Zenker's Diverticulum Research Articles

Novel technique of flexible endoscopic therapy of Zenker’s diverticulum using a pulsed Holmium laser—a retrospective single-center analysis

BackgroundIn recent years, flexible endoscopic therapy of Zenker’s diverticulum seems to become the standard approach. The aim of this study was to assess the safety, efficacy and short-term outcome of flexible endoscopic diverticulotomy of Zenker’s diverticulum with a pulsed Holmium laser (PHL).Patients and methodsAll patients treated with endoscopic laser-diverticulotomy using a PHL between February 2013 and November 2021 at the University Hospital Salzburg were extracted from our prospectively maintained endoscopic database. Demographic data, size of Zenker’s diverticulum, procedure duration, complications, short-term outcome and rate of recurrence were evaluated.ResultsIn the study period, 45 procedures in 36 patients were performed. Mean depth of the Zenker diverticulum was 21 mm (10–60 mm), mean procedure time was 31 min (15–60 min), intraprocedural adverse events occurred in 2 out of 45 patients (5%) which were both managed endoscopically, post-procedural stenosis occurred in 1 patient (2%). In the follow-up examinations (mean follow-up after 6.4 months), 27 out of 36 patients (75%) were symptom-free, 6 patients (17%) reported an improvement of dysphagia. 3 patients (9%) suffered from persistent dysphagia. After initial symptom relief, a recurrent diverticulum occurred in 5 patients. Endoscopic re-intervention with PHL was done in these cases.ConclusionsFlexible endoscopic treatment of primary and recurrent Zenker’s diverticulum using a PHL is a promising, safe and effective treatment with, in our opinion, technical advantages in comparison to the CO2 laser. Further controlled prospective trials are needed.

Endoscopic stapler versus laser diverticulotomy for Zenker's diverticulum: a systematic review and meta-analysis.

A literature review and meta-analysis was performed to assess for difference in rate of complications and need for revision surgery between endoscopic stapler-assisted diverticulotomy and endoscopic carbon dioxide laser diverticulotomy. The hypothesis was that endoscopic stapler-assisted diverticulotomy has a lower complication rate but endoscopic carbon dioxide laser diverticulotomy has a lower need for revision surgery. This was a systematic review of English-language studies comparing endoscopic stapler-assisted diverticulotomy and endoscopic carbon dioxide laser diverticulotomy for the treatment of Zenker's diverticulum. Meta-analysis of results with regard to rate of pharyngeal perforation, major post-operative complication and need for re-operation was performed. Nine retrospective studies were included with pooled analysis of 417 endoscopic stapler-assisted diverticulotomy and 413 endoscopic carbon dioxide laser diverticulotomy cases. Meta-analysis found no significant difference in rate of pharyngeal perforation, major complication or need for re-operation between the two groups. This study demonstrated both endoscopic stapler-assisted diverticulotomy and endoscopic carbon dioxide laser diverticulotomy to be a safe alternative to open surgery for Zenker's diverticulum. Both appear to be similar in terms of adverse events and efficacy. The authors recommend either approach, guided by surgeon's preference and experience, where patients are unsuitable for an open surgery approach.

Endoscopic stapler-assisted Zenker's diverticulotomy: The surgical technique with video

ObjectiveThe aim of the present article is to describe step by step the endoscopic stapler-assisted Zenker's diverticulotomy (ESD) and to show in details pre- and post-operative management. Study designCase study with instructional video. SettingDepartment Of Otolaryngology, San Bortolo Hospital of Vicenza. BackgroundSeveral comparable surgical approaches have been proposed for the treatment of hypopharyngeal Zenker's diverticulum, however determining the best operative facility in terms of safety, outcomes and hospital stay is still a matter of debate. In this scenario the endoscopic treatment of Zenker's diverticulum using the stapler device permits simultaneous sectioning and suturing of the septum between the pouch and esophagus, creating a more functional common cavity. MethodsWe here present a step by step description of an endoscopic treatment of Zenker's diverticulum using the stapler device. Common referral symptoms are persistent hoarseness and globus sensation associated with transient dysphagia. An endoscopic dynamic examination of upper airway may reveal the presence of a hypopharyngeal pouch, which should be confirmed by a fluoroscopic barium esophageal radiography. If a Zenker's diverticulum is diagnosed, an endoscopic single or multiple diverticulotomy with a stapler device is indicated. The patient may be discharged after 24–48 h without any dietary restrictions, once a post-operative esophageal radiography rules out any sort of perforation. ConclusionIt is of relevance to precisely know the Endoscopic Stapler-assisted Zenker's Diverticulotomy as it represents a safe and efficient procedure and ensures good outcomes with the benefit of being performed even on a planned 24-hour-stay basis.

