particularly radiation and surgery. Clear understanding of the triggers and responses of the UES will enable clinicians to choose the correct therapy for their dysphagic patients.
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Treatment of Zenker’s Diverticulum With Endoscopic Stapled Esophago-divertisculostomy (ESD): Analysis of Long-term Outcome. Surg Laparosc Endosc Percutan Tech 2017; 27:445-448. [DOI: 10.1097/sle.0000000000000473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Functional results in endoscopic Zenker's diverticulum surgery. Eur Ann Otorhinolaryngol Head Neck Dis 2017; 134:309-313. [DOI: 10.1016/j.anorl.2017.02.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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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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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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Voice Outcomes in Surgical Repair of Zenker’s Diverticulum. Dysphagia 2017; 32:678-682. [DOI: 10.1007/s00455-017-9813-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 05/16/2017] [Indexed: 11/27/2022]
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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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