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DeKloe J, Shing SR, Herzig L, Bertoni D, Tibbetts KM. Complications Following Surgical Management of Zenker Diverticulum: A Comparative Analysis of Endoscopic and Open Approaches. Otolaryngol Head Neck Surg 2025; 172:1328-1333. [PMID: 39764670 DOI: 10.1002/ohn.1119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2024] [Revised: 11/17/2024] [Accepted: 12/14/2024] [Indexed: 03/28/2025]
Abstract
OBJECTIVE We aim to explore the differences in complication rates in endoscopic versus open transcervical treatment of Zenker diverticulum. STUDY DESIGN Retrospective Cohort Study from January 1, 2015 to December 31, 2023. SETTING Queries of the TriNetX database's United States Collaborative Network. METHODS A retrospective cohort study was conducted using patients ≥18 years old diagnosed with Zenker diverticulum selected from the TriNetX United States Collaborative Network. Patients undergoing open and endoscopic diverticulectomy between 2015 and 2023 were identified and divided into cohorts and propensity score matched by age, sex, race, ethnicity, and common comorbidities. RESULTS Patients that underwent transcervical approach (n = 1033), when compared to patients that underwent endoscopic approach (n = 2182), had higher rates of dysphonia (odds ratio [OR]: 2.44; 95% confidence interval [CI]: 1.47-4.05; P = .001), long-term enteral feeding access (OR: 3.08; 1.74-5.46; P > .001), and infection (OR: 6.65; 3.50-12.65; P > .001). No significant difference was found in rates of esophageal perforation (OR: 1.60; 0.93-2.75; P = .087) or persistent postoperative dysphagia (OR: 1.03; 0.86-1.23, P = .75). There was no significant difference in the number of patients receiving repeat diverticulectomy procedures (OR: 0.83; 0.58-1.19; P = .314). CONCLUSION Based on analysis of a large healthcare database, endoscopic Zenker diverticulectomy is associated with rates of postoperative dysphonia, enteral feeding, and soft tissue infection. Both the open and endoscopic approaches offer relative advantages not captured by this population-level analysis. Thus, judicious selection of patients based on comorbidities and anatomical factors is essential for optimizing outcomes.
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Affiliation(s)
- Jefferson DeKloe
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Samuel R Shing
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Lia Herzig
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dylan Bertoni
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kathleen M Tibbetts
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Kenarli K, Ödemiş B. Flexible endoscopic treatment of Zenker's diverticulum: a retrospective study in a single center from Turkey. Clin Endosc 2025; 58:261-268. [PMID: 39722138 PMCID: PMC11983138 DOI: 10.5946/ce.2024.180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 08/03/2024] [Accepted: 08/15/2024] [Indexed: 12/28/2024] Open
Abstract
BACKGROUND/AIMS We aimed to contribute to the literature by sharing the findings of patients treated by cricopharyngeal myotomy with a flexible endoscopic septal division. METHODS This retrospective study included patients with Zenker's diverticulum who underwent cricopharyngeal myotomy with a traditional flexible endoscopic septal division at our center. Clinical success was defined as a significant reduction in dysphagia score, and relapse was defined as an increase in dysphagia score occurring at any time over 1 month after the procedure. RESULTS Fifteen patients with symptomatic Zenker's diverticulum were treated with 16 cricopharyngeal myotomies. A dysphagia score of 100% indicated clinical success, but three (20%) of the patients experienced recurrence during follow-up. CONCLUSIONS While advances in interventional flexible endoscopy have opened doors for novel treatments, cricopharyngeal myotomy based on traditional flexible endoscopic septal division remains a reliable approach for treating Zenker's diverticulum.
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Affiliation(s)
- Kerem Kenarli
- Department of Gastroenterology, Ankara Bilkent City Hospital, Ankara, Turkiye
| | - Bülent Ödemiş
- Department of Gastroenterology, Ankara Bilkent City Hospital, Ankara, Turkiye
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Sheridan B, Dinh T, Hendrick LE, Moran L, Zhao J, Leesley H, Ng T. Critical analysis of outcomes after surgical management of Zenker diverticulum. J Gastrointest Surg 2024; 28:1915-1916. [PMID: 39179020 DOI: 10.1016/j.gassur.2024.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/28/2024] [Accepted: 08/18/2024] [Indexed: 08/26/2024]
Affiliation(s)
- Brenden Sheridan
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Theresa Dinh
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Leah E Hendrick
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Lindsey Moran
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI, United States
| | - Jane Zhao
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States; Division of Thoracic Surgery, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Haley Leesley
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI, United States
| | - Thomas Ng
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States; Division of Thoracic Surgery, University of Tennessee Health Science Center, Memphis, TN, United States.
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Corsello A, Antoine M, Sharma S, Bertrand V, Oliva S, Fava G, Destro F, Huang A, Fong WSW, Ichino M, Thomson M, Gottrand F. Over-the-scope clip for closure of persistent gastrocutaneous fistula after gastrostomy tube removal: a multicenter pediatric experience. Surg Endosc 2024; 38:6305-6311. [PMID: 39187732 PMCID: PMC11525288 DOI: 10.1007/s00464-024-11166-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 08/05/2024] [Indexed: 08/28/2024]
Abstract
BACKGROUND Percutaneous endoscopic gastrostomy is commonly used for enteral nutritional access, but gastrocutaneous fistulae (GCF) may persist after tube removal, posing clinical challenges. The use of endoscopic closure devices, including over-the-scope clips (OTSC), has shown promise in managing non-healing fistulae, although data in the pediatric population are limited. METHODS A retrospective multicenter study analyzed pediatric patients who underwent GCF closure following gastrostomy tube removal. Data from seven centers across multiple countries were collected, including patient demographics, procedural details, complications, and outcomes. Closure techniques were compared between OTSC and surgical closure. RESULTS Of 67 pediatric patients included, 21 underwent OTSC closure and 46 had surgical closure. Surgical closure demonstrated a higher success rate (100%) compared to OTSC closure (61.9%, P < 0.001). While procedural duration was shorter for OTSC closure (25 vs. 40 min, P = 0.002), complications, and scar quality were comparable between techniques. A subsequent sub-analysis did not reveal differences based on center experience. CONCLUSION OTSC closure is feasible and safe in pediatric patients, but surgical closure remains superior in achieving sustained GCF closure, although OTSC offers benefits, such as shorter procedural duration, potentially reducing the duration of general anesthesia exposure. Non-operative approaches, including OTSC, may be a valuable alternative to surgical closure.
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Affiliation(s)
- Antonio Corsello
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, University of Lille, Inserm, CHU Lille, U1286 - INFINITE, Lille, France
- University of Milan, Milan, Italy
| | - Matthieu Antoine
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, University of Lille, Inserm, CHU Lille, U1286 - INFINITE, Lille, France
| | - Shishu Sharma
- Centre for Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | | | - Salvatore Oliva
- Pediatric Gastroenterology and Liver Unit, Department of Maternal and Child Health, Sapienza University of Rome, Rome, Italy
| | - Giorgio Fava
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Destro
- Department of Pediatric Surgery, Buzzi Children's Hospital, Milan, Italy
| | - Andrew Huang
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Nebraska Medical Center and Children's Hospital & Medical Center, Omaha, NE, USA
| | - Wei S W Fong
- Centre for Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Martina Ichino
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mike Thomson
- Centre for Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Frederic Gottrand
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, University of Lille, Inserm, CHU Lille, U1286 - INFINITE, Lille, France.
- Service d'hépato, gastroentérologie et nutrition pédiatrique, Pôle enfant, Hôpital Jeanne de Flandre, Avenue Eugène Avinée, Lille, France.
