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Ponsky J, Kroh M, Strong AT. Hypopharyngeal diverticula. Dysphagia 2024:41-74. [DOI: 10.1016/b978-0-443-19063-6.00011-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Brimioulle M, Corbridge R, Elsayed M. Transcervical pharyngeal pouch stapling. Eur Arch Otorhinolaryngol 2023; 280:487-490. [PMID: 36040518 DOI: 10.1007/s00405-022-07603-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/06/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Pharyngeal pouches are generally treated with surgery, via either an endoscopic or an external approach. Large pouches extending to the mediastinum carry an increased risk of post-operative mediastinitis in the event of a leak following external approach surgery, and may not always be amenable to endoscopic stapling. METHODS Transcervical stapling is a newly described technique that uses the endoluminal stapling approach but in which the diverticuloscope is inserted into the pharynx via a neck incision. CONCLUSIONS This technique has been used successfully on three patients with large pharyngeal pouches, where endoscopic stapling was not possible due to access limitations.
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Affiliation(s)
- Marina Brimioulle
- Ears, Nose and Throat Department, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, UK.
| | - Rogan Corbridge
- Ears, Nose and Throat Department, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, UK
| | - Mahmoud Elsayed
- Ears, Nose and Throat Department, Royal Berkshire Hospital, London Road, Reading, RG1 5AN, UK
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Fugazza A, Cappello A, Capogreco A, Repici A. Endoscopic Myotomy and Septotomy for Zenker’s Diverticulum (Z-POEM). GASTROINTESTINAL AND PANCREATICO-BILIARY DISEASES: ADVANCED DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2022:543-557. [DOI: 10.1007/978-3-030-56993-8_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Uoti S, Andersson SEM, Robinson E, Räsänen J, Kytö V, Ilonen I. Epidemiology and Management of Zenker Diverticulum in a Low-Threshold Single-payer Health Care System. JAMA Otolaryngol Head Neck Surg 2021; 148:235-242. [PMID: 34913965 DOI: 10.1001/jamaoto.2021.3671] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The incidence of Zenker diverticulum has been established; previous estimates have been extrapolated from small institutional cohorts. Objective To describe the population-wide incidence of Zenker diverticulum over a 20-year period and characterize management strategies across specialties and treatment settings. Design, Setting, and Participants This retrospective national cohort study was conducted from January 1, 1996, through December 31, 2015, and reviewed patient records from the Care Register for Healthcare in Finland, from which patients with Zenker diverticulum were identified. The data were analyzed in October 2021. Exposures Zenker diverticulum. Main Outcome and Measure The incidence of Zenker diverticulum per 100 000 person-years. Results A total of 2736 patients (median [IQR] age at diagnosis 72.0 [19-106] years; 1278 women [46.7%]) were identified, making the annual incidence of Zenker diverticulum in Finland 2.9/100 000 person-years. Men had higher incidence (3.7/100 000 person-years) compared with women (2.3/100 000 person-years), with an incidence rate ratio of 1.61 (95% CI, 1.48-1.76; P < .001). Within the study population, 1044 patients (38.2%) underwent surgical treatment and 227 (8.3%) underwent 2 or more surgeries. The choice of initial operative approach depended on the medical specialty (Cramer V = 0.41) and on specific catchment area (Cramer V = 0.41). Overall, endoscopic approaches for initial operations were most popular. Conclusions and Relevance The cohort study results found that the incidence of Zenker diverticulum was 2.9/100 000 person-years. Most patients with Zenker diverticulum did not undergo definitive therapy. Some hospital districts and some medical specialties were more likely to opt for conservative treatment than others. The choice of operative approach depended more on physician-level factors rather than patient profiles.
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Affiliation(s)
- Sandra Uoti
- Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Saana E-M Andersson
- Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Eric Robinson
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jari Räsänen
- Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Ville Kytö
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland.,Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland.,Administrative Center, Hospital District of Southwest Finland, Turku, Finland
| | - Ilkka Ilonen
- Clinicum, Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Department of General Thoracic and Esophageal Surgery, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
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Zhang LY, Wu PIC, Szczesniak M, Cook IJ, Craig PI. Clinical utility of cricopharyngeal distensibility measurements during endoscopic myotomy for Zenker's diverticulum. Gastrointest Endosc 2021; 93:390-397. [PMID: 32535194 DOI: 10.1016/j.gie.2020.05.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/26/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Flexible endoscopic cricopharyngeal myotomy (FECM) allows minimally invasive treatment of patients with Zenker's diverticulum (ZD); however, retreatment rates are substantial. We hypothesized that the functional lumen imaging probe (FLIP) may provide insight into ZD pathophysiology and serve as an intraprocedural guide to adequacy of myotomy. METHODS We prospectively evaluated 11 ZD patients undergoing FECM and compared the baseline cricopharyngeal (CP) distensibility with 16 control subjects. Intraprocedural CP distensibility was measured immediately pre- and postmyotomy. The CP distensibility index (CP-DI) was defined as a ratio of the narrowest cross-sectional area (nCSA) and the corresponding intrabag pressure at 40 mL distension. Same-procedure myotomy extension was undertaken in a subgroup if threshold distensibility changes were not met. RESULTS ZD patients had reduced baseline nCSA and CP-DI compared with control subjects, (169.6 vs 227.5 mm2 [P < .001] and 3.8 vs 7.6 mm2/mm Hg [P < .001], respectively). After CP myotomy, both nCSA and CP-DI increased significantly by an average of 74.2 mm2 (95% confidence interval [CI], 35.1-113.3; P = .002) and 2.2 mm2/mm Hg (95% CI, .6-3.8; P = .01), respectively. In the subgroup with no significant change in CP distensibility after initial myotomy (n = 6), myotomy extension resulted in significant increases in both mean nCSA and CP-DI of 66.6 mm2 (95% CI, 16.4-116.8; P = .03) and 1.9 mm2/mm Hg (95% CI, .4-3.3; P = .015), respectively. There were no adverse events. CONCLUSIONS CP distensibility is reduced in ZD patients and is partially reversible by FECM. An intraprocedural FLIP CP distensibility measurement is safe and sensitive in detecting myotomy-induced changes. These findings support using FLIP to optimize FECM outcome. Further studies are required to derive precise metrics predictive of clinical response.
