Surgical Treatment of Zenker's Diverticulum

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Abstract

Background: Different surgical techniques have been indicated for the management of Zenker's diverticulum (ZD), including diverticulectomy, diverticulopexy, and diverticular inversion, with or without myotomy, and myotomy alone. More recently, minimally invasive techniques (such as the transoral endoscopic approach) have become increasingly reliable for this disorder. We therefore conducted this systematic review in order to gain a profound understanding of the current trend and evidence in surgical management of ZD. Methods: Medline and PubMed were searched to identify studies on surgical intervention of ZD published in English between January 1990 and March 2011. Results: We identified 6,915 patients from 93 studies evaluating the effect of the surgical intervention for ZD. No randomized controlled trials comparing one technique with another were identified. Conclusion: Diverticulectomy with myotomy has become the mainstream treatment option for ZD. In certain selected patients, endoscopic diverticulotomy may offer some advantages over open surgery, such as less trauma and a lower complication rate. It is important to individualize optimal therapy for each patient. More randomized controlled trials with long-term follow-up results are required to draw a valid conclusion on the best surgical intervention modality for ZD.

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Endoscopic incision of Zenker's diverticula.

E Melo, P Sakai, Daniela F. Maluf … (1995)

The endoscopic treatment of symptomatic pharyngoesophageal diverticula (PED) with rigid instruments involves the incision of the septum between the diverticulum and the esophageal lumen, within which the cricopharyngeal muscle is present. The aim of this study is to report on the feasibility and efficacy of our method using flexible endoscopy and an electro-surgery system with minimal trauma to the patients. Forty-two patients (13 female, 29 male) with symptomatic pharyngoesophageal diverticula underwent endoscopic treatment. The average age of the patients was 68.4 years (range 46 to 102 years) and 26 of them (61%) had concomitant cardiopulmonary diseases. The procedure consisted of endoscopic incision of the septum with a needle knife, using cutting/coagulation current. It was performed under preparation for routine endoscopic examination. All patients were clinically and endoscopically evaluated at two and four weeks, and afterwards followed clinically at 12, 24, and 60 months after the procedure. The endoscopic incision was performed in one to live sessions (mean of 1.8 session per patient). Two complications (one cervical emphysema, and one hemorrhage) were managed clinically. Dysphagia disappeared in all patients soon after the treatment, although the post-operative radiological and endoscopic controls revealed the presence of a remaining diverticulum. Manometric findings disclosed a significant reduction in upper esophageal sphincter pressures in all five patients after endoscopic incision. Mean follow-up was 38 months. There was recurrence of dysphagia in three patients (7.1%) at 12, 22, and 60 months after the procedure. They experienced relief of dysphagia after a repeated endoscopic incision. Endoscopic incision of PED using flexible equipment proved to be a highly efficient and safe method of treating symptomatic disease. It should be considered as an alternative therapy for Zenker's diverticula, especially for patients at a high surgical risk.

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Endoscopic staple diverticulostomy for Zenker's diverticulum: review of literature and experience in 159 consecutive cases.

Christopher Y Chang, Rose J Payyapilli, Richard L Scher (2003)

Several reports since the early 1990s have advocated a minimally invasive technique, endoscopic staple diverticulostomy (ESD), to treat Zenker's diverticulum. However, long-term results and comparisons with the reported experience with external or other endoscopic approaches have been lacking in the literature. We present follow-up on our experience with ESD since 1995 and compare it with the results obtained by other endoscopic or external techniques for treatment of Zenker's diverticulum. Retrospective review of 159 consecutive ESD procedures performed on 150 unique patients with Zenker's diverticulum between March 1995 and August 2002. Telephone interviews of patients were conducted to assess long-term treatment outcome. Review of the literature was performed by Ovid MEDLINE search for all reports on the surgical treatment of Zenker's diverticulum in the English language between January 1990 and August 2002. Data were retrospectively reviewed and information was tabulated for age, sex, size of diverticulum, symptoms, duration of symptoms, operative time, length of hospital stay, time before oral intake, complications, and relief of symptoms at first postoperative visit. Follow-up interviews of patients were conducted to assess current status of symptoms and, if any symptoms returned, how many months after the procedure they recurred. All case series in the literature in the English language since 1990 that were found in the Ovid MEDLINE database and referenced from identified articles were also tabulated for the same information. At the time of initial follow-up after ESD, 98% of patients reported complete or improved symptoms. Average hospital stay was 0.76 days, with a diet started on postoperative day 0.25. There was a 2.0% significant complication rate without mortality. Further follow-up (average, 32.2 mo) identified a recurrence rate of 11.8%. On review of the literature, patients who underwent ESD had shorter perioperative courses, quicker return to diet, and lower complication and mortality rates compared with external procedures. ESD had comparable operative times and mortality rates, but fewer complications and more rapid convalescent times compared with other endoscopic procedures. Recurrence rates were found to be variable. Overall, ESD is an outpatient procedure with few complications. The technique has a faster operative and convalescence period with fewer complication rates compared with other endoscopic or external transcervical approaches. The results in the present study and those reported in the English language literature advocate that ESD be the initial preferred treatment for Zenker's diverticulum.