Characterizing a CT esophagram protocol after flexible endoscopic diverticulotomy for Zenker's diverticulum: a retrospective series.

BackgroundFlexible endoscopic cricopharyngeal myotomy and septotomy offer a minimally invasive transluminal option for the treatment of symptomatic Zenker’s diverticulum (ZD). There is currently no consensus regarding postoperative follow-up imaging. We suggest a standardized computed tomography (CT) esophagram protocol for radiographic evaluation of postoperative findings.MethodsSingle center retrospective analysis of patients with symptomatic ZD who underwent flexible endoscopic diverticulotomy and postoperative imaging with CT esophagram from January 2015 to March 2020. An experienced radiologist blinded to the initial imaging reports prospectively interpreted all CT esophagram findings, in order to minimize bias.ResultsTwenty-one patients underwent CT esophagram following flexible endoscopic diverticulotomy for ZD. Diverticulotomy was technically successful in all patients. Most common findings on imaging included: atelectasis (13/21; 62%), persistent esophageal diverticulum (7/21; 33%), pneumomediastinum (3/21; 14%), aspiration (2/21; 10%), and extraluminal air and contrast extravasation consistent with focal esophageal perforation (1/21; 5%).ConclusionsWe describe a standardized, simple, and accessible CT esophagram protocol for postoperative imaging of patients with post-flexible endoscopic cricopharyngeal myotomy and septotomy for ZD. CT esophagram facilitates a definitive exclusion of focal esophageal perforation as a postoperative complication of flexible endoscopic diverticulotomy by ruling out extraluminal air and contrast extravasation.

S2348 Novel Approach to Proximal Esophageal Stricture

Introduction: We present you a case of Stricture-induced severe dysphagia that was discovered to be caused by ulceration secondary to very proximal Zenker’s diverticulum (ZD). This case report also describes a novel approach to esophageal endoscopy through a retrograde approach. Case Description/Methods: Patient is an 80 y/o African American female with a past medical history of Gastroesophageal Reflux disease, Congestive Heart Failure, Chronic Kidney disease and Dementia who presented with Heart failure exacerbation. Patient reported weight loss and dysphagia to solid food and liquids for about 2 months. Patient then underwent a modified barium swallow study (MBSS), which showed concerns for esophageal stricture and evidence that the contrast material was not passing through the esophagus. Patient then underwent Esophagogastroduodenoscopy (EGD), which showed complete esophageal obstruction approximately 25 cm from the incisors and impacted food. The food was removed and a repeat EGD was done the next day showing a circumferential ulcer and no lumen could be identified. Biopsies were taken, which was negative for dysplasia or malignancy. After discussion with General Surgery, it was decided to proceed with Open Gastrostomy tube to allow enteral nutrition as well as access to dilate the esophagus in the retrograde fashion in the future. A repeat EGD after 4 weeks showed a healing ulcer and a blind pouch without an identifiable lumen. The ultrathin scope was advanced through the gastrostomy tract into the stomach and carefully advanced in a retrograde fashion through the lower esophageal sphincter throughout the esophagus. Narrowing was seen at the proximal end of the esophagus. The scope was advanced through this and with minimal resistance able to be advanced past the level of the stricture about 15 cm from the Incisors. Esophageal stent was deployed over the wire in an antegrade fashion with fluoroscopic guidance. This time, an area of concern was identified as a possible ZD proximal to the prior ulceration site which was later confirmed on an esophagram at the level of thoracic esophagus on the right side. Discussion: This case was challenging as the diagnosis of ZD was missed despite various testing. Patient had a long history of dysphagia and the impacted food led to ulceration and esophageal strictures. The diagnosis was established after a unique approach to the stricture. This case highlights that sometimes a careful examination is required as an approach to diagnosis of dysphagia in elderly.

