Comparison of Surgical Treatments for Zenker Diverticulum

Abstract

IMPORTANCEZenker 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 SYNTHESISThe 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 MEASUREThe primary outcome measure was the incidence of persistent or recurrent symptoms following surgery. The primary study outcome was planned before data collection began. RESULTSThe 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 (χ 2 1 = 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.

The impact of prior endoscopic or surgical therapy on open Zenker’s diverticulum surgery: analysis on a large single center cohort

“…They demonstrated stapler line leakages of 4.7%, recurrent laryngeal nerve injury rates of 5.7% and pneumonia rates of 2.8% [4,5]. However, and often neglected, endoscopic treatment is associated with a significantly higher recurrence rate and also reduced effectiveness in symptom control [12]. Protagonists of endoluminal treatment consider these drawbacks as being of lesser importance due to the ease of repeating the procedure if required.…”

“…On the other hand, voices are increasingly raised that in particular young patients have an increased risk of recurrence of a Zenker's diverticulum after endoscopic therapy [13], and, on the other hand, have a longer remaining life span. It has also been shown that open surgery has lower recurrence rates, especially in the recurrence situation [2,12,13]. Of course, it must not be forgotten that the majority of patients demonstrate high comorbidity rates and that there is a clear advantage here with regard to endoscopy in terms of the lower post-interventional complications [14].…”

Assessing the Clinical Utility of the Early Postoperative Pharyngogram in Hypopharyngeal Surgery for Dysphagia

“…Treatment options for it include either open approaches, that remove (diverticulectomy) or suspend (diverticulopexy) the pharyngeal pouch, or endoscopic diverticulotomy that divides the wall shared by the pouch and esophagus. A CP myotomy (CPM) is frequently performed concurrently as ZD is believed to develop due to CP muscle dysfunction 4–6 . CPM can also be performed alone to treat pharyngeal dysphagia related to abnormal CP muscle tone or structure without the presence of a diverticulum 7 …”

“…A CP myotomy (CPM) is frequently performed concurrently as ZD is believed to develop due to CP muscle dysfunction. [4][5][6] CPM can also be performed alone to treat pharyngeal dysphagia related to abnormal CP muscle tone or structure without the presence of a diverticulum. 7 In patients undergoing hypopharyngeal dysphagia surgery, postoperative leaks are critical complications, as they can result in pharyngocutaneous fistulas, neck infections and abscesses, mediastinitis, readmissions, and prolonged hospital stays.…”

Commentary: Transoral endoscopic repair of Zenker's diverticulum by a thoracic surgical service

“…Despite the lack of consensus on the treatment of Zenker's diverticulum (ZD), open surgery is being progressively replaced by endoluminal endoscopic surgery, which appears to allow for a lower rate of complications and lower hospital costs and provides satisfactory long-term outcomes with the possibility of redo endoluminal treatment. 1,2 In this issue of the Journal, Levy and colleagues 3 provide early and late functional results after transoral stapling repair based on a consecutive series of 151 ZD patients. Based on a single-institution database, the authors report a low rate of conversion (10%), a low rate of complications (4%), and a median hospital stay of 2 days.…”