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Dell’Anna G, Fasulo E, Fanizza J, Barà R, Vespa E, Barchi A, Cecinato P, Fuccio L, Annese V, Malesci A, Azzolini F, Danese S, Mandarino FV. The Endoscopic Management of Zenker's Diverticulum: A Comprehensive Review. Diagnostics (Basel) 2024; 14:2155. [PMID: 39410559 PMCID: PMC11475965 DOI: 10.3390/diagnostics14192155] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Revised: 09/15/2024] [Accepted: 09/24/2024] [Indexed: 10/20/2024] Open
Abstract
Zenker's Diverticulum (ZD) is the most common hypopharyngeal diverticulum; however, it is often underdiagnosed. It results from the herniation of the mucosa and submucosa through Killian's Triangle. Dysphagia is the primary symptom, occurring in 80-90% of cases. The primary goal of treatment is to transect the cricopharyngeal muscle (CM) and connect the ZD cavity to the esophageal lumen. Traditional treatments include surgical open transcervical diverticulectomy and CM septomyotomy, using rigid or flexible endoscopes. However, surgery is burdened by technical difficulties and not negligible rates of adverse events (AEs). For this reason, endoscopic techniques for ZD treatment have gained traction in recent years. Flexible endoscopic septum division (FESD), introduced nearly 20 years ago, involves a full-thickness incision of the diverticular septum. The advent of third-space endoscopy has led to the application of these techniques to ZD treatment as well. Zenker-POEM (Z-POEM) and, subsequently, Per Oral Endoscopic Septomyotomy (POES) have been developed. Hybrid techniques, such as Peroral Endoscopic Diverticulotomy (POED) and tunneling-free methods, represent additional ZD treatment options. This review outlines the armamentarium of ZD endoscopic management, summarizing the characteristics of these techniques, their benefits and limitations, and highlighting future research directions.
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Affiliation(s)
- Giuseppe Dell’Anna
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy;
| | - Ernesto Fasulo
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Jacopo Fanizza
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Rukaia Barà
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Edoardo Vespa
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
| | - Alberto Barchi
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Paolo Cecinato
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (P.C.); (L.F.)
| | - Lorenzo Fuccio
- Unit of Gastroenterology, Department of Medical and Surgical Sciences, S. Orsola-Malpighi University Hospital, University of Bologna, Via Massarenti 9, 40138 Bologna, Italy; (P.C.); (L.F.)
| | - Vito Annese
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS Policlinico San Donato, Piazza Edmondo Malan 2, 20097 San Donato Milanese, Italy;
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Alberto Malesci
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Francesco Azzolini
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
| | - Silvio Danese
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
| | - Francesco Vito Mandarino
- Gastroenterology and Gastrointestinal Endoscopy Division, IRCCS San Raffaele Institute, Via Olgettina 60, 20132 Milan, Italy; (G.D.); (E.F.); (J.F.); (R.B.); (E.V.); (A.B.); (A.M.); (F.A.); (F.V.M.)
- Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Via Olgettina 56, 20132 Milan, Italy
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Dahiya DS, Deliwala S, Chandan S, Ramai D, Ali H, Kassab LL, Facciorusso A, Kochhar GS. Effectiveness and safety of stag beetle knife (SB knife) in management of Zenker's diverticulum: a systematic review and meta-analysis. Dis Esophagus 2024; 37:doad069. [PMID: 38100729 DOI: 10.1093/dote/doad069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/24/2023] [Indexed: 12/17/2023]
Abstract
Stag Beetle Knife (SB Knife) is increasingly being utilized for Zenker's Diverticulectomy (ZD). Our study assessed the effectiveness and safety of the SB Knife for the management of ZD. Ovid EBM reviews, Ovid Embase, Ovid Medline, ClinicalTrials.gov, Scopus, and Web of Science were searched to identify studies that utilized SB knife for ZD. Pooled proportions (PP) were calculated using the random-effects model. Heterogeneity was evaluated using I2 statistics. A total of 7 studies with 268 patients were included in the final analysis. Dysphagia and regurgitation were the most common clinical symptoms. The mean size of the ZD was 2.8 ± 0.7 cm and 28 (of 148) patients had undergone previous treatments. The PP of technical success was 98% (95% CI: 92.3-99.5; I20) with a mean procedure duration of 26.2 ± 8.3 minutes. The PP of clinical response at first follow-up and relapse after index procedure was 87.9% (95% CI: 81.6-92.3; I219) and 13.5% (95% CI: 9.6-18.6; I22), respectively. At final follow-up, the PP of clinical remission was 96.2% (95% CI: 91-98.4; I230.6) while the PP of procedure failure was 3.6% (95% CI: 1.6-8.1; I20). No severe adverse events (AEs) were noted while using the SB Knife. However, the PP of intraprocedural and postprocedural AEs was 13.2% (95% CI: 9.6-17.8; I20) and 9.3% (95% CI: 5.7-14.9; I2 < 20.9), respectively. SB Knife is highly safe and effective for Zenker's Diverticulectomy with a failure rate of only 3.6%.
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Affiliation(s)
- Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology & Motility, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - Smit Deliwala
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Saurabh Chandan
- Division of Gastroenterology & Hepatology, CHI Creighton University Medical Center, Omaha, NE, USA
| | - Daryl Ramai
- Department of Gastroenterology, University of Utah, Salt Lake City, UT, USA
| | - Hassam Ali
- Division of Gastroenterology and Hepatology, East Carolina University/Brody School of Medicine, Greenville, NC, USA
| | - Lena L Kassab
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology & Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
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Palat S, Singh H, Madi MY, Bazarbashi AN. Endoscopic management of recurrent Zenker diverticula after failed surgical repairs. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2024; 9:203-205. [PMID: 38618623 PMCID: PMC11009434 DOI: 10.1016/j.vgie.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Sanjay Palat
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Harsh Singh
- Department of Internal Medicine, University of Nevada, Reno School of Medicine, Reno, Nevada
| | - Mahmoud Y Madi
- Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Ahmad Najdat Bazarbashi
- Division of Gastroenterology, Hepatology, and Endoscopy, Washington University School of Medicine, St. Louis, Missouri
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Pan Q, Tsuji Y, Sreedevi Madhavikutty A, Ohta S, Fujisawa A, Inagaki NF, Fujishiro M, Ito T. Prevention of esophageal stenosis via in situ cross-linkable alginate/gelatin powder in a new submucosal exfoliation model in rats. Biomater Sci 2023; 11:6781-6789. [PMID: 37614197 DOI: 10.1039/d3bm00887h] [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: 08/25/2023]
Abstract
Endoscopic submucosal dissection (ESD) for the treatment of esophageal mucosal lesions often leads to postoperative stenosis, causing difficulty in swallowing, known as dysphagia. In this study, we developed an in situ cross-linkable powder composed of alginate, gelatin, transglutaminase (TG), and calcium chloride ions (Ca2+), which can be administered through a 1.5 m-long and 3.2 mm-diameter endoscopic instrument channel. The powdered mixture of alginate and gelatin quickly formed a hydrogel by absorbing body fluids and was cross-linked by TG and Ca2+, which adhered ex vivo to porcine submucosal layers for over 2 weeks. In addition, we developed a new submucosal exfoliation model in rats that induced severe stenosis, similar to the ESD-induced stenosis models in clinical practice. When administered to the new rat model, the powder system effectively reduced the severity of esophageal stenosis based on body weight change monitoring, anatomical findings, and histological analysis. The body weight of the rats was maintained at the initial weight on postoperative day 14 (POD14), and epithelialization on POD7 and 14 improved to almost 100%. Additionally, collagen accumulation and the number of α-SMA-positive cells decreased due to powder administration. Therefore, these findings indicate that the in situ cross-linkable powder can prevent esophageal stenosis after ESD.
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Affiliation(s)
- Qi Pan
- Center for Disease Biology and Integrative Medicine, School of Medicine, the University of Tokyo, Japan.
| | - Yosuke Tsuji
- Department of Gastroenterology, School of Medicine, the University of Tokyo, Japan
| | | | - Seiichi Ohta
- Center for Disease Biology and Integrative Medicine, School of Medicine, the University of Tokyo, Japan.
