Endoscopic stapling of Zenker’s diverticulum: establishing national baselines for auditing clinical outcomes in the United Kingdom

Abstract

Endoscopic stapling of Zenker's diverticulum (ZD) is now established practice in the UK and is routinely performed by the vast majority of otolaryngologists. Both The National Confidential Enquiry into Peri-Operative Deaths and the National Institute for Health and Clinical Excellence recommended that the procedure be undertaken at specialist centres and that each department should audit their respective outcomes. Despite the abundance of review articles, it remains unclear what variables a meaningful audit is required to collate and what gold standards every department in the UK undertaking surgery for ZD should aspire to achieve. The objective was to review the outcomes of endoscopic stapling of Zenker's diverticulum at this institution. In addition, a review of other UK departments was undertaken to formulate minimum clinical standards and recommendations of best practice. Review of patient case notes and a structured search of PubMed were used as materials. Fifteen retrospective case series were identified from the literature search which fulfilled the inclusion criteria. Fifty-one patients were identified from the present audit. When these were added to the review, a total of 585 patients were available for meta-analysis. 540 (92.3%) were successfully stapled. Forty-five (7.7%) procedures were abandoned intra-operatively. The most common reason was difficulty assessing the small pouch. The majority of patients (92%) had resumed oral intake by the second post-operative day. Most patients (87%) were discharged by the second post-operative day. Outcomes were good with over 90% reporting resolved or significantly improved symptoms. Minor complications included dental trauma, transient hoarseness and sore throat causing delayed resumption of oral intake. The overall perforation rate was 4.8%. One death was reported. In conclusion endoscopic stapling of pharyngeal pouch is a safe procedure that is associated with good outcomes and low complication rates. No death has been reported since 2000 in the UK. The data presented in this review represent current clinical standards reported over the past 15 years by UK departments and serve as a useful benchmark for any future audits undertaken.

The role of flexible endotherapy for the treatment of recurrent Zenker’s diverticula after surgery and endoscopic stapling

“…All treatment options have a satisfactory success rate (80-100 % for surgery, 90-100 % for rigid endoscopy and 43-100 % for flexible endoscopy), but symptom recurrence can be as high as 19 % for surgery, 12.8 % for rigid endoscopy and 20 % for flexible endoscopy [2,[4][5][6][7]. In addition surgery is associated with significant morbidity and mortality rates, which can be as high as 30 and 3 %, respectively.…”

Traction on the septum during transoral septotomy for Zenker diverticulum improves the final outcome

“…In our experience, the procedure time, resumption of oral feeding, and length of hospital stay were much the same as in the literature. None of our patients required conversion to a cervical approach (whereas the conversion rate reported in the literature was 7.7%) …”

New and emerging techniques for endoscopic treatment of Zenker's diverticulum: State‐of‐the‐art review

“…Although therapy should be considered for all symptomatic patients, contraindications for each procedure should be considered and these are summarized in Table . Success rates of therapy appear comparable between modalities (surgery: 80–100%, rigid endoscopy: 90–100%, flexible endoscopy: 43–100%), but symptomatic recurrence can be as high as 19% for surgery, 12.8% for rigid endoscopy and 20% for flexible endoscopy . Surgery is associated with significant morbidity and mortality, with rates of 30% ( vs 3% for rigid endoscopy and 1.5% for flexible endoscopy) and 3%, respectively .…”

“…Surgery is associated with significant morbidity and mortality, with rates of 30% ( vs 3% for rigid endoscopy and 1.5% for flexible endoscopy) and 3%, respectively . Approaches using rigid endoscopy have limitations, including the need for general anesthesia and high rates of intraoperative abandonment (7.7%), mainly in cases of small diverticular size (<3 cm) and restricted neck mobility (Table ) . Although the open approach may be feasible for smaller pouch sizes, it is an invasive procedure which merits careful patient selection .…”