Manometric Characteristics of Opioid Esophageal Dysmotility Disorder by High-Resolution Manometry

Abstract

Background: Zenker diverticulum (ZD) is a lesion most often seen in elderly patients. The traditional treatment is surgical but recently endoscopic septoplasty has been described as an alternative approach, especially in high surgical risk patients. We aimed to determine the efficacy and safety of flexible endoscopic septoplasty (FES) for symptomatic ZD. Methods: Retrospective review of all patients who underwent FES for ZD over the previous 5 years at St Michael's Hospital, Toronto were identified. Patient charts were reviewed to record patient demographics, procedure technique, operative times, sedation requirements, and complications. Patients were contacted via telephone to establish postoperative symptoms within 12 months of treatment and to evaluate current symptoms using a validated dysphagia score from 0 (no dysphagia) to 4 (complete dysphagia) and overall symptoms in terms of complete/near complete response, moderate response and complete recurrence. Results: Forty-three patients underwent FES between 2005 and 2010. The median age was 75 years (IQR 68-83). Twenty-nine (67.4%) were male. The mean (range) ZD size was 3.0cm (1 5cm). All patients were treated on an outpatient basis. A total of 90 procedures were performed, with a median of 2 procedures (IQR 1-3) per patient. Procedures were performed with conscious sedation in 88 (97.8%) cases, with median sedation requirements of 3mg (IQR 3-6) of midazolam and 100mcg (IQR 87.5-100) of fentanyl. The mean procedure time was 34 minutes (range 10 65). Thirty patients were contactable to assess response to therapy. Within 12 months of the initial therapy, 15 (50%) had complete/near complete symptom resolution, 10 (33.3%) moderate symptom improvement and 5 (16.7%) complete symptom recurrence. Following retreatment in the latter two groups, at a mean follow-up of 13.5 months, 2 (13.3%) had complete/near complete symptom resolution, 9 (60%) moderate symptom improvement and 3 (20%) complete symptom recurrence. Complications included 2 perforations (one requiring surgical drainage of a neck abscess); 2 cases of minor bleeding and 1 patient admitted with fever post procedure (perforation excluded on imaging). Mean admission duration was 7.8 days (range 1-13). Conclusion: (i) FES using needle-knife papillotome is a safe and effective therapy for ZD. (ii) FES should be considered in patients in whom surgery is considered high-risk or technically difficult. (iii) Repeat FES in poor responders is effective and safe (iv) Further studies to refine this technique are required to improve symptoms. Acknowledgment S.R. has been supported by a UWA Medical Research fellowship and the Faculty of Medicine, Dentistry and Health Sciences in Perth, Western Australia.