S2376 Squamous Cell Carcinoma Arising From Zenker's Diverticulum

S2376 Squamous Cell Carcinoma Arising From Zenker's Diverticulum

Endoscopic Treatment of Zenker's Diverticulum. A Review of The Literature

Zenker's diverticulum (ZD) is a sac-like evagination of the mucosa and submucosa through the Killian triangle, an area of muscle weakness between the transverse fibers of the cricopharyngeal muscle and the oblique fibers of the inferior inferior constrictor muscle. The reported prevalence of ZD is between 0.01 and 0.11 percent. The Killian triangle is more frequent in men than in women (60 versus 34 percent). The definitive treatment of symptomatic ZD is surgical. The treatment must be individualized for each case, likewise, the doctor must adopt the one in which he feels most comfortable and as there is more experience in the center in which it is performed, taking into account the technique and the adequate management of complications.

Endoscopic Treatment of Zenker's Diverticulum. A Review of The Literature

Endoscopic Treatment of Zenker's Diverticulum. A Review of The Literature

672 Endoscopic Laser Pharyngeal Pouch Surgery: Is It Safe?

Abstract Aim Zenker diverticulum can cause significant dysphagia and surgery is the definitive management. NICE guidelines describe inadequate evidence on laser cricopharyngeal myotomy (CPM). This study aimed to assess the safety and efficacy of carbon dioxide laser and stapling CPM to treat Zenker diverticulum. Method Retrospective data was collected from patients who underwent endoscopic CPM at the Royal Berkshire Hospital between 2011 and 2021. Two cohorts were assigned: endoscopic laser (EL) or endoscopic stapling (ES). Primary outcomes evaluated safety. These were surgical complication rates, duration of inpatient stay, readmissions, barium swallow leak and considered case complexity (revision cases). The secondary outcomes, persistence or recurrence of symptoms evaluated efficacy. Results One-hundred and eight patients (mean [range] age 75 [38 – 95] yr, 71 (66%) men, 23 (21%) revision surgeries) underwent CPM. The EL (n = 76) cohort had two (2.63%) surgical complications (mucosal tear requiring no repair, mediastinitis from an oesophageal leak). The ES (n = 32) cohort had one (3.13%) surgical complication (mucosal tear requiring suture repair). The average duration of inpatient stay was 3.61 and 1.53 days for the EL and ES cohorts respectively. 65 patients (60%) underwent a post-operative barium swallow of which 2 (0.03%) patients, both from the EL cohort, had a leak. There were no readmissions. A chi-square test of independence showed no significant association between type of surgery and persistence [X2 (1) = 0.169, p = .681] or recurrence of symptoms [X2 (1) = 0.443, p = .506] Conclusions Treatment of pharyngeal pouches with endoscopic laser CPM is safe and efficacious.

Anthropometric Variables Predict Feasibility and Long-term Outcomes of Trans-oral Septum Stapling for Zenker Diverticulum

Anthropometric Variables Predict Feasibility and Long-term Outcomes of Trans-oral Septum Stapling for Zenker Diverticulum

Postoperative management of Zenker's diverticulum: Results of the American Bronchoesophagological Association survey