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Affiliation(s)
- Linda Yun Zhang
- Department of Gastroenterology & Hepatology, St George Hospital, Sydney, New South Wales, Australia
| | - Peter Iung-Chiang Wu
- Department of Gastroenterology & Hepatology, St George Hospital, Sydney, New South Wales, Australia; St George Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Michal Szczesniak
- Department of Gastroenterology & Hepatology, St George Hospital, Sydney, New South Wales, Australia; St George Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Ian James Cook
- Department of Gastroenterology & Hepatology, St George Hospital, Sydney, New South Wales, Australia; St George Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Philip Ian Craig
- Department of Gastroenterology & Hepatology, St George Hospital, Sydney, New South Wales, Australia; St George Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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Pharyngoesophageal diverticuli: diagnosis, incidence and management. Curr Opin Otolaryngol Head Neck Surg 2018; 24:500-504. [PMID: 27636983 DOI: 10.1097/moo.0000000000000309] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Pharyngoesophageal diverticuli such as Zenker's diverticulum are relatively rare diseases that may have a significant impact on a patient's quality of life. Open surgical techniques have historically been the mainstay of treatment for Zenker's diverticuli and remain the preferred approach for many surgeons operating on Killian-Jamieson diverticuli (KJD) and pharyngoceles. However, advances in technology in recent decades have allowed for the development of successful endoscopic surgical techniques for the management of these conditions. RECENT FINDINGS Endoscopic management of Zenker's diverticulum with carbon dioxide laser-assisted diverticulotomy or endoscopic stapler-assisted diverticulostomy has gained wide acceptance in recent years. This is based on studies showing high rates of successful outcomes, low rates of complications and shorter operative time with an associated impact on overall cost and patient recovery. Endoscopic management of KJD and pharyngoceles has recently been described, but remains controversial with many surgeons preferring open surgical approaches for the ability to identify and protect the recurrent laryngeal nerve. SUMMARY Open and endoscopic techniques are accepted for the treatment of Zenker's diverticulum with open approaches remaining the traditional technique for management of non-Zenker's diverticulum. Further investigation of endoscopic approaches for management of KJD is necessary to assess safety and efficacy.
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Treatment of Zenker’s Diverticulum With Endoscopic Stapled Esophago-divertisculostomy (ESD): Analysis of Long-term Outcome. Surg Laparosc Endosc Percutan Tech 2017; 27:445-448. [DOI: 10.1097/sle.0000000000000473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Siboni S, Asti E, Sozzi M, Bonitta G, Melloni M, Bonavina L. Respiratory Symptoms and Complications of Zenker Diverticulum: Effect of Trans-Oral Septum Stapling. J Gastrointest Surg 2017; 21:1391-1395. [PMID: 28470561 DOI: 10.1007/s11605-017-3435-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 04/24/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Zenker diverticulum is a rare condition commonly associated with dysphagia and respiratory symptoms/complications, which are alarming especially in the elderly population. Aim of this study was to investigate the prevalence of respiratory symptoms/complications and the effects of minimally invasive trans-oral surgery in these patients. METHODS Consecutive adult patients who underwent trans-oral septum stapling for Zenker diverticulum were included in a retrospective, observational cohort study. Pre- and postoperative symptoms, including chronic cough and aspiration pneumonia, were evaluated using a dedicated foregut questionnaire and were recorded on a prospectively maintained database. The operation was performed under general anesthesia. A barium swallow study and an upper gastrointestinal endoscopy were performed 6 months after the operation, and the foregut questionnaire was administered yearly. RESULTS A total of 139 patients were finally included in the study. The median age was 72 years. In 62 (44.6%, CI 36.2-53.3) patients, there was a history of chronic cough and/or aspiration pneumonia. Chronic cough was associated with pneumonia (p < 0.001), while pneumonia was associated with severe regurgitation (p < 0.042) and weight loss (p = 0.001). The overall postoperative morbidity rate was 2.2% and there was no mortality. The median postoperative hospital stay was 2 days (range 0-22). The median follow-up was 38 months (range 2-105). At 3 years, a statistically significant reduction in the rate of chronic cough (36.8 vs. 7.9%, p < 0.001), recurrent episodes of pneumonia (6.6 vs. 0.0%, p = 0.031), dysphagia (78.9 vs. 6.6%, p < 0.001), and regurgitation (67.1 vs. 6.6%, p < 0.001) was recorded. The probability of remaining symptom-free at 90 months of follow-up was 0.818 (CI: 0.745-0.899). CONCLUSIONS Trans-oral septum stapling is safe and can effectively reduce the burden of respiratory symptoms and complications associated with Zenker diverticulum.
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Affiliation(s)
- Stefano Siboni
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Emanuele Asti
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Marco Sozzi
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Matteo Melloni
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy.