- Institute of Engineering Innovation, School of Engineering, the University of Tokyo, Japan
- Department of Bioengineering, School of Engineering, the University of Tokyo, Japan
| | - Ayano Fujisawa
- Department of Bioengineering, School of Engineering, the University of Tokyo, Japan
| | - Natsuko F Inagaki
- Center for Disease Biology and Integrative Medicine, School of Medicine, the University of Tokyo, Japan.
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, School of Medicine, the University of Tokyo, Japan
| | - Taichi Ito
- Center for Disease Biology and Integrative Medicine, School of Medicine, the University of Tokyo, Japan.
- Department of Chemical System Engineering, School of Engineering, the University of Tokyo, Japan
- Department of Bioengineering, School of Engineering, the University of Tokyo, Japan
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Wallerius KP, Bowen AJ, O'Byrne TJ, Aden AA, Peraza LR, Xie KZ, Richards BA, El-Badaoui J, Bayan SL, Wong Kee Song LM, Ekbom DC. Comparing Open Versus Rigid Endoscopic and Flexible Endoscopic Techniques for the Treatment of Zenker's Diverticulum. Otolaryngol Head Neck Surg 2023; 169:962-970. [PMID: 36906817 DOI: 10.1002/ohn.318] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/16/2023] [Accepted: 01/27/2023] [Indexed: 03/13/2023]
Abstract
OBJECTIVE To describe the outcomes of patients undergoing open stapler versus transoral rigid and flexible endoscopic therapies for symptomatic Zenker's diverticulum. STUDY DESIGN Single institution retrospective review. SETTING Tertiary care academic hospital. METHODS We retrospectively evaluated the outcomes of 424 consecutive patients who underwent Zenker's diverticulotomy via an open stapler, rigid endoscopic CO2 laser, rigid endoscopic stapler, rigid endoscopic harmonic scalpel, or flexible endoscopic technique from January 2006 to December 2020. RESULTS A total of 424 patients (173 females, mean age 73.1 ± 11.2 years) from a single institution were included. A total of 142 patients (33%) underwent endoscopic laser treatment, 33 (8%) underwent endoscopic harmonic scalpel, 92 (22%) underwent endoscopic stapler, 70 (17%) underwent flexible endoscopic, and 87 (20%) underwent open stapler. All open and rigid endoscopic procedures and most of the flexible endoscopic procedures (65%) were performed under general anesthesia. The flexible endoscopic group had a higher percentage of procedure-related perforation, defined as subcutaneous emphysema or contrast leak on imaging (14.3%). The recurrence rates were higher in the harmonic stapler, flexible endoscopic, and endoscopic stapler groups at 18.2%, 17.1%, and 17.4%, respectively, and lower in the open group (1.1%). Length of hospital stay and return to oral intake were similar among groups. CONCLUSION The flexible endoscopic technique was associated with the highest rate of procedure-related perforation, while the endoscopic stapler had the lowest number of procedural complications. Recurrence rates were higher among the harmonic stapler, flexible endoscopic, and endoscopic stapler groups and lower in the endoscopic laser and open groups. Prospective comparative studies with long-term follow-up are needed.
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Affiliation(s)
- Katherine P Wallerius
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew J Bowen
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas J O'Byrne
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Aisha A Aden
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lazaro R Peraza
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Katherine Z Xie
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bradley A Richards
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph El-Badaoui
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Semirra L Bayan
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Dale C Ekbom
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Rudler F, Pineton de Chambrun G, Lallemant B, Garrel R, Pouderoux P, Ramdani M, Caillo L, Reynaud C, Valats JC, Blanc P. Management of the Zenker diverticulum: multicenter retrospective comparative study of open surgery and rigid endoscopy versus flexible endoscopy. Surg Endosc 2023; 37:7064-7072. [PMID: 37380740 DOI: 10.1007/s00464-023-10225-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 06/17/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND AND STUDY AIM Zenker's diverticulum is a rare disease that affects quality of life due to dysphagia and regurgitation. This condition can be treated by various surgical or endoscopic methods. PATIENTS AND METHOD Patients treated for Zenker's diverticulum in three centers in the south of France between 2014 and 2019 were included. The primary objective was clinical efficacy. Secondary objectives were technical success, morbidities, recurrences, and need for a new procedure. RESULTS One hundred forty-four patients with a total of one hundred sixty-five procedures performed were included. A significant difference was found between the different groups in terms of clinical success (97% for open surgery versus 79% for rigid endoscopy versus 90% for flexible endoscopy, p = 0.009). Technical failure occurred more frequently in the rigid endoscopy group than in the flexible endoscopy and surgical groups (p = 0.014). Median procedure duration, median time to resumption of feeding, and hospital discharge were statistically shorter for endoscopies than for open surgery. On the other hand, more recurrences occurred in patients treated by endoscopy than those treated by surgery, and more reinterventions were required. CONCLUSION Flexible endoscopy appears to be as effective and safe as open surgery in the treatment of Zenker's diverticulum. Endoscopy allows a shorter hospital stay at the expense of a higher risk of recurrence of symptoms. It could be used as an alternative to open surgery for the treatment of Zenker's diverticulum, especially in frail patients.
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Affiliation(s)
- Franz Rudler
- Gastroenterology Department, CHU Montpellier, Montpellier, France.
| | | | | | - Renaud Garrel
- ORL Department, CHU Montpellier, Montpellier, France
| | | | | | | | | | | | - Pierre Blanc
- Gastroenterology Department, CHU Montpellier, Montpellier, France
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11
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Cadena Aguirre DP, de Moura DTH, Hirsch B, Peixoto de Oliveira GH, Kum AST, Mahmood S, Bernardo WM, Sharma NR, De Moura EG. Flexible Endoscopy Versus Rigid Endoscopy or Surgery for the Management of Zenker's Diverticulum: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e43021. [PMID: 37680421 PMCID: PMC10480577 DOI: 10.7759/cureus.43021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2023] [Indexed: 09/09/2023] Open
Abstract
Zenker's diverticulum treatment options range from endoscopic rigid or flexible procedures to surgery. There are limited studies available comparing these techniques. Frequently, the choice of treatment depends on the physician's preference or experience, as well as the institution's resources and capacity. Therefore, this study aims to define the best approach based on the highest efficacy and the lowest severe adverse events. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search was performed. Only comparative studies were included, analyzing flexible endoscopy versus rigid endoscopy or surgery. The outcomes analyzed were clinical and technical success, severe adverse events, length of stay, and duration of the procedure. Analysis was performed using Review Manager 5.4.1 (RevMan 5.4, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Eight retrospective cohort studies met the inclusion criteria. A total of 1281 patients were identified, 492 underwent flexible endoscopy, 453 underwent rigid endoscopy, and 336 underwent surgery. There was no difference in clinical success [risk difference (RD), 0.07 (95% CI -0.05 to 0.19%); P = 0.26], technical success [RD, 0.07 (95% CI -0.03 to 0.16); P = 0.18], severe adverse events [RD, -0.03 (95% CI -0.13 to 0.07; P = 0.052), perforation [RD, 0.07 (95% CI -0.04 to 0.19); P = 0.22] or procedure time [mean difference (MD), - 10.03 (95% CI -26.93 to 6.88); P = 0.24). There was lower length of stay with flexible endoscopy compared to the other approaches [MD, -1.98 (95% CI -3.56 to -0.40); P = 0.001]. Based on the current evidence, the three main techniques are effective for the treatment of Zenker's diverticulum. Although there was no significant difference in the safety of each technique in this meta-analysis, this result should be interpreted cautiously due to the limited data and the risk of vies between the techniques, considering that the results tend to favor flexible endoscopy, mainly explained by the newer and safer devices. Length of stay is lower with flexible endoscopy versus the other techniques, which can be beneficial considering the geriatric populations where Zenker's diverticulum mainly occurs.