IntroductionAlthough treatment of Zenker's diverticulum (ZD) is commonly performed by otolaryngologists using a variety of surgical techniques, there is little published data on the postoperative management of patients. We sought to determine practice patterns among members of the American Bronchoesophagological Association (ABEA) after surgery for ZD. MethodsAn online questionnaire was designed via JotForm™ and subsequently sent to active members of the ABEA. Responses were analyzed using descriptive statistics. ResultsTwenty-three members (6.6 %) completed the survey. Most (73.9 %) were fellowship trained in laryngology and reported performing >5 procedures per year. Most laryngologists reported employing multiple techniques including transcervical (TC) (73.9 %), endoscopic stapling (ES) (65.2 %), endoscopic CO2 laser (EL) (56.5 %), and endoscopic harmonic scalpel (EH) (4.3 %). Postoperatively, 52.3 % of respondents placed patients in 23-hour observation after TC, 66.7 % after ES, 69.2 % after EL, and 100 % after EH. 47.1 % of respondents used standard overnight admission after TC, as compared to 13.3 % after ES, 23.1 % after EL and 0 % after EH. Postoperative esophagography was utilized by 70.6 % of respondents after TC, 20 % after ES, 38.5 % after EL, and 100 % after EH. A peroral diet was started postoperatively on the day of surgery by 26.7 % respondents after ES but not after any of the other techniques. ConclusionMost laryngology trained respondents employ multiple techniques for the treatment of ZD including at least 1 endoscopic technique. Respondents were more likely to hospitalize patients after a transcervical than endoscopic approach. Postoperative esophagography was utilized in most patients after TC, but not after ES or EL. Most respondents admit patients for 23-hour observation and start a peroral diet on postoperative day 1 regardless of technique.

Peroral Endoscopy Myotomy (POEM) for Esophageal Motility Disorders.

This review aims to provide an overview of the current role of per oral endoscopic myotomy (POEM) in the management of primary esophageal motility disorders and treatment of Zenker's diverticulum. POEM has been shown to be an effective treatment for achalasia. Recent research has suggested that the length of myotomy may be tailored to the disease phenotype and that short myotomy may be equally effective compared to long myotomy. The role of intra-operative EndoFLIP has shown promise as a tool to assess of the adequacy of myotomy. Further research is needed to determine the role of POEM in other esophageal motility disorders and for treatment of Zenker's diverticulum. Per oral endoscopic myotomy has been shown to be an effective and durable treatment option for achalasia with additional potential roles for the treatment of other esophageal motility disorders and Zenker's diverticulum.

Diverticulopexy using left cervical incision for Zenker diverticulum (with video).

Diverticulopexy using left cervical incision for Zenker diverticulum (with video).

Peroral cricopharyngeal myotomy for the management of Zenker's diverticulum in the hands of a general surgeon.

The treatment of Zenker's diverticulum has been shifted from open cricopharyngeal myotomy and rigid endoscopy to the use of flexible endoscopy. Few studies evaluate general surgeon's performance of flexible endoscopic management of Zenker's diverticulum as the majority are performed by gastroenterologists. The objective of our case series is to show that general surgeons trained in surgical endoscopy can perform this procedure with favorable outcomes. A retrospective review of peroral cricopharyngeal myotomies performed at Spectrum Health hospital in Grand Rapids, Michigan by a single surgical endoscopist between the 2018 and 2021 was conducted. The primary outcome was the improvement of dysphagia. Intra-procedural complications, post-procedural complications, hospital length of stay, time to oral intake, and recurrence were also evaluated. Age, sex, body mass index, diverticulum size, and procedure time were abstracted. Median (ranges) and frequencies (percentages) are used to describe the patient population and outcomes. Forty patients were included in the study. Median age was 74years old (60-95) with a male predominance (n = 27, 67.5%). Median BMI was 28kg/m2 (18-43), average procedure length of 64min (41-119), diverticulum size of 28mm (19-90), and average length of stay of 0.9days (0-8). There were no intra-procedural complications. All patients had a post-procedural esophagram prior to initiation of diet. Esophageal leak was the only complication that occurred, which was found on post-procedural esophagram (n = 5). Only two patients had clinical sequelae. All leaks closed without additional surgical intervention. The majority of patients had their diet resumed and discharged the same day of the procedure. Frequency of recurrence was 17.5% (n = 7). Our study demonstrates that general surgeons trained in endoscopy can perform endoscopic myotomies for Zenker's diverticula on a wide range of sizes, with favorable patient outcomes, and few complications.