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Atypical Pharyngeal Pouch Arising Bilaterally between the Hyoid Bone and Thyroid Cartilage. Case Rep Otolaryngol 2017; 2017:3515438. [PMID: 28480090 PMCID: PMC5396435 DOI: 10.1155/2017/3515438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/30/2017] [Indexed: 11/17/2022] Open
Abstract
Introduction. Pharyngoesophageal diverticuli are a common cause of dysphagia; they are associated with various morbidities and a decreased quality of life. There are several different types of the diverticuli, and they are divided based on the anatomical location of origin relative to the cricopharyngeal muscle; these include Zenker's, Killian-Jamieson's, and Laimer's diverticula. The authors present a unique case of pharyngoesophageal diverticulum that has not been previously described. Case Presentation. A 65-year-old male presented with a 12-month history of dysphagia and odynophagia for solids. Barium swallow revealed bilateral moderately sized diverticuli that altered in size during the different phases of swallow. CT scan of the neck with oral contrast further identified the anatomy of the diverticuli, arising between the hyoid bone and thyroid cartilage. Discussion. An external transcervical approach was utilised to successfully repair the diverticuli. Subsequent cricopharyngeal spasm was treated with botulinum toxin, and the patient recovered with no ongoing symptoms. The barium swallow study is a commonly utilised initial investigation as it is easy to perform and safe and has good diagnostic value. Definitive management usually involves either endoscopic or open surgery. This case depicts a unique case of a pharyngeal diverticulum arising between the hyoid bone and thyroid cartilage.
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Abstract
Zenker's diverticula (ZDs) are a relatively common cause of cervical dysphagia. Diagnosis is best by a good upper GI exam though upper endoscopy should be performed as well. Treatment is either by open, transcervical approaches or trans-oral. Over the past 20 years, transoral approach has mostly replace transcervical approaches due to less pain, no scarring and a rapid recovery. Transoral approaches are either using rigid access or flexible endoscopy. Today, the most common approach is transoral stapling using a 12 mm laparoscopic linear cutting stapler. This has the drawbacks of requiring extreme neck extension, the massive size of the stapler making visualization mostly impossible and the current staple design that does not cut/staple all the way to the end of the blades-resulting in a residual pouch. Flexible endoscopy allows a more tailored approach under direct vision, the myotomy can even be extended beyond the diverticulum and onto the esophageal wall to minimize the risk of incomplete myotomy. Experienced endoscopists report high technical success and low complication. Success rates are similar but maybe slightly higher than with ridged transoral approaches or open surgery. Today, flexible endoscopic Zenkers is our preferred initial approach-with open or ridged being reserved for special indications.
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Affiliation(s)
- Kristen Beard
- Providence Portland Comprehensive Cancer Center, Portland, OR, USA
| | - Lee L Swanström
- Division of GI and MIS Surgery, The Oregon Clinic, Portland, OR, USA.,Institute for Image Guided Surgery, IHU-Strasbourg, Strasbourg, France
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Bencini L, Moraldi L, Bartolini I, Coratti A. Esophageal surgery in minimally invasive era. World J Gastrointest Surg 2016; 8:52-64. [PMID: 26843913 PMCID: PMC4724588 DOI: 10.4240/wjgs.v8.i1.52] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 11/28/2015] [Accepted: 12/04/2015] [Indexed: 02/06/2023] Open
Abstract
The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.
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Abstract
BACKGROUND Management of the pharyngeal pouch has evolved enormously since the first description by Ludlow in 1764 and the first case series by Zenker and Von Ziemssen in 1877. With the introduction of antibiotics, and the advancement of surgical technique with the advent of endoscopic surgery and lasers, current management is vastly different to that in the nineteenth century. OBJECTIVES This paper traces the history of pharyngeal pouch management, and discusses the various treatment options and opinions recorded during the nineteenth and twentieth centuries, comparing these with techniques popular today. RESULTS AND CONCLUSION Pharyngeal pouch surgery has been associated with significant morbidity, both because of the elderly age of patients typically affected by the condition and because of the surgery itself and potential post-operative complications encountered. The historical development of pharyngeal pouch management and the understanding of pharyngeal pouch pathophysiology are discussed.
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Bonavina L, Bona D, Aiolfi A, Sironi A. Transoral septum stapling of Zenker diverticulum is feasible and safe through a soft overtube. Surg Innov 2015; 22:207-9. [PMID: 25646007 DOI: 10.1177/1553350614554236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Luigi Bonavina
- IRCCS Policlinico San Donato, University of Milan Medical School, 20097 San Donato Milanese, Milano, Italy
| | - Davide Bona
- IRCCS Policlinico San Donato, University of Milan Medical School, 20097 San Donato Milanese, Milano, Italy
| | - Alberto Aiolfi
- IRCCS Policlinico San Donato, University of Milan Medical School, 20097 San Donato Milanese, Milano, Italy
| | - Andrea Sironi
- IRCCS Policlinico San Donato, University of Milan Medical School, 20097 San Donato Milanese, Milano, Italy
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Bonavina L, Aiolfi A, Scolari F, Bona D, Lovece A, Asti E. Long-term outcome and quality of life after transoral stapling for Zenker diverticulum. World J Gastroenterol 2015; 21:1167-1172. [PMID: 25632189 PMCID: PMC4306160 DOI: 10.3748/wjg.v21.i4.1167] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2014] [Revised: 05/02/2014] [Accepted: 11/11/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate long-term results and quality of life after transoral stapling of Zenker diverticulum.
METHODS: The data of all patients admitted to our institution for the surgical treatment of Zenker diverticulum were entered into a prospective database. Demographics, symptoms, intraoperative and postoperative data, morbidity, time to oral feeding, and length of hospital stay were recorded. All patients underwent upper gastrointestinal endoscopy and a barium swallow study to measure the length of the diverticulum from the apex of the septum to the bottom of the pouch. Transoral stapling was performed using a Weerda diverticuloscope under general anesthesia. Over time, the technique was modified by applying traction sutures to ease engagement of the common septum inside the stapler jaws. Perioperative variables, symptoms, long-term outcome, and quality of life were analyzed. The operation was considered successful if the patient reported complete remission (grade 1) or marked improvement (grade 2) of dysphagia, regurgitation, and respiratory symptoms. Statistical analysis was performed using Statistical Package for Social Science (SPSS, Version 15, SPSS, Inc., Chicago, IL).
RESULTS: Between 2001 and 2013, the transoral approach was successfully completed in 100 patients with a median age of 75 years. Patients with a larger (≥ 3 cm) diverticulum were older than those with a smaller pouch (P < 0.038). Complications occurred in 4% of the patients but there was no mortality. A statistically significant improvement of dysphagia and regurgitation scores (P < 0.001) was recorded over a median follow-up of 63 mo. Similarly, a significant decrease in the median number of pneumonia episodes per year (P < 0.001) was recorded after surgery. The overall long-term success rate of the procedure was 76%. The success rate of the operation was greater in patients of 70 years of age or older compared to younger individuals (P = 0.038). Use of traction sutures on the septum was associated with an improved success rate compared with the standard procedure (P = 0.04). All items of the health related quality of life questionnaire were significantly higher compared to baseline (P < 0.05).
CONCLUSION: Transoral stapling is safe and effective. The operation significantly improves patients’ quality of life. It appears that elderly patients with large diverticula significantly benefit from the procedure and that the modified surgical technique including traction sutures can further improve the success rate.
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Zhang X, Cheng S, Xu Y, Wang S. Treatment of giant pharyngoesophageal diverticulum by video-assisted thoracoscopy. Ann Thorac Surg 2014; 97:2184-6. [PMID: 24882303 DOI: 10.1016/j.athoracsur.2013.08.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 08/26/2013] [Accepted: 08/28/2013] [Indexed: 11/29/2022]
Abstract
A 67-year-old woman presented with a giant pharyngoesophageal diverticulum (Zenker's diverticulum) that extended deep into the chest. Surgery, using either an open or endoscopic approach, was difficult. We stapled the common wall between the diverticulum and the esophagus using video-assisted thoracoscopic surgery. The patient exhibited good anatomic and functional results at 6 months' follow-up.
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Affiliation(s)
- Xun Zhang
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin, China.
| | - Shizhao Cheng
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Yijun Xu
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Shunhua Wang
- Department of Thoracic Surgery, Tianjin Chest Hospital, Tianjin, China
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Leibowitz JM, Fundakowski CE, Abouyared M, Rivera A, Rudman J, Lo KM, Weed D, Civantos F. Surgical Techniques for Zenker's Diverticulum: A Comparative Analysis. Otolaryngol Head Neck Surg 2014; 151:52-8. [PMID: 24705225 DOI: 10.1177/0194599814529405] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 03/06/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To compare the different modalities for treatment of Zenker's diverticulum and the associated clinical outcomes. STUDY DESIGN Case series with chart review. SETTING Tertiary care hospital. SUBJECTS AND METHODS Between 1995 and 2011, 164 patients underwent surgery for Zenker's diverticulum (stapler, n = 69; laser, n = 68; open, n = 27). Patient sociodemographics, medical comorbidities, pre- and postoperative subjective dysphagia and regurgitation score, complications, length of stay, time to oral intake, and recurrence were reviewed for each surgical modality. RESULTS No statistically significant difference in diverticulum prevalence was associated with age, gender, or treatment group. Mean length of hospital stay was not significantly different between the 3 groups (P = .14). A significant difference in time to oral intake was observed in the laser group compared with the other 2 groups (P = .012). No significant difference in recurrence (P = .21) or complication (P = .12) rates was identified between the 3 groups. Although all 3 groups demonstrated a significant decrease between preoperative and postoperative dysphagia and regurgitation scores, the degree of improvement was not significant when the 3 groups were compared. CONCLUSION There is no single "best" approach to Zenker's diverticulum. The open, laser, and stapler methods are equally effective and have similar complication rates.
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Affiliation(s)
- Jason M Leibowitz
- Department of Otolaryngology-Head and Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, USA
| | - Christopher E Fundakowski
- Department of Otolaryngology-Head and Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, USA
| | - Marianne Abouyared
- Department of Otolaryngology-Head and Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, USA
| | - Andrew Rivera
- Department of Otolaryngology-Head and Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, USA
| | - Jason Rudman
- Department of Otolaryngology-Head and Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, USA
| | - Ka-Ming Lo
- Department of Epidemiology and Public Health, University of Miami-Miller School of Medicine, Miami, Florida, USA
| | - Donald Weed
- Department of Otolaryngology-Head and Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, USA
| | - Francisco Civantos
- Department of Otolaryngology-Head and Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, USA
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Zenker's diverticulum: carbon dioxide laser endoscopic surgery. BIOMED RESEARCH INTERNATIONAL 2014; 2014:516231. [PMID: 24729975 PMCID: PMC3963375 DOI: 10.1155/2014/516231] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 01/28/2014] [Indexed: 11/25/2022]
Abstract
Nowadays endoscopic diverticulotomy is the surgical approach of the first choice in treatment of Zenker's diverticulum. We report our experience with this procedure and try to sum up recent recommendations for management of surgery and postoperative care. Data of 34 patients with Zenker's diverticulum, treated by endoscopic carbon dioxide laser diverticulotomy at the Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University, University Hospital Motol, Prague, Czech Republic, were prospectively stored and followed in relatively short period from May 2009 to December 2013. The average length of diverticulum was 32 mm. The average duration of surgery was 32 min. The patients were fed via feeding tube for 6.1 days and antibiotics were administered for 7 days. Mean hospitalization time was 7.4 days. We observed one transient recurrent laryngeal nerve paralysis and no other serious complications. Recurrence rate was 3%. We recommend complete transection of the diverticular septum in one procedure, systemic antibiotic treatment and exclusion of transoral intake for minimally 5 days, and contrast oesophagogram before resumption of oral intake to exclude fistula. Open diverticulectomy should be reserved for cases with inadequate endoscopic exposure and for revision surgery for multiple recurrences from endoscopic diverticulotomies.
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Huberty V, El Bacha S, Blero D, Le Moine O, Hassid S, Devière J. Endoscopic treatment for Zenker's diverticulum: long-term results (with video). Gastrointest Endosc 2013; 77:701-7. [PMID: 23394840 DOI: 10.1016/j.gie.2012.12.008] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 12/09/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND Diverticulotomy is a standard treatment for Zenker's diverticulum (ZD). This technique was adapted to flexible endoscopy. OBJECTIVE We report our long-term results of ZD treatment by using flexible endoscopy assisted by a soft diverticuloscope. DESIGN Follow-up study. SETTING Academic hospital. Tertiary-care referral center. PATIENTS A total of 150 patients with ZD were treated with the same technique from July 2002 to June 2011. INTERVENTION The procedure was performed by using a soft diverticuloscope to expose the septum, which was then cut with a needle-knife, and the procedure was completed by use of endoclip placement at the bottom of the section. MAIN OUTCOME MEASUREMENTS Symptoms were compared before and after the procedure, 1 month later, and at the end of follow-up. RESULTS The median size of the ZD was 3 cm (range 1-8 cm). The endoscopic incision was performed in one session (range 1-3 sessions). Clinical success at 1 month was 90.3%. Four adverse events (2.2%) occurred and were managed conservatively. Symptom evaluation at 1 month and at the end of follow-up was obtained in 103 and 134 patients, respectively. The dysphagia score dropped from 1.88 to 0.29 (P < .01) and 0.34 (P < .05) at 1 month and at the end of follow-up, respectively (median 43 months, range 13-121 months). Regurgitations and chronic cough dropped from 73% and 27% to 11% and 2% at the end of follow-up, respectively. Symptom recurrence occurred in 31 patients (23.1%); among them 23 had a second treatment, and only 5 required a third one. LIMITATIONS Retrospective study, single center. CONCLUSION Endoscopic incision of ZD by using a soft diverticuloscope and completed by endoclips is safe and efficient at short term and long term.
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Affiliation(s)
- Vincent Huberty
- Medical-Surgical Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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Herrero Egea A, Pérez Delgado L, Tejero-Garcés Galve G, Guallar Larpa M, Orte Aldea C, Ortiz García A. Treatment of Zenker's Diverticulum: Comparison of Different Techniques. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2013. [DOI: 10.1016/j.otoeng.2013.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Tratamiento del divertículo de Zenker: comparación de diferentes técnicas. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2013; 64:1-5. [DOI: 10.1016/j.otorri.2012.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 06/02/2012] [Accepted: 06/06/2012] [Indexed: 11/18/2022]
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Undavia S, Anand SM, Jacobson AS. Killian-Jamieson diverticulum: a case for open transcervical excision. Laryngoscope 2012. [PMID: 23184336 DOI: 10.1002/lary.23639] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Killian-Jamieson diverticulum (KJD) is rare hypopharyngeal defect. As in other forms of esophageal diverticuli (i.e., Zenker's), recent literature has described minimally invasive endoscopic approaches to its management.1, 2 We present a case of a 62-year-old female with symptoms consistent with an esophageal diverticulum. A barium swallow study was consistent with a KJD. The patient was brought to the operating room and endoscopically examined to confirm the presence of this entity. A open transcervical approach was performed to remove the diverticulum without complication. During our dissection, the recurrent laryngeal nerve (RLN) was noted to be adherent to the base of the diverticulum and needed to be freed prior to performing the diverticulectomy. We provide a review of recent literature and medical illustrations to highlight the importance of the open transcervical approach in the management of KJD to avoid inadvertent transection of the RLN.
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Affiliation(s)
- Satyen Undavia
- Otorhinolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, New York, USA.
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Bonavina L, Rottoli M, Bona D, Siboni S, Russo IS, Bernardi D. Transoral stapling for Zenker diverticulum: effect of the traction suture-assisted technique on long-term outcomes. Surg Endosc 2012; 26:2856-61. [PMID: 22538675 DOI: 10.1007/s00464-012-2261-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 03/13/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Long-term outcomes and predictors of success after transoral stapling for Zenker diverticulum are still unclear. METHODS Between 2001 and 2010, 91 patients with Zenker diverticulum underwent transoral stapling under general anesthesia. Since 2008, the technique was modified by applying traction sutures to ease engagement of the common septum inside the stapler jaws. Perioperative variables, distribution of symptoms, and outcome of surgery were analyzed. Long-term results were compared between patients undergoing standard versus modified technique of transoral stapling. RESULTS The transoral approach was successfully completed in 79 (86.8 %) patients with a median age of 74 years. Overall morbidity was 5 %, and there was no mortality. The median length of hospital stay was 2 days. Six patients were lost to follow-up. After a median follow-up of 53 (range, 12-114) months, an improvement of dysphagia and regurgitation scores (p < 0.001) and a reduction in the number of pneumonia episodes per year (p < 0.001) was recorded. The long-term success rate of the procedure was 80.1 %. At a median time of 12 months, 14 patients complained of recurrent symptoms, 7 of whom needed an open (n = 4) or transoral (n = 3) reoperation. Use of traction sutures resulted in a greater long-term success compared with the standard procedure (p = 0.04). CONCLUSIONS Transoral stapling is a safe and effective technique. A repeat procedure is feasible in case of recurrent diverticulum. The use of traction sutures applied at the apex of the common septum before stapling might increase the long-term success of the technique.
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Affiliation(s)
- Luigi Bonavina
- Department of Surgery, University of Milano, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, San Donato Milanese, Milano, Italy.
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Cañete-Gómez J, Ramírez-Plaza CP, López Rueda B, Ibáñez-Delgado F, Vázquez-Medina A, Bondía-Navarro JA, Padillo-Ruiz FJ. Diverticulectomía y miotomía del cricofarígeo para el tratamiento del divertículo de Zenker. Presentación de una serie de 33 casos. Cir Esp 2012; 90:233-7. [DOI: 10.1016/j.ciresp.2011.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Revised: 09/25/2011] [Accepted: 09/27/2011] [Indexed: 10/14/2022]
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Verhaegen VJO, Feuth T, van den Hoogen FJA, Marres HAM, Takes RP. Endoscopic carbon dioxide laser diverticulostomy versus endoscopic staple-assisted diverticulostomy to treat Zenker's diverticulum. Head Neck 2011; 33:154-9. [PMID: 20848433 DOI: 10.1002/hed.21413] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND The 2 most frequently used endoscopic methods to treat Zenker's diverticulum are staple-assisted and CO(2) laser esophagodiverticulostomy. METHODS The study centered around a retrospective evaluation of 107 patients with Zenker's diverticulum who were treated endoscopically by CO(2) laser (n = 72) or staple-assisted diverticulostomy (n = 35). RESULTS Patients in the staple-assisted group had a shorter duration of postoperative hospitalization, attributed to earlier oral intake, than patients in the CO(2) laser group. There were no serious postoperative complications in either group. Postoperative fever and emphysema in the neck or mediastinum occurred more frequently in the CO(2) laser group, but this did not lead to any complications. Most patients reported partial or complete relief of their symptoms and there was no significant difference in the number of reoperations between the 2 treatment groups. CONCLUSIONS Zenker's diverticulum was treated safely and effectively by the 2 endoscopic techniques, but the staple-assisted method seemed to be the most favorable.
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Affiliation(s)
- Veronique J O Verhaegen
- Department of Otolaryngology/Head and Neck Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Weksler B, Cook C, Luketich JD. Endoscopic transoral stapling of Zenker's diverticula. Multimed Man Cardiothorac Surg 2010; 2010:mmcts.2007.002923. [PMID: 24413419 DOI: 10.1510/mmcts.2007.002923] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The pharyngoesophageal pouch was first described by Ludlow in 1764 and later by Zenker. It is a pulsion diverticulum of the posterior pharynx, arising in Killian's triangle. Zenker's diverticula are related to a non-compliant upper esophageal sphincter and have been associated with gastroesophageal reflux. Surgical therapy has been recommended for dysphagia and regurgitation. Many surgical options exist. More recently, minimally invasive, transoral stapling has been used. Transoral stapling may be a less morbid operation and may allow patients a quicker return to oral diet and usual activities.
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Affiliation(s)
- Benny Weksler
- The Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Surgical experience of the national institution in the treatment of Zenker's diverticula. ACTA ACUST UNITED AC 2009; 56:25-33. [PMID: 19504986 DOI: 10.2298/aci0901025s] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AIM To review the 8-year experience of the Department of Esophagogastric Surgery, First Surgical University Hospital in Belgrade in the surgical management of Zenker's diverticula (ZD). METHODS Between January 2000 and January 2009, 52 patients underwent surgical procedure for the treatment of ZD. Complete preoperative workup including the symptom evaluation and large variety of structural and functional diagnostic procedures were conducted before the surgery. After the operative treatment patients underwent detailed follow-up in regular intervals up to 3 years. RESULTS Preoperative evaluation marked higher incidence of hiatal hernia and pathologic gastroesophageal reflux (GER) among the patients with ZD then in normal population. According to the preoperative evaluation and size of diverticula, as well as due to the intraopertive findings, a variety of surgical procedures were performed, including myotomy alone (n = 2), diverticulopexy and myotomy (n = 36) and diverticulectomy and myotomy (n = 14). Regardless of the operative treatment no salivary cervical fistulas were observed. Late and early postoperative results revealed low incidence in postoperative transitory dysphagia or regurgitation. CONCLUSION The results of this study show that the open surgical procedures are safe and effective in the treatment of ZD. Cricopharyngeal myotomy remains the essential focus of treatment, while the choice of resecting or suspending the diverticulum is brought upon its size. Complete preoperative investigation must be conducted in ZD patients, and the role of pathologic GER must be taken into account when we discuss the origin of this disorder.
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Brigand C, Bajcz K, Elamrani H, Dan S, Rohr S, Meyer C. [Suspension diverticulopexy for Zenker's diverticulum]. ACTA ACUST UNITED AC 2009; 145:341-5. [PMID: 18955924 DOI: 10.1016/s0021-7697(08)74313-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Zenker's diverticulum is an unusual condition. Its treatment requires surgery but there is no consensus regarding the various operative techniques. Through an open cervical approach, the diverticulum can be either resected or suspended with or without a concurrent myotomy of the cricopharyngeus muscle. An innovative option is endoscopic trans-oral stapled esophago-diverticulostomy. PATIENTS and method: We retrospectively reviewed a consecutive series of 36 patients operated on between 1988 and 2006. Median age was 77.5 years and M/F sex ratio was 1.4. Through an open neck approach, diverticulectomy without cricopharyngeal myotomy was performed in 7 patients, diverticulectomy with myotomy in 11, and diverticulopexy with myotomy in 18. RESULTS Morbidity rate was 13.8%. One fistula and one recurrence occurred in both diverticulectomy groups with and without myotomy. There was no morbidity after suspension diverticulopexy which also allowed earlier oral feeding (1 vs. 6 days) and shortened hospitalization (6 vs. 13.5 days). CONCLUSION Diverticulopexy with cricopharyngeus myotomy is an effective, reliable, and reproducible technique for the correction of Zenker's diverticula smaller than 5 cm. Diverticulectomy should be reserved for larger diverticula. Technical improvements of transoral stapled diverticulostomy are still required before it can be promoted as an alternative therapy.
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Affiliation(s)
- C Brigand
- Service de chirurgie générale et digestive, pôle des pathologies digestives, hépatiques et de la transplantation, hôpital de Hautepierre Strasbourg.
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Grant PD, Morgan DE, Scholz FJ, Canon CL. Pharyngeal Dysphagia: What the Radiologist Needs to Know. Curr Probl Diagn Radiol 2009; 38:17-32. [DOI: 10.1067/j.cpradiol.2007.08.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Ko SM, Kim HI, Kim CB. Surgical Treatment of the Esophageal Diverticulum. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2009. [DOI: 10.4174/jkss.2009.77.4.250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Si Mon Ko
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Choong Bai Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Ribeiro GBS, Mielke F, Volkweis BS, Schirmer CC, Kruel CDP, Morellato G, Binato M, Gurski RR. Tratamento cirúrgico do divertículo de Zenker. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2008. [DOI: 10.1590/s0102-67202008000300003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
RACIONAL: O tratamento cirúrgico do divertículo de Zenker inclui na maioria dos casos a cricomiotomia do músculo cricofaríngeo, a qual pode ser associada à diverticulopexia ou diverticulectomia. A escolha destas opções cirúrgicas ainda é controversa. OBJETIVO: Avaliar os resultados de dois tratamentos cirúrgicos (diverticulopexia ou diverticulectomia, ambos associados à cricomiotomia) em uma série de casos. MÉTODOS: Estudo retrospectivo em período de 10 anos de 26 pacientes submetidos ao tratamento cirúrgico do divertículo de Zenker. Para análise estatística, os pacientes foram divididos em dois grupos: Grupo 1 - diverticulectomia (n=17) e Grupo 2 - diverticulopexia (n=9). Em todos realizou-se miotomia. Foram avaliadas as variáveis: tempo cirúrgico, de internação e de início da alimentação via oral, complicações gerais, ocorrência de fístulas, recidiva dos sintomas e mortalidade. Consideraram-se diferenças significativas quando P<0.05. RESULTADOS: A idade média dos pacientes foi de 64 anos. Sintomas pré-operatórios principais: disfagia (91%) e regurgitação (46%). Todos foram investigados com estudo radiográfico contrastado de faringe-esôfago-estômago e 58% dos casos com endoscopia digestiva alta. Não houve diferença significativa entre os Grupos 1 e 2 em relação ao tempo operatório (96 x 99 min), tempo de internação (5,5 x 5 dias), início da alimentação via oral (7,5 x 4 dias), ocorrência de fístulas esôfago-cutâneas (35 x 22%), recidiva da disfagia (6 x 11%), complicações pós-operatórias em geral (41 x 33%) e tempo de seguimento (7,5 x 9 meses). A mortalidade foi nula. CONCLUSÃO: O tratamento cirúrgico do divertículo de Zenker é método terapêutico relativamente seguro, com morbidade aceitável e seus resultados independem da opção por ressecção ou pexia do divertículo.
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Barry B, Chevalier D, Lacau St-Guily J, Makeieff M, Reyt E. [Zenker diverticulum]. ANNALES D'OTO-LARYNGOLOGIE ET DE CHIRURGIE CERVICO FACIALE : BULLETIN DE LA SOCIETE D'OTO-LARYNGOLOGIE DES HOPITAUX DE PARIS 2008; 125:98-104. [PMID: 18436187 DOI: 10.1016/j.aorl.2007.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2007] [Accepted: 04/17/2007] [Indexed: 05/26/2023]
Affiliation(s)
- B Barry
- Service ORL et CCF, hôpital Bichat-Claude-Bernard, 75877 Paris cedex 18, France
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Esophagus Benign Diseases of the Esophagus. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Clavé P, Arreola V, Velasco M, Quer M, Castellví JM, Almirall J, García Peris P, Carrau R. [Diagnosis and treatment of functional oropharyngeal dysphagia. Features of interest to the digestive surgeon]. Cir Esp 2007; 82:62-76. [PMID: 17785140 DOI: 10.1016/s0009-739x(07)71672-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Digestive surgeons should form part of the multidisciplinary team managing patients with oropharyngeal dysphagia. These patients can be diagnosed through clinical methods and complementary investigations such as videofluoroscopy and pharyngoesophageal manometry. These techniques also allow specific treatment to be selected. Up to one-third of patients with dysphagia suffer from malnutrition as a result of alterations in food bolus transport. Furthermore, up to two-thirds show alterations in swallowing safety (penetrations and aspirations, especially when swallowing liquids), as well as a high risk of respiratory infections and aspiration pneumonia. Increasing food bolus viscosity to 3500-4000 mPas (pudding viscosity) improves the effectiveness of swallowing and reduces the risk of aspirations. Botulinic toxin injection in the upper esophageal sphincter is indicated in patients with spasticity of neuromuscular origin. Cricopharyngeal myotomy is the basis of treatment for Zenker's diverticulum and is also indicated in patients with alterations in the upper esophageal sphincter and preserved oropharyngeal motor response.
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Affiliation(s)
- Pere Clavé
- Unidad de Exploraciones Funcionales Digestivas, Servicio de Cirugía, Hospital de Mataró, Universidad Autónoma de Barcelona, Carretera Cirera s/n, 08304 Mataró, Barcelona, España.
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Wiedemann K, Graser A, Lang RA, Rader T, Suckfuell M. [Persistent pharyngeocutaneous fistula after transcervical resection of a diverticulum of the hypopharynx]. HNO 2007; 57:1275-9. [PMID: 17882393 DOI: 10.1007/s00106-007-1613-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
CASE A 26-year-old white male patient had undergone resection of a diverticulum of the hypopharynx and myotomy of the cricopharyngeal muscle elsewhere. A transcervical approach had been chosen owing to the presence of an arteria lusoria and the associated risk of vessel injury. The patient had subsequently had recurrent fistulas through the skin incision, which had not resolved despite four further operations. He presented in our department with significant weight loss and persistent retrosternal pain. Esophageal manometry revealed that resting muscle tone in the upper esophageal sphincter was still significantly elevated. Assuming that the earlier myotomy had not been completely successful, we decided to complete this operation as revision surgery. The pharynx was closed with a running suture using the Conley technique. The fistula healed, and there were no further recurrences. CONCLUSION Complete and careful dissection of all muscle fibers back to the mucosa is essential, as well as complete removal of the diverticulum if this operation is to be successful when performed by the transcutaneous approach. Recurrent diverticula are not the only possible complication; persistent pharyngeocutaneous fistulas can also arise.
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Affiliation(s)
- K Wiedemann
- Klinik für Hals-, Nasen- und Ohrenheilkunde, Ludwig-Maximilians-Universität, Marchioninistrasse 15, 81377, München, Deutschland
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Brigand C, Ferraro P, Martin J, Duranceau A. Risk factors in patients undergoing cricopharyngeal myotomy. Br J Surg 2007; 94:978-83. [PMID: 17497757 DOI: 10.1002/bjs.5760] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Cricopharyngeal myotomy for oropharyngeal dysphagia is designed to improve symptoms, but the operation can result in significant morbidity and even death.
Methods
A retrospective analysis was carried out of all complications and deaths among 253 patients who had cricopharyngeal myotomy performed by a single surgeon.
Results
A single wound infection developed among 15 patients with neurological dysphagia. The same patient subsequently required laryngeal exclusion and tracheostomy. Of 139 patients treated for dysphagia secondary to muscular dystrophy, haematoma formation or infection occurred in four, and eight patients developed postoperative pulmonary complications, four of whom died from respiratory distress syndrome. Two patients with myogenic dysphagia required laryngeal exclusion with a permanent tracheostomy. Infection of the wound or retropharyngeal space was the main problem in 90 patients with a pharyngo-oesophageal diverticulum, affecting 9 per cent of the patients. Fistula was documented in three patients overall (1·2 per cent). Systemic morbidity unrelated to the technique occurred in 26 patients (10·3 per cent).
Conclusion
Pulmonary aspiration and lethal respiratory distress occurred only in patients with myogenic dysphagia. Local infection was the main complication in those with pharyngo-oesophageal diverticulum. Persistent aspiration can lead to laryngeal exclusion or resection with permanent tracheostomy.
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Affiliation(s)
- C Brigand
- Department of Surgery, Division of Thoracic Surgery, University of Montreal Hospital Centre, 1560 Sherbrooke Street East, Montreal, Quebec H2L 4M1, Canada
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McLean TR, Haller CC. Stapled diverticulectomy and myotomy for symptomatic Zenker's diverticulum. Am J Surg 2006; 192:e28-31. [PMID: 17071177 DOI: 10.1016/j.amjsurg.2006.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2006] [Revised: 08/01/2006] [Accepted: 08/01/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND Few surgeons have extensive experience with the operative management of Zenker's diverticulum (ZD). METHODS Retrospective review of stapled diverticulectomy and cricopharyngeal myotomy (SDM) for ZD. All procedures were performed by midlevel surgery residents supervised by single board-certified surgeon. A drain was not used, and patients were liberally advanced to a regular diet postoperatively. RESULTS Three patients with ZD underwent this procedure during a 6-year period. The mean age of the patients was 81 years, and all had multiple comorbidities. Time to discharge was less than 48 hours in 2 patients and 5 days in 1 patient who developed new atrial fibrillation. There were no deaths or clinical leaks. At a mean follow-up of 33 (range 6-62) months, 1 patient died of an unrelated cause, and the other 2 are free of esophageal-related symptoms. CONCLUSIONS SDM for ZD is a safe and effective operation that is easily taught to surgical residents.
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Affiliation(s)
- Thomas R McLean
- Department of Surgery, EKVAHCS, 4104 S Fourth Street Trafficway, Leavenworth, KS 66048, USA.
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Parr J, Macdonald CE. Different diagnosis for two decades of dysphagia. Br J Hosp Med (Lond) 2006; 67:96. [PMID: 16498918 DOI: 10.12968/hmed.2006.67.2.20470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J Parr
- Cumberland Infirmary, Carlisle
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