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Affiliation(s)
- Diego P Cadena Aguirre
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Diogo Turiani Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Bruno Hirsch
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Guilherme Henrique Peixoto de Oliveira
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Angelo So Taa Kum
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | | | - Wanderley Marques Bernardo
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Neil R Sharma
- Division of Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Health, Fort Wayne, USA
| | - Eduardo Guimarães De Moura
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
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12
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Steinway S, Zhang L, Amundson J, Nieto J, Desai P, Jacques J, Bejjani M, Pioche M, Kumta N, Hernandez-Mondragon O, Ujiki M, Khashab M. Long-term outcomes of Zenker's peroral endoscopic myotomy (Z-POEM) for treatment of Zenker's diverticulum. Endosc Int Open 2023; 11:E607-E612. [PMID: 37397859 PMCID: PMC10310448 DOI: 10.1055/a-2067-9105] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/30/2023] [Indexed: 07/04/2023] Open
Abstract
Background and study aims Z-POEM is now an established therapy for symptomatic Zenker's diverticulum (ZD). Short-term follow-up of up to 1-year post Z-POEM suggests excellent efficacy and safety; however, long-term outcomes are not known. Thus, we sought to report on longer-term outcomes (≥ 2 years) following Z-POEM for treatment of ZD. Patients and methods This was an International multicenter retrospective study at eight institutions across North America, Europe, and Asia over a 5-year period (from December 3, 2015 to March 13, 2020) of patients who underwent Z-POEM for management of ZD with a minimum 2-year follow-up. The primary outcome was clinical success, defined as improvement in dysphagia score to ≤ 1 without need for further procedures during the first 6 months. Secondary outcomes included rate of recurrence in patients initially meeting clinical success, rate of reintervention, and adverse events (AEs). Results A total of 89 patients (male 57.3 %, mean age 71 ± 12 years) underwent Z-POEM for treatment of ZD (mean diverticulum size was 3.4 ± 1.3 cm). Technical success was achieved in 97.8 % of patients (n = 87) with a mean procedure time of 43.8 ± 19.2 minutes. The median post-procedure hospital stay was 1 day. There were eight AEs (9 %) (3 mild, 5 moderate). Overall, clinical success was achieved in 84 patients (94 %). Mean dysphagia, regurgitation, and respiratory scores all improved dramatically from 2.1 ± 0.8, 2.8 ± 1.3, and 1.8 ± 1.6 pre-procedure to 0.13 ± 0.5, 0.11 ± 0.5, and 0.05 ± 0.4, respectively, post-procedure at most recent follow-up (all P < 0.0001). Recurrence occurred in six patients (6.7 %) during a mean length of follow-up of 37 months (range 24 to 63 months). Conclusions Z-POEM is a highly safe and effective treatment for Zenker's diverticulum with durable treatment effect to at least 2 years.
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Affiliation(s)
- Steven Steinway
- Johns Hopkins Medicine, Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Linda Zhang
- Johns Hopkins Medicine, Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Julia Amundson
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, United States
| | - Jose Nieto
- University of Central Florida, Department of Gastroenterology, Orlando, Florida, United States
| | - Pankaj Desai
- Surat Institute of Digestive Sciences, GI Endoscopy, Surat, India
| | - Jeremie Jacques
- CHU Dupytren Limoges, Service d'Hépato-gastro-entérologie, Limoges, France
| | - Michael Bejjani
- Johns Hopkins Medicine, Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Mathieu Pioche
- Hôpital Edouard Herriot, Endoscopy Unit, Digestive Disease Department, Lyon, France
| | - Nikhil Kumta
- Icahn School of Medicine at Mount Sinai, Division of Gastroenterology, New York, New York, United States
| | | | - Michael Ujiki
- NorthShore University Health Systems, NorthShore Center for Simulation and Innovation, Evanston, Illinois, United States
| | - Mouen Khashab
- Johns Hopkins Medicine, Gastroenterology and Hepatology, Baltimore, Maryland, United States
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13
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Kana M, Kalfert D, Lukes P, Zabrodsky M, Plzak J. C-reactive protein as an early marker of postoperative leakage in patients after endoscopic laser assisted Zenker's diverticulotomy. Eur Arch Otorhinolaryngol 2023; 280:2007-2016. [PMID: 36449093 DOI: 10.1007/s00405-022-07764-2] [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: 10/11/2022] [Accepted: 11/22/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND AND AIM Minimally invasive endoscopic techniques are the treatment of choice for Zenker's diverticulum (ZD). Our objective was to evaluate the results and efficacy of endoscopic and open approaches, to determine whether postoperative C-reactive protein (CRP) serum levels can be used as a marker to exclude the presence of esophageal leakage, and to identify risk factors for development of postoperative leakage and complications. MATERIALS AND METHODS Patients who underwent transcervical myotomy and diverticulotomy (TMD) or endoscopic cricopharyngeal myotomy (ECM) with CO2 laser for ZD in years 2008-2021 at our department were included in this retrospective study. RESULTS Of the 101 patients enrolled, 83 patients underwent ECM and 18 TMD. The procedure time of the endoscopic technique was significantly shorter compared to that of transcervical method (p < 0.001). The median time to oral intake was 6 days for ECM and 10.5 days in the TMD group (p < 0.001). There was a 13% (n = 11) and 16.7% (n = 3) symptomatic recurrence rate and 3.6% (n = 3) and 16.7% (n = 3) major complications rate for ECM and TMD groups, respectively. The incidence of contrast leak (CL) evaluated by postoperative swallow study was 8.9% (9 from 83 patients in the ECM group only). In patients with CL, a significant increase in CRP levels on postoperative day (POD) 2 and 3 was detected when compared to patients without CL. CONCLUSIONS Endoscopic diverticulotomy with CO2 laser represents a safe and efficient treatment of ZD. Elevation of postoperative CRP serum levels over 123.8 mg/L on POD2 and 98.8 mg/L on POD3 may indicate presence of an esophageal leakage.
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Affiliation(s)
- Martin Kana
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Motol, First Faculty of Medicine, Charles University, V Uvalu 84, 150 06, Prague, Czech Republic
| | - David Kalfert
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Motol, First Faculty of Medicine, Charles University, V Uvalu 84, 150 06, Prague, Czech Republic.
| | - Petr Lukes
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Motol, First Faculty of Medicine, Charles University, V Uvalu 84, 150 06, Prague, Czech Republic
| | - Michal Zabrodsky
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Motol, First Faculty of Medicine, Charles University, V Uvalu 84, 150 06, Prague, Czech Republic
| | - Jan Plzak
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Motol, First Faculty of Medicine, Charles University, V Uvalu 84, 150 06, Prague, Czech Republic
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14
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Dimpel R, Jell A, Reim D, Berlet M, Kranzfelder M, Vogel T, Friess H, Feussner H, Wilhelm D. The impact of prior endoscopic or surgical therapy on open Zenker's diverticulum surgery: analysis on a large single center cohort : Comparison of primary and revisional open surgery for Zenker's diverticulum. Surg Endosc 2023; 37:2112-2118. [PMID: 36316583 PMCID: PMC10017560 DOI: 10.1007/s00464-022-09690-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 09/25/2022] [Indexed: 03/17/2023]
Abstract
BACKGROUND Endoscopic treatment of Zenker's diverticulum is an attractive minimally invasive alternative compared to the classic open approach. However, increased recurrence rate were reported. In case of relapse, endoscopic therapy might be repeated, or alternatively open surgery is performed. This study aimed to identify potential differences in the outcomes between primary or secondary surgical treatment in Zenker's diverticulum. METHODS From January 2003 to April 2019, 227 subsequent patients underwent surgical diverticulectomy and cervical myotomy at the surgical department of TUM. 41 of 227 patients had received previous therapy, either open or endoscopic. Perioperative parameters in priorly untreated patients were retrospectively compared to those after previous therapy (mostly endoscopic) with special regard to perioperative data and postoperative complications. Univariate and multivariate regression analyses were performed to identify predictors for postoperative complications. RESULTS We could show that the number of complications (p = 0.047) in pretreated patients is significant higher as well as the severity after Clavien-Dindo (p = 0.025). Stapler line leakage, wound infections, and operative revision rate was higher also pretreated group. Pretreatment and surgery time showed a significant association with postoperative complications in univariate analysis. In multivariate analysis, pretreatment remained a significant independent predictor of complications. CONCLUSION The present data indicate that endoscopic therapy might represent a risk factor for postoperative complications in case of relapse surgery. Therefore primary open surgery should be debated in patients with an increased high risk of relapse.
