Endoscopic Stapled Diverticulotomy: Treatment of Choice for Zenker's Diverticulum

Abstract

Objective: To evaluate the efficacy and safety of endoscopic stapled diverticulotomy in the treatment of patients with Zenker's diverticulum. Study Design: Cohort study. Methods: Fourteen elderly patients (11 men and 3 women) with Zenker's diverticulum were evaluated in a community hospital setting from July 1996 to November 1999. Before surgery patients had significant dysphagia, regurgitation, cough, or aspiration pneumonia. The common septum between the diverticulum and cervical esophagus was visualized with a Weerda diverticuloscope. While using videoendoscopic monitoring, the septum was divided and the edges simultaneously sealed with a linear endoscopic stapler. Average operative time was 31 minutes. Results: The operation was successfully performed in 11 of 14 patients. In the three unsuccessful cases, one patient's pouch was too small to staple and the other two patients had a septum that was difficult to visualize with the diverticuloscope. There was no significant postoperative morbidity or mortality. Patients started a liquid diet on the first postoperative day and resumed a soft diet a week later. They were usually discharged on the first postoperative day. Most patients reported significant improvement with resolution of dysphagia and regurgitation. Conclusions: Compared with the traditional open technique, the endoscopic stapled diverticulotomy technique is safe, quick, and effective and requires a shorter length of stay in the hospital. Therefore it has become our treatment of choice for elderly, high-risk patients with a large (>2 cm) hypopharyngeal (Zenker's) diverticulum.

Staple-assisted endoscopic management of Zenker’s diverticula: a role in the geriatric population

“…The mean surgical time of 34 min is consistent with literature reports of other endoscopic diverticulotomies [7,9,15,16]. Elderly and frail patient are at an increased risk from general anesthetic and thus this select patient population can benefi t from this relatively short surgical procedure.…”

“…These included two cases of perforations and one complicated course of aspiration pneumonia in a patient that had pre-morbid lung disease. In comparison, hospital stays for open procedures are typically much longer with mean stays averaging 5.2 days [9]. Gross et al have gone so far as to suggest that patients undergoing endoscopic staple-assisted ZD can be managed safely even on an outpatient basis [10].…”

“…Gross et al have gone so far as to suggest that patients undergoing endoscopic staple-assisted ZD can be managed safely even on an outpatient basis [10]. This abbreviated in-hospital convalescence can be translated by Smith et al's New York charge analysis demonstrating that cost savings can be appreciated with patients undergoing endoscopic management [9].…”

“…Also benefi cial is a reduced risk of perforation and subsequent mediastinitis since the divided edges of the septum are sealed by the staples [7]. When compared to traditional open procedures, the endoscopic staple-assisted approach offers numerous advantages by potentially allowing for a shorter operative time and associated anesthetic duration, shorter hospital stays, and reduced time to resume oral feedings and overall convalescence [9][10][11]. Some studies also quote minimal postoperative pain and increased patient satisfaction [12].…”

Tratamento cirúrgico do divertículo de Zenker

“…Várias abordagens foram desenvolvidas, incluindo diverticulectomia e diverticulopexia transcervical com ou sem cricomiotomia e as técnicas minimamente invasivas (tratamento endoscópico com stapler ou laser) 9 . Estas últimas possuem os benefícios inerentes aos procedimentos minimamente invasivos, mas têm maior taxa de recidiva e risco de perfuração esofágica 6,12,22 , além de possuírem limitações técnicas e menor disponibilidade em nosso meio. Quanto à cricomiotomia associada, apesar de haver alguma discussão quanto à necessidade de ser realizada em todos os pacientes, provavelmente acarreta melhores resultados a longo prazo, possivelmente por tratar uma das causas do DZ 3,7,12,25,29 .…”