Zenker’s diverticulum: outcome of endoscopic surgery is dependent on the intraoperative exposure

Abstract

The purpose of the present study is to evaluate long-term outcome and patients' satisfaction after endoscopic therapy of Zenker's diverticulum (ZD) and to analyze the results of the stapler technique in comparison with the application of the carbon dioxide (CO2) laser. A retrospective cohort study with outcome analysis of patients undergoing endoscopic cricopharyngeal myotomy with either stapler or CO2 laser between October 2000 and December 2010 by a single surgeon was performed. Patient's medical charts were reviewed with respect to symptoms before intervention, intra and post operative complications, reasons for the choice of endoscopic technique, and postoperative relief of symptoms. Long-term follow-up was acquired by a standardized self-assessment questionnaire. Seventy-four patients (51 men, 23 women) with a median age at operation of 74 years (range 45-93 years) were enrolled in this study. Forty-five patients underwent endoscopic repair of a ZD with stapler, 29 patients with CO2 laser. The mean follow-up was 4.7 years. We did not observe significant differences for intra and post operative complications, hospital stay, time until normal oral food intake, need for revision, and long-term subjective symptom relief between the two groups. Overall complication (12 %) and recurrence rate (11 %) for the endoscopic techniques were low. Endoscopic surgery had also a high success rate in recurrence cases (87.5 %). According to our study, the most important factor for the success rate of endoscopic treatment was the intraoperative exposure of the ZD. The endoscopic minimally invasive approach is a safe and effective treatment modality and can be considered as the treatment of choice for primary and recurrent ZD. The intraoperative exposure is decisive for the technique applied and the long-term success.

Endoscopic Staple Diverticulostomy for Zenker’s Diverticulum

“…11,29,30 However, literature comparing ESD to the external transcervical (ET) approaches has raised several concerns for endoscopic approaches including difficulty accessing the diverticulum, ability to resolve symptoms completely, and the long-term durability of the results. 18,31,32 In addition, there is controversy in the literature regarding the optimal management of recurrent ZD following endoscopic diverticulostomy and whether revision endoscopic versus external diverticulectomy is the preferred approach. 33…”

“…[9][10][11] Review of the literature demonstrates a rate of procedure abandonment ranging from 3.1% to 26%. 18,19,32,34 Common reasons for difficult endoscopy and inadequate diverticular exposure include a small oral inlet, limited neck extension, presence of cervical osteophytes, and a deep or anteriorly located larynx. In the current series, the diverticular wall was not able to be visualized in 13 (3.9%) of the primary ESD patients and 1 (4.5%) revision ESD patient.…”

“…In review of the literature on ESD, recurrence of dysphagia symptoms has been shown to range from approximately 7% to 18%. 31,32 Murer et al 32 recently published a series of 45 patients who underwent ESD and found an average recurrence rate of 7% with a mean follow-up time of 4.5 years, and they cited endoscopic exposure as the most important factor in determining the long-term outcome. Bonavina and colleagues 31 found in their review of 79 cases in 2012 that 14 patients (17.7%) had recurrent symptoms with an average 12-month follow-up period.…”

Endoscopic management of Zenker’s diverticulum: stapling vs. Z-POEM

“…Two studies out of 20 were prospective (6,7), 11 were retrospective (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18), 6 case reports (19)(20)(21)(22)(23)(24) and 1 clinical review (25).…”

Management of Zenker’s diverticulum using flexible endoscopy

“…Flexible endoscopy has been increasingly popular because of its suitability for patients who are otherwise unsuitable for rigid endoscopy, such as those with limited neck mobility or medical comorbidities 8 . Flexible endoscopy can be performed with the patient under sedation or general anesthesia and has been shown to be comparable to rigid endoscopy and open techniques in terms of safety and effectiveness 9, 10, 11, 12…”