Long-term success of flexible endoscopic septal division with the stag beetle knife for Zenker’s diverticulum: a tertiary center study

Abstract

Summary Objectives Flexible endoscopic septum division is an established treatment for Zenker’s diverticulum (ZD); however, long-term outcome data are lacking. We aimed to evaluate the long-term efficacy of flexible endoscopic septal division (FESD) using the stag beetle knife for ZD and identify predictors of symptom recurrence. Methods Patients undergoing the procedure between 2013 and 2018 were prospectively enrolled. Procedures were performed by a single operator. Symptom severity pre- and postprocedure was recorded using the dysphagia, regurgitation, and complications scale. Symptom recurrence was defined as a total score > 1 after the index procedure. Time-to-event analyses were performed using Kaplan–Meier plots, with multivariable analyses performed using Cox regression models. Results Altogether, 65 patients (mean age 74.0 years, 60% male) were included. Previous stapling had been performed in 44.6% of patients. Over the mean posttreatment follow-up period of 19 months, 5.6% of the treatment naïve group and 34.5% of the recurrent group underwent repeated FESD (P = 0.003), with rates of symptom remission and improvement of 75.4% and 92.7%, respectively. Recurrence at 48 months was higher in patients with recurrent ZD (84.7%) than in treatment-naïve patients (10.7%). On multivariable analysis, recurrent disease (hazard ratio [HR] 20.8, P = 0.005) and younger age (HR 0.96/year, P = 0.047) were associated with symptom recurrence. Conclusions In patients with treatment-naïve ZD, flexible endoscopic septal division is safe and provides durable symptom remission. However, in patients with poststapling recurrence, the risk of recurrence is high and time-dependent.

Authors' reply

“…The definitions in the tool also appear to change between the initial paper (where complications are defined as cough and aspiration, and graded with numerical frequency analogue scales ranging from 0 to 4) 2 and subsequent use (complications graded from 0, representing no complications, to 2, representing recurrent chest infections and unintentional weight loss). 3 Our paper cites the Eating Assessment Tool 10 ('EAT-10') score as a preferred tool, first published in 2008, as this has been validated in patients with Zenker's diverticulum, showing excellent internal consistency, test-retest reproducibility, and criterion-based validity, both during initial development 4 and in further studies. 5 To our knowledge, no studies have yet performed pre-and post-operative validation of these tools using videofluoroscopic swallowing studies.…”

“…The definitions in the tool also appear to change between the initial paper (where complications are defined as cough and aspiration, and graded with numerical frequency analogue scales ranging from 0 to 4) 2 and subsequent use (complications graded from 0, representing no complications, to 2, representing recurrent chest infections and unintentional weight loss). 3…”

Zenker's peroral endoscopic myotomy (Z-POEM) for recurrent Zenker diverticulum: not so fast!

“…Third, we recently found the Dysphagia, Regurgitation, Complication (DRC) score to be superior to the Dysphagia (Dakkak) score alone in ZD. Of note, regurgitation can be a particularly disabling symptom, even in the absence of dysphagia [2]. Finally, flexible endoscopic septal division (FESD) has been shown to effectively improve symptoms in recurrent ZD, with an excellent safety profile [2 -4].…”

Letter to the Editors regarding ‘A multi-centre analysis of a decade of endoscopic pharyngeal pouch surgery in Cheshire and Merseyside’

“…Letter to the Editors regarding 'A multi-centre analysis of a decade of endoscopic pharyngeal pouch surgery in Cheshire and Merseyside' Z Heng 1 , H R Nieto 1 and S Ishaq 2 1 Departments of Otolaryngology and 2 Gastroenterology, Dudley Group NHS Foundation Trust, West Midlands, UK Dear Editors, We read with great interest the paper titled 'A multi-centre analysis of a decade of endoscopic pharyngeal pouch surgery in Cheshire and Merseyside' by the Mersey ENT Trainee Research Collaborative, 1 in your esteemed journal. We would like to commend the authors for their contribution to the overall limited knowledge available on the endoscopic treatment of pharyngeal pouches, and it is heartening to see the trainee collaborative model at play, involving six separate centres and adopting a common, pre-defined audit standard.…”

“…In their publication, the authors mentioned that they only used a crude assessment of patient-reported symptom improvements, instead of utilising any symptom assessment tools to evaluate patients pre- and post-procedure. The validated Dysphagia, Regurgitation and Complications Scale scoring tool 2 is superior to the dysphagia score alone for assessing Zenker's diverticulum. Of note, regurgitation can be a particularly disabling symptom even in the absence of dysphagia.…”