Minimally invasive surgery for motility disorders of the oesophagus

Introduction and aims. We present our experience with minimally invasive surgery for pharyngoesophageal (Zenker) diverticulums, epiphrenic diverticulums and achalasia cardiae focusing on the perioperative features and patients’ quality of life. Patients and methods. Between 1 January 2003 and 31 December 2020, patients were selected with a symptom-causing Zenker diverticulum, epiphrenic diverticulum and achalasia cardiae. In 17 cases, transoral stapler diverticulostomy, in 23 cases transcervical diverticulectomy and cricomyotomy were done because of Zenker diverticulum, in 14 cases, laparoscopic transhiatal surgery was performed because of epiphrenic diverticula, while in 63 cases, laparoscopic Heller–Dor operation were carried out because of achalasia cardiae. Perioperative results, the quality of life outcomes of various surgeries were evaluated in mid- and long-term. Results/conclusions. The surgeries were performed with minimal blood loss, zero mortality and low morbidity. According to our result, the two different surgical approaches in the therapy of Zenker’s diverticulum, the laparoscopic Heller–Dor procedure applied in the management of epiphrenic diverticulas and achalasia cardiae are safe and effective operations. In the long term, the symptom control in patients after minimally invasive surgeries is sufficient and only a small percentage of the patients may require additional medication therapy and/or reintervention due to persistent complaints.

Transoral endoscopic repair of Zenker diverticulum by a thoracic surgical service.

Zenker diverticulum (ZD), a pulsion diverticulum of the esophagus, has been traditionally managed with an open surgical approach, but endoscopic transoral stapling has been reported with increasing frequency. The objective of this study was to evaluate the results of endoscopic repair of ZD by a thoracic surgery service. We conducted a retrospective review of patients who underwent transoral stapling repair of ZD at our institution by the thoracic surgery service. We evaluated perioperative outcomes including dysphagia (1, no dysphagia to 5, unable to swallow saliva) and failure of repair requiring surgical intervention. A total of 151 patients (median age, 78years; 75 men, 76 women) underwent evaluation for endoscopic repair of ZD. Endoscopic stapled repair of the ZD was completed in 135. Sixteen patients underwent conversion to open repair. The perioperative mortality was 0.6% (1 patient). The median hospital stay was 2days (range, 0-18days). Complications occurred in 5 patients who underwent endoscopic repair. The mean preoperative dysphagia score was 2.8 and improved to 1.2 during follow-up (median, 16months; P<.001). During further follow-up (median, 52months), 8 patients (5.3%) had failure of the endoscopic repair requiring open surgery (n=5) or redo transoral stapling (n=3). Endoscopic stapling repair of ZD can be performed safely with good results in experienced centers by thoracic surgeons with significant esophageal experience. Long-term follow-up is required to evaluate the durability of endoscopic repair of ZD.

Flexible endoscopic incisional therapy for Zenker's diverticulum (FEIT-Z) is an effective treatment for surgical failures or non-operative patients.

Symptomatic Zenker's diverticulum (ZD) occurs mostly in the elderly, who often have significant comorbidities, and poor neck hyperextension, putting them at high risk for surgical management while also increasing the potential of technical failure. Flexible endoscopic incisional therapy for Zenker's diverticulum (FEIT-Z) offers a safe approach to this problem with high technical and clinical success rates. There are limited data on its use following a failed surgical approach or in patients unfit for a surgical approach. The aim of this study was to assess clinical and technical outcomes of FEIT-Z in patients who were non-operative candidates or refused or failed surgical management. Patients who underwent FEIT-Z from January 2015 to February 2019 at a tertiary referral center were included. Patient demographics, prior ZD surgical history, procedural data, dysphagia scores, clinical success, and adverse events (AE) were collected. Univariable analysis was performed to assess differences between pre- and post-FEIT-Z dysphagia scores. 30 patients undergoing FEIT-Z were included. Seven had a prior failed ZD surgical approach, 6 refused surgical management, and 17 were deemed to be non-operative candidates based on medical comorbidities. Mean age was 78.4 (± 12.1) and 36.7% were male. Technical success of FEIT-Z was 96.7%. There was a significant improvement in dysphagia scores after FEIT-Z: 2.3 (± 0.64) vs. before, 0.4 (± 0.76) (p < 0.001). Long-term clinical success was achieved in 73.3% of patients. Adverse events were seen in 23.3% of patients; however, these were graded as mild in 85.7% of patients. One microperforation was managed with antibiotics. FEIT-Z is a safe procedure with low adverse events and a high rate of technical and clinical success. FEIT-Z can be done in patients who fail previous surgical treatment, refuse a surgical approach, or are not surgical candidates due to medical comorbidity or other factors.