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Endotherapy of Zenker's diverticulum using the needle-knife technique: long-term follow-up.

A Vogelsang, C Preiss, H Neuhaus … (2007)

Endotherapy of Zenker's diverticulum by mucomyotomy of the bridge between the diverticulum and the esophageal lumen has been introduced as a promising alternative to surgical techniques. However the data on long-term clinical outcome are limited. After poor results in four patients treated by argon plasma coagulation, we studied the efficacy and the long-term outcome of dissection using a needle-knife in a consecutive series of patients. Between December 2001 and November 2004, 31 consecutively treated symptomatic patients (18 men; median age 69 years; range 52-92) with Zenker's diverticulum were enrolled into this retrospective study. In all cases mucomyotomy was performed with a needle-knife with the patient under conscious sedation. The procedure was repeated in the case of incomplete relief from dysphagia or of recurrent symptoms during follow-up. All patients completed questionnaires on the frequency and severity of dysphagia, using a numeric analogue scale, ranging from 0 (never/none/excellent) to 10 (each time of swallowing/very severe/very bad). Endoscopic mucomyotomy was achieved in all 31 patients, with initial symptomatic improvement. Repeat treatment was required in 10 patients after a mean of 5.3 months, due to recurrence of symptoms. During a mean follow-up period of 26 months (range 14-49), 26 patients (84%) had long-term success of variable degree (65% with no or minimal remaining symptoms); four patients (13%) had insufficient relief and wanted a repeat treatment; and one patient (3%) underwent surgery. The success rate in the entire group was 84% (26/31) including those with repeat treatment, and 61% (19/31) if only success following a single treatment session was counted. Minor complications such as subcutaneous or mediastinal emphysema were observed in 23% and were conservatively managed. There were no major complications. A single needle-knife mucomyotomy procedure can achieve long-term symptomatic improvement in about two out of three cases of Zenker's diverticulum. The success rate can be increased to above 80% by repeated sessions. Minor complications occur frequently but they can be conservatively managed. Major complications were not observed. Further long-term studies are warranted to elucidate the role of endoscopy as a definitive single treatment, with determination of prognostic parameters for a successful long-term outcome.

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Journal

Journal ID (publisher-id): DSU

Journal ID (nlm-ta): Dig Surg

Journal ID (doi): 10.1159/issn.0253-4886

Title: Digestive Surgery

Publisher: S. Karger AG

ISSN (Print): 0253-4886

ISSN (Electronic): 1421-9883

Publication date Subscription-year: 2013

Publication date (Print): August 2013

Publication date (Electronic): 06 July 2013

Volume: 30

Issue: 3

Pages: 207-218

Affiliations

Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China

Author notes

*Long-Qi Chen, No. 37, Guo Xue Xiang, Chengdu 610041 (China), E-Mail drchenlq@gmail.com

Article

Publisher ID: 351433 Other ID: Dig Surg 2013;30:207-218

DOI: 10.1159/000351433

PubMed ID: 23838812

SO-VID: 16c17245-c852-4693-b082-d2b0dd095a34

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Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

History

Date received : 08 October 2012

Date accepted : 10 April 2013

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Tables: 5, Pages: 12

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Karger: Gastroenterology

Most cited references 86

Endoscopic incision of Zenker's diverticula.

Endoscopic staple diverticulostomy for Zenker's diverticulum: review of literature and experience in 159 consecutive cases.

Endotherapy of Zenker's diverticulum using the needle-knife technique: long-term follow-up.

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