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Affiliation(s)
- Rebekka Dimpel
- Department of Surgery, Faculty of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
- MITI Research Group (Minimally Invasive Interdisciplinary Therapeutical Interventions), Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Alissa Jell
- Department of Surgery, Faculty of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- MITI Research Group (Minimally Invasive Interdisciplinary Therapeutical Interventions), Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Daniel Reim
- Department of Surgery, Faculty of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Maximilian Berlet
- Department of Surgery, Faculty of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- MITI Research Group (Minimally Invasive Interdisciplinary Therapeutical Interventions), Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kranzfelder
- Department of Surgery, Faculty of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- MITI Research Group (Minimally Invasive Interdisciplinary Therapeutical Interventions), Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Thomas Vogel
- Department of Surgery, Faculty of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- MITI Research Group (Minimally Invasive Interdisciplinary Therapeutical Interventions), Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Helmut Friess
- Department of Surgery, Faculty of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Hubertus Feussner
- Department of Surgery, Faculty of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- MITI Research Group (Minimally Invasive Interdisciplinary Therapeutical Interventions), Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Dirk Wilhelm
- Department of Surgery, Faculty of Medicine, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
- MITI Research Group (Minimally Invasive Interdisciplinary Therapeutical Interventions), Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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15
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Constantin A, Constantinoiu S, Achim F, Socea B, Costea DO, Predescu D. Esophageal diverticula: from diagnosis to therapeutic management-narrative review. J Thorac Dis 2023; 15:759-779. [PMID: 36910058 PMCID: PMC9992562 DOI: 10.21037/jtd-22-861] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 12/12/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Esophageal diverticulum (ED) is a relatively rare condition, characterized by high etio- and pathophysiological versatility, with an uncommon clinical impact, consequently requiring a complete and complex diagnostic evaluation, so that the therapeutic decision is "appropriate" to a specific case. The aim of the paper is, therefore, a reassessment of the diagnostic possibilities underlying the establishment of the therapeutic protocol and the available therapeutic resources, making a review of the literature, and a non-statistical retrospective analysis of cases hospitalized and operated in a tertiary center. METHODS Thus, classical investigations (upper digestive endoscopy, barium swallow) need to be correlated with complex, manometric, and imaging evaluations with direct implications in therapeutic management. Moreover, in the absence of a precise etiology, the operative indication needs to be established sparingly, with the imposition of the identification and interception of the pathophysiological mechanisms through the therapeutic gesture. KEY CONTENT AND FINDINGS The identification of the pathophysiological mechanisms is mandatory for the management of diverticular disease, the result obtained-restoring swallowing and comfort/good quality of life in the postoperative period-is directly related to the chosen therapeutic procedure. In addition, management appears to be a difficult goal in the context of the low incidence of ED but also of the results that emphasize important differences in the reports in the medical literature. Although ED is a benign condition, surgical techniques are demanding, impacted by significant morbidity and mortality. The causes of these results are multiple: possible localizations anywhere in the esophagus, diverticulum size/volume from a few millimeters to an impressive one, over 10-12 cm, metabolic impact in direct relation to the alteration swallowing, numerous diverticular complications but, perhaps most importantly, alteration of the quality of the diverticular wall by inflammatory phenomena, with an impact on the quality of the suture. CONCLUSIONS The accumulation of cases in a tertiary profile center, with volume/hospital, respectively volume/surgeon + gastroenterologist could be a solution in improving the results. One consequence would be the identification of alternative solutions to open surgical techniques, a series of minimally invasive or endoscopic variants can refine these results.
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Affiliation(s)
- Adrian Constantin
- General and Esophageal Clinic, Sf. Maria Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Silviu Constantinoiu
- General and Esophageal Clinic, Sf. Maria Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Florin Achim
- General and Esophageal Clinic, Sf. Maria Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Bogdan Socea
- Department of Surgery, Sf. Pantelimon Emergency Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Daniel Ovidiu Costea
- Department II of Surgery, Emergency Hospital, Ovidius University of Medicine, Constanta, Romania
| | - Dragos Predescu
- General and Esophageal Clinic, Sf. Maria Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
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16
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Schoeman S, Kobayashi R, Marcon N, May G, Mosko J, Teshima C. Outpatient flexible endoscopic diverticulotomy for the management of Zenker's diverticulum: a retrospective analysis of a large single-center cohort. Gastrointest Endosc 2023; 97:226-231.e2. [PMID: 36228698 DOI: 10.1016/j.gie.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/10/2022] [Accepted: 09/26/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUNDS AND AIMS Flexible endoscopic Zenker's diverticulotomy (EZD) is well established as a safe and effective technique. Because of rare but concerning adverse events, most centers admit patients for observation and barium swallow study. Our center routinely performs EZD as a day procedure, discharging appropriate patients on the same day after clinical review. This study evaluates outcomes of this cohort compared with previously published studies where patients are admitted for observation. METHODS A retrospective analysis was performed of EZD procedures done at our center using a flexible endoscope and, in most cases, a diverticulotomy overtube with patients under moderate sedation or general anesthesia. Patients were observed for 2 hours and discharged if no clinical concerns were found. Patient comorbidities, American Society of Anesthesiologists physical status, and endoscopic adverse events were recorded against the American Society for Gastrointestinal Endoscopy severity grading system. RESULTS Two hundred forty EZD procedures were performed between January 2015 and February 2021. Eleven (4.6%) intraprocedural adverse events occurred: 4 perforations, 4 bleeds, and 1 each postprocedural pain, delirium, and vomiting, respectively. All were recognized within the 2-hour observation period and were managed conservatively, except 1 patient who required surgery. Six patients (2.5%) presented with delayed adverse events: 2 bleeds, 2 perforations, and 2 postprocedural pain. All patients recovered uneventfully with supportive care. CONCLUSIONS All significant adverse events requiring endoscopic or surgical intervention were identified before discharge. Delayed adverse events occurred in 2.5% of cases, all of which were managed supportively. Our data are comparable with published cohorts of admitted patients, demonstrating that appropriately selected patients may be managed as outpatients while maintaining similar safety outcomes.
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Affiliation(s)
- Scott Schoeman
- Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, Division of Gastroenterology and Hepatology, Department of Medicine, St Michael's Hospital, Toronto, Ontario, Canada; Division of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Ryosuke Kobayashi
- Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, Division of Gastroenterology and Hepatology, Department of Medicine, St Michael's Hospital, Toronto, Ontario, Canada; Division of Endoscopy, Yokohama City University Medical Center, Yokohama, Japan
| | - Norman Marcon
- Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, Division of Gastroenterology and Hepatology, Department of Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Gary May
- Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, Division of Gastroenterology and Hepatology, Department of Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Jeffrey Mosko
- Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, Division of Gastroenterology and Hepatology, Department of Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Christopher Teshima
- Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, Division of Gastroenterology and Hepatology, Department of Medicine, St Michael's Hospital, Toronto, Ontario, Canada
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Indications and Outcomes of Per Oral Endoscopic Myotomy from Mouth to Anus. Gastrointest Endosc Clin N Am 2023; 33:99-125. [PMID: 36375890 DOI: 10.1016/j.giec.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Third space endoscopy or submucosal endoscopy using a mucosal flap valve allows secure access to the submucosal and deeper layers of the gastrointestinal tract without the risk of a full-thickness perforation. This allows the performance of submucosal tunneling and myotomy for spastic segments of the gastrointestinal tract. Per oral endoscopic myotomy (POEM) has been described for the treatment of achalasia cardia and other spastic esophageal disorders and is widely implemented. Endoscopic pyloromyotomy (G-POEM) has been performed for the treatment of refractory gastroparesis. Z-POEM for Zenker's diverticulum, D-POEM for epiphrenic diverticulum, and per-rectal endoscopic myotomy for treatment of Hirschsprung's disease are described..
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Maehata T, Sato Y, Nakamoto Y, Kato M, Kawashima A, Kiyokawa H, Yasuda H, Yamamoto H, Tateishi K. Updates in the Field of Submucosal Endoscopy. LIFE (BASEL, SWITZERLAND) 2022; 13:life13010104. [PMID: 36676053 PMCID: PMC9864725 DOI: 10.3390/life13010104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 12/24/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022]
Abstract
Submucosal endoscopy (third-space endoscopy) can be defined as an endoscopic procedure performed in the submucosal space. This procedure is novel and has been utilized for delivery to the submucosal space in a variety of gastrointestinal diseases, such as a tumor, achalasia, gastroparesis, and subepithelial tumors. The main submucosal endoscopy includes peroral endoscopic myotomy, gastric peroral endoscopic myotomy, Zenker peroral endoscopic myotomy, submucosal tunneling for endoscopic resection, and endoscopic submucosal tunnel dissection. Submucosal endoscopy has been used as a viable alternative to surgical techniques because it is minimally invasive in the treatment and diagnosis of gastrointestinal diseases and disorders. However, there is limited evidence to prove this. This article reviews the current applications and evidence regarding submucosal endoscopy while exploring the possible future clinical applications in this field. As our understanding of these procedures improves, the future of submucosal endoscopy could be promising in the fields of diagnostic and therapeutic endoscopy.
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19
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Orbán-Szilágyi Á, Bakucz T, Gyökeres T. [Characteristics and outcomes of 47, conventional flexible endoscopic interventions for Zenker's diverticulum Review of therapeutic options]. Orv Hetil 2022; 163:677-687. [PMID: 35462353 DOI: 10.1556/650.2022.32460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/05/2022] [Indexed: 01/04/2025]
Abstract
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.
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Affiliation(s)
- Ákos Orbán-Szilágyi
- 1 Magyar Honvédség Egészségügyi Központ, Honvédkórház, Gasztroenterológiai Osztály Budapest, Róbert Károly krt. 44., 1134 Magyarország
| | - Tamás Bakucz
- 1 Magyar Honvédség Egészségügyi Központ, Honvédkórház, Gasztroenterológiai Osztály Budapest, Róbert Károly krt. 44., 1134 Magyarország
| | - Tibor Gyökeres
- 1 Magyar Honvédség Egészségügyi Központ, Honvédkórház, Gasztroenterológiai Osztály Budapest, Róbert Károly krt. 44., 1134 Magyarország
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Saraniti C, Greco G, Verro B, Chianetta E, Lo-Casto A. Zenker's Diverticulum in Forestier Disease: Chance or Causality? IRANIAN JOURNAL OF OTORHINOLARYNGOLOGY 2022; 34:107-112. [PMID: 35655763 PMCID: PMC9119336 DOI: 10.22038/ijorl.2021.60053.3068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/02/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Zenker's diverticulum is an acquired sac-like outpouching of the mucosa and submucosa layers originating at the pharyngoesophageal junction. The predominant symptom of Zenker's diverticulum is dysphagia. Videofluoroscopy confirms the diagnosis. Forestier disease is a clinical entity characterized by ossification of anterolateral vertebral ligament and anterior osteophyte formation along the anterolateral spinal column. Its etiopathogenesis remains unknown and common symptoms are dysphagia, dysphonia and airway obstruction. The objective of this study is to identify a pathophysiological correlation between Forestier disease and the onset of Zenker's diverticulum. MATERIALS AND METHODS A retrospective observational study was conducted. The electronic database of our Radiology Unit was analyzed in order to identify patients with hypopharyngeal diverticulum and osteophytes at the cervical vertebrae level, from January 2010 to January 2021. The search was performed using precise keywords. RESULTS The computerized database search outlined 10 imaging exams: 5 videofluorographies and 5 computed tomography scans. In 100% of the cases, dysphagia was the main symptom that led to the diagnostic assessment; 30% of patients, on the other hand, reported dyspnoea. From the data analysis, the male / female ratio is 1: 1 and the average age of the patients is 64.8 (+/- 11.31) years. CONCLUSIONS We assume that the anatomical abnormalities in Forestier disease may cause an increase of pharyngeal pressure and consequently support the development of the Zenker's diverticulum. Hence, it is always recommended to investigate the presence of Zenker's diverticulum in a patient with Forestier disease, especially for the life-threatening complications of Zenker's diverticulum.
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Affiliation(s)
- Carmelo Saraniti
- Department of Biomedicine, Neuroscience and Advanced Diagnostic, University of Palermo, Palermo, Italy.,Corresponding Author: Otorhinolaryngology Clinic, Department of Biomedicine, Neurosciences and Advanced Diagnostic University of Palermo,Via del Vespro n°129,Palermo, 90127, Italy.E-mail:
| | - Giuseppe Greco
- Department of Biomedicine, Neuroscience and Advanced Diagnostic, University of Palermo, Palermo, Italy.
| | - Barbara Verro
- Department of Biomedicine, Neuroscience and Advanced Diagnostic, University of Palermo, Palermo, Italy.
| | - Enzo Chianetta
- Department of Biomedicine, Neuroscience and Advanced Diagnostic, University of Palermo, Palermo, Italy.
| | - Antonio Lo-Casto
- Department of Biomedicine, Neuroscience and Advanced Diagnostic, University of Palermo, Palermo, Italy.
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21
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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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22
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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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23
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Sanaei O, Ichkhanian Y, Mondragón OVH, Nieto J, Krishnan A, Tantau M, Tantau A, Desai PN, Ginsberg GG, Saumoy M, Deshmukh A, Attaar M, Farha J, Jovani M, Al-Ghamdi SS, Ujiki M, Khashab MA. Impact of prior treatment on feasibility and outcomes of Zenker's peroral endoscopic myotomy (Z-POEM). Endoscopy 2021; 53:722-726. [PMID: 33096576 DOI: 10.1055/a-1276-0219] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Zenker's peroral endoscopic myotomy (Z-POEM) is a novel procedure for the management of symptomatic Zenker's diverticulum. This study aims to report the technical feasibility and outcomes of Z-POEM in the management of Zenker's diverticulum after prior failed interventions. METHODS Patients with persistent or recurrent symptoms after prior endoscopic and/or surgical intervention for Zenker's diverticulum were retrospectively included. The primary outcome was clinical success, defined as complete or near complete resolution of dysphagia (dysphagia score of 0 or 1) without the need for repeat endoscopic or surgical intervention during follow-up. RESULTS Z-POEM was technically successful in 30/32 patients (93.8 %). Clinical success was achieved in 29/30 patients (96.7 %), and Z-POEM significantly reduced the median (interquartile range [IQR]) dysphagia score of patients from 2 (1 - 2) to 0 (0) (P < 0.001) over a median duration of follow up of 166 days (IQR 39 - 566). Four patients (12.5 %) had adverse events (two inadvertent mucosotomies and two leaks found on post-procedural esophagrams). CONCLUSION Z-POEM is feasible, safe, and effective in the majority of patients with recurrent symptoms after prior surgical or endoscopic interventions.
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Affiliation(s)
- Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
- Department of Medicine, MedStar Health System, Baltimore, Maryland, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | | | - Jose Nieto
- Division of Gastroenterology and Hepatology, Borland Groover Clinic, Jacksonville, Florida, USA
| | - Arunkumar Krishnan
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Marcel Tantau
- Gastroenterology and Hepatology Medical Center, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Alina Tantau
- Gastroenterology and Hepatology Medical Center, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | | | - Gregory G Ginsberg
- Endoscopic Services, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Monica Saumoy
- Endoscopic Services, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ameya Deshmukh
- Division of Gastroenterology and Hepatology, Borland Groover Clinic, Jacksonville, Florida, USA
| | - Mikhail Attaar
- Department of Surgery, Grainger Center of Simulation and Innovation, NorthShore University Health System, Evanston, Illinois, USA
| | - Jad Farha
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Manol Jovani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Sarah S Al-Ghamdi
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Michael Ujiki
- Department of Surgery, Grainger Center of Simulation and Innovation, NorthShore University Health System, Evanston, Illinois, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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24
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Devices and techniques for flexible endoscopic management of Zenker's diverticulum (with videos). Gastrointest Endosc 2021; 94:3-13. [PMID: 33926711 DOI: 10.1016/j.gie.2021.02.020] [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: 02/12/2021] [Accepted: 02/13/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Zenker's diverticulum (ZD) has traditionally been treated with open surgery or rigid endoscopy. With the advances in endoscopy, alternative flexible endoscopic treatments have been developed. METHODS This document reviews current endoscopic techniques and devices used to treat ZD. RESULTS The endoscopic techniques may be categorized as the traditional flexible endoscopic septal division and the more recent submucosal tunneling endoscopic septum division, also known as peroral endoscopic myotomy for ZD. This document also addresses clinical outcomes, safety, and financial considerations. CONCLUSIONS Flexible endoscopic approaches treat symptomatic ZD with results that are favorable compared with traditional open surgical or rigid endoscopic alternatives.
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25
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Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel JDJ, Valenzuela-Salazar C, Rodriguez-Parra A, Del Rio-Suarez I, Vargas-Madrigal J, Akar T, Günay S, Houmani Z, Abayli B, Elkady MA, Alzamzamy A, Wahba M, Madkour A, Mahdy RE, Essam K, Khashab MA. Peroral endoscopic myotomy as treatment for Zenker's diverticulum (Z-POEM): a multi-center international study. Esophagus 2021; 18:693-699. [PMID: 33387150 DOI: 10.1007/s10388-020-00809-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/18/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Peroral endoscopic myotomy for the treatment of Zenker's diverticulum (Z-POEM) is a novel technique that has been described in several recent reports. This method utilizes the third space (submucosal layer) to create a tunnel to facilitate complete visualization of the septum and hence cutting it entirely. Conventional endoscopic septotomy carries the risk of recurrence due to incomplete visualization of the septum. While surgical correction is a risky and lengthy procedure in old comorbid patients with Zenker's diverticulum. The aim of this study is to assess the efficacy and safety of Z-POEM. METHODS The study enrolled 24 patients diagnosed with Zenker's diverticulum (ZD) who underwent Z-POEM at seven independent endoscopy centers in five different countries. RESULTS Mean patient age ± standard deviation (SD) was 74.3 ± 11 years. Most of the patients were males (n = 20, 83.3%); four (16.7%) were females. More than 50% of the patients (n = 14, 58.3%) had associated comorbidities. The mean size of the diverticula was 4 cm (range 2-7 cm). The Kothari-Haber Score was used to assess clinical symptoms; values ranged from 6 to 14 (median = 9). We achieved 100% technical success with a median procedure time of 61 min and no adverse events. Median hospital stay was 1 day (range 1-5 days). There is a significant reduction in the Kothari-Haber Score after Z-POEM (P < 0.0001). Technical success was achieved in 100% of the patients. Clinical success was achieved in 23/24 (95.8%) of the patients with a median follow-up of 10 months (range 6-24 months). CONCLUSION Z-POEM is a safe and effective modality for managing ZD.
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Affiliation(s)
- Shaimaa Elkholy
- Gastroenterology Division, Internal Medicine Department, Faculty of Medicine, Cairo University, Kasr Alainy Street Cairo, Cairo, 11311, Egypt.
| | - Mohamed El-Sherbiny
- Gastroenterology Division, Internal Medicine Department, Faculty of Medicine, Cairo University, Kasr Alainy Street Cairo, Cairo, 11311, Egypt
| | - Roberto Delano-Alonso
- Gastroenterology Department, Manuel Gea Gonzalez General Hospital, Mexico City, Mexico
| | | | | | | | | | - Jorge Vargas-Madrigal
- Gastroenterology Department, Enrique Baltodano Briceno Hospital, Liberia, Costa Rica
| | - Tarik Akar
- Gastroenterology Department, Faculty of Medicine, Bulent Ecevit University, Zonguldak, Turkey
| | - Süleyman Günay
- Gastroenterology Department, Ataturk Education and Research Hospital, Izmir Katip Celebi University, Izmir, Turkey
| | - Zaher Houmani
- Gastroenterology Department, Faculty of Medicine, Najdeh Hospital, Lebanese University, Beirut, Lebanon
| | - Bahri Abayli
- Gastroenterology Department, Seyhan State Hospital, Adana, Turkey
| | - Mohammad A Elkady
- Gastroenterology and Hepatology Department, Theodor Bilharz Research Institute, Cairo, Egypt
| | - Ahmed Alzamzamy
- Gastroenterology and Hepatology Department, Military Medical Academy, Cairo, Egypt
| | - Mahmoud Wahba
- Gastroenterology Division, Internal Medicine Department, Faculty of Medicine, Cairo University, Kasr Alainy Street Cairo, Cairo, 11311, Egypt
| | - Ahmad Madkour
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Reem Ezzat Mahdy
- Gastroenterology Division, Internal Medicine Department, Faculty of Medicine, Assuit University, Assuit, Egypt
| | - Kareem Essam
- Gastroenterology Division, Internal Medicine Department, Faculty of Medicine, Cairo University, Kasr Alainy Street Cairo, Cairo, 11311, Egypt
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, USA
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Delliturri A, Wiesel O, Shaw J, Brichkov I. A Narrative Review of update in per oral endoscopic myotomy (POEM) and endoscopic esophageal surgery. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:909. [PMID: 34164543 PMCID: PMC8184417 DOI: 10.21037/atm-20-5057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The field of endoscopic esophageal surgery is based on the concept of natural orifice transluminal endoscopic surgery (NOTES). Submucosal space surgery or third space surgery with the use of flexible endoscopy allows for decreased morbidity and hospital length of stay with equivalent outcomes for patients. In the case of achalasia, per oral endoscopic myotomy (POEM) allows for management of refractory cases in setting of previous Heller Myotomy or in patients whom laparoscopic or thoracoscopic surgery is contraindicated. Lastly, POEM more directly divides circular muscular layer of esophagus without destroying surrounding structures that exist to prevent reflux. The innovations in endoscopic surgery began in the animal lab with experiments in the porcine model to develop a way to access the peritoneal cavity through an entry point in the gastric mucosa. Over the last 10 years, the biggest treatment innovations in endoscopy have focused on management of achalasia with the use of POEM. POEM became possible as technology was developed that revolutionized the use of flexible technology and the methods of mucosal closure. In addition to benign esophageal disease, endoscopic methods improved in management of esophageal malignancy with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). The innovations of endoscopic surgery have been developed through the utilization of the submucosal space as a method to ensure adequate closure of the mucosal entry point into the peritoneal cavity. The goal of this review paper is to explore POEM and other techniques in endoscopic esophageal surgery for the management of esophageal diverticulum, submucosal tumors, gastroparesis, and gastrointestinal esophageal reflux disease.
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Affiliation(s)
| | - Ory Wiesel
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Jason Shaw
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Igor Brichkov
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
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27
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Vetshev FP, Tskhovrebov AT, Shestakov AL, Dergunova AP. [Transaxillary minimally invasive Zenker's diverticulectomy]. Khirurgiia (Mosk) 2021:57-61. [PMID: 33710827 DOI: 10.17116/hirurgia202103157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We evaluated the possibility and effectiveness of transaxillary gas-free approach for minimally invasive Zenker's diverticulectomy. A 64-year-old patient with large Zenker's diverticulum (6 cm) and pathognomonic symptoms is presented. Transaxillary gas-free minimally invasive diverticulectomy was performed using an endoscopic linear stapler. Surgery time was 137 min. There were not any postoperative complications including recurrent laryngeal nerve injury. X-ray examination after 2 postoperative days revealed no signs of anastomotic leakage, so the patient was allowed to drink and consume liquid food from the 3rd day. Patient was discharged on the 7th day. Minimally invasive surgical technology ensures effective and radical transaxillary diverticulectomy in patients with Zenker's diverticulum. The advantages of this method are good and detailed exposition of surgical field, including recurrent laryngeal nerve, more precise and less invasive manipulations and better cosmetic effect. The method may be an alternative to traditional and endoscopic diverticulectomy for a certain group of patients. However, experience accumulation and further prospective studies are required.
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Affiliation(s)
- F P Vetshev
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - A T Tskhovrebov
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - A L Shestakov
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - A P Dergunova
- Petrovsky National Research Center of Surgery, Moscow, Russia
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28
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Affiliation(s)
- Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, United States
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29
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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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30
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Kaaki S, Hartwig MG. Commentary: Zenker's diverticulum: One size does not fit all. J Thorac Cardiovasc Surg 2021; 163:1977-1978. [PMID: 33551074 DOI: 10.1016/j.jtcvs.2020.12.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 12/28/2020] [Accepted: 12/28/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Suha Kaaki
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC.
| | - Matthew G Hartwig
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC
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Affiliation(s)
- Mihir S Wagh
- Division of Gastroenterology, University of Colorado-Denver, Aurora, Colorado.
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
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Moroco AE, Saadi RA, Patel VA, Lehman EB, Gniady JP. 30-Day Postoperative Outcomes Following Transcervical Zenker's Diverticulectomy in the Elderly: Analysis of the NSQIP Database. Otolaryngol Head Neck Surg 2020; 165:129-136. [PMID: 33287659 DOI: 10.1177/0194599820970503] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To compare the effect of patient factors, including age, on 30-day postoperative outcomes and complications for patients undergoing transcervical Zenker's diverticulectomy. STUDY DESIGN Retrospective cross-sectional analysis. SETTING American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database. METHODS Patients who underwent open Zenker's diverticulectomy (Current Procedural Terminology code 43130) were queried via the NSQIP (2006-2018). Outcomes analyzed include patient demographics, medical comorbidities, admission type, operative characteristics, length of admission, postoperative complication, readmission, and reoperation. RESULTS A total of 614 patients were identified. Mean age at time of surgery was 71.1 years, with 13.4% older than 85 years. Outpatient procedures were performed in 29.8%. Postoperative complications occurred in 6.7%, with reoperation and readmission rates of 6.4% and 7.2%, respectively. A mortality rate of 0.3% was observed. Only smoking status (odds ratio, 2.94; P = .008) and history of congestive heart failure (odds ratio, 10.00; P = .014) were shown to have a significant effect on postoperative complications. CONCLUSION Smoking status confers a high risk for postoperative complication. Age was not an independent risk factor associated with adverse outcomes following open diverticulectomy, suggesting this procedure can be safely performed in patients with advanced age.
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Affiliation(s)
- Annie E Moroco
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert A Saadi
- Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - Vijay A Patel
- Department of Otolaryngology, University of Pittsburgh School of Medicine, UPMC Centers for Cranial Base Surgery & Sinonasal Disorders and Allergy, Pittsburgh, Pennsylvania, USA
| | - Erik B Lehman
- Department of Public Health Sciences, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
| | - John P Gniady
- Department of Otolaryngology-Head and Neck Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania, USA
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Sun PH, Ding XY. Submucosal tunneling endoscopic septum division for treatment of esophageal diverticulum: A pilot study. Shijie Huaren Xiaohua Zazhi 2020; 28:959-963. [DOI: 10.11569/wcjd.v28.i19.959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Submucosal tunneling endoscopic septum division (STESD) is a new endoscopic technique for the treatment of esophageal diverticulum. However, there are few studies on the application of STESD, so its safety and feasibility need to be further evaluated.
AIM To evaluate the feasibility and efficacy of STESD for esophageal diverticulum.
METHODS Three patients who underwent STESD at Ningbo First Hospital from November 2017 to January 2019 were enrolled in this study, and the clinical data were analyzed retrospectively. The symptoms including dysphagia, heartburn, regurgitation, weight loss, and retrosternal pain were scored using a system modified according to Eckardt score, with the score of each symptom ranging from 0 to 3 (maximum total score 15, minimum total score 0; the higher the score, the more severe the symptoms).
RESULTS One patient had epiphrenic diverticulum, and two had Zenker's diverticula. All the three patients underwent STESD successfully. No major adverse events such as perforation or bleeding were found in the perioperative period. The patients were followed for at least 9 mo, and the longest follow-up time was 23 mo. The preoperative symptom scores for the three patients were 4, 7, and 8, and the postoperative scores declined to 0, 0, and 2, respectively. No recurrence or aggravation of symptoms was observed.
CONCLUSION STESD is efficient and safe to relieve symptomatic esophageal diverticulum in short term.
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Affiliation(s)
- Ping-Hu Sun
- Department of Digestive Medicine, Ningbo First Hospital, Ningbo 315000, Zhejiang Province, China
| | - Xiao-Yun Ding
- Department of Digestive Medicine, Ningbo First Hospital, Ningbo 315000, Zhejiang Province, China
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Pugliese F, Dioscoridi L, Italia A, Forgione A, Cintolo M, Forti E, Bonato G, Massad M, Mutignani M. Peroral Endoscopic Diverticulotomy (POED) for Zenker Diverticulum Using Submucosal Injection to Perform a Complete Myotomy. Surg Laparosc Endosc Percutan Tech 2020; 30:e30-e32. [PMID: 33021771 DOI: 10.1097/sle.0000000000000814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Endoscopic diverticulotomy associated with cricopharyngeal myotomy is a well-known and safe treatment for Zenker diverticulum. We describe our first 5 consecutive cases treated by a new variant of the technique that allows a deeper and longer myotomy than the standard one. Technical success was achieved in all the cases. All patients showed a significant improvement and relevant disappearance of preoperative dysphagia. Tips for the technique are described in the paper. This variant of peroral endoscopic diverticulotomy for Zenker diverticulum is feasible, effective, and guarantees a complete myotomy in selected patients.
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Affiliation(s)
| | | | | | - Antonello Forgione
- Mininvasive and Oncological Surgery Unit, Niguarda Hospital, ASST Niguarda, Milan, Italy
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Nitschke P, Kemper M, König P, Zahnert T, Weitz J, Reissfelder C, Distler M. Interdisciplinary Comparison of Endoscopic Laser-Assisted Diverticulotomy vs. Transcervical Myotomy as a Treatment for Zenker's Diverticulum. J Gastrointest Surg 2020; 24:1955-1961. [PMID: 31482409 DOI: 10.1007/s11605-019-04381-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 08/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Currently, there are different competing techniques for the treatment of Zenker's diverticulum (ZD). To improve patient selection, we compared endoscopic laser-assisted diverticulotomy (ELAD) with transcervical myotomy (TCM) with regard to possible risk factors for treatment failure. METHODS Data of ZD patients (n = 104) treated between 2004 and 2016 with either TCM (38%) or ELAD (62%) were analyzed retrospectively. Univariate and multivariate analyses were performed. RESULTS TCM is associated with a higher morbidity (27.8% vs. 10.2%; p = 0.095) but lower recurrence rate (7.3% vs. 19.3%; p = 0.095). Preoperative reflux disease (OR 8.755; p = 0.021) was identified as an independent risk factor for complications. CONCLUSIONS Although short-term outcome and symptom relief are similar, TCM tends to have a higher complication rate but better long-term results. Preoperative reflux disease is an independent risk factor for postoperative complications.
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Affiliation(s)
- Philipp Nitschke
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Max Kemper
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Patricia König
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Thomas Zahnert
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Christoph Reissfelder
- Department of Surgery, Medical Faculty Heidelberg, University Hospital Mannheim, Mannheim, Germany
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
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Endoscopic mucosal incision and muscle interruption (MIMI) for the treatment of Zenker's diverticulum. Surg