Endoscopic suturing for repair of an obstructing Zenker's diverticulum using a bidirectional endoscopic approach for lumen delineation.

Video 1Endoscopic suturing of an obstructing Zenker's diverticulum.

Zenker's Diverticle endoscopic treatment or open technique?

Introduction: Zenker's diverticulum is a protrusion of the pharyngeal mucosa through Killian's triangle. It is a rare pathology, but of great importance since it compromises the quality of life of patients who suffer from it. In addition, it can be treated by different methods which have been evolving over the years, but at the moment applying them to each patient, each one has its own advantages and disadvantages, so these should be evaluated with caution, individually according to each case requires it. Materials and Methods: A narrative review was carried out, using databases such as Scielo, PubMed, Science direct, academic google. A search for articles in indexed journals in English and Spanish was carried out from 2010 to 2021. Results: In the management of Zenker's diverticulum there are several methods, endoscopic approach and open technique, currently the endoscopic approach is preferred over the external one. Although the open technique has been more studied and the endoscopic one represents a challenge that requires the expertise of the professional who performs it, surgeons prefer endoscopic techniques since they are minimally invasive and are believed to cause fewer complications. Also, they produce results similar to classic Tran’s cervical repair. Conclusion: The open technique is a more definitive and immediate method that relieves symptoms and prevents recurrence. The endoscopy technique is shorter, it avoids recurrence, but the results are highly variable in each patient.

Characteristics and outcomes of 47, conventional flexible endoscopic interventions for Zenker's diverticulum Review of therapeutic options

Introduction: In the treatment of symptomatic Zenker's diverticulum, the flexible endoscopic myotomy of the cricopharyngeal muscle is considered to be a safe and effective technique. Objective and method: We retrospectively analyzed our experiences with conventional flexible endoscopic myotomy. Results and discussion: 38 patients with symptomatic Zenker's diverticulum were treated with flexible endoscopic myotomy and 47 myotomies were performed from September 2012 until February 2020. Most of our patients were male (23/38), with an average age of 71.5 (40-88) years. The mean size of diverticula was 3.94 (2-10) cm. In most cases, we used diverticuloscope, while free-hand technique was needed in 8 cases. We assessed our patients' symptoms by applying DRC (dysphagia, regurgitation, complication) score before the treatment and during follow-up. The overall rate of significant complications was 4.2% (2/47), and there was no procedure-related mortality. We observed pneumomediastinum in one patient that was treated conservatively. Intraprocedural bleeding occurred in several (8/47) cases, in all of them the bleeding was successfully stopped during intervention. In one of them, early recurrent massive bleeding required urgent surgery. All 38 patients were followed (mean 34.7 months). Clinical success at 1.5 months was 91.9% among endoscopically treated patients (34/37). 3 patients remained symptomatic, 2 of them were treated with re-myotomy, 1 of them needed surgery later on, another patient underwent percutan endo-scopic gastrostomy at 18 months. Over long-term period, complete success (DRC<2) was 78.4% (29/37), while clinical success (DRC: 0/1/2) reached in 89.2% (33/37). Conclusion: Our experiences confirmed that conventional method of flexible endoscopic myotomy is safe and effec-tive for the treatment of Zenker's diverticulum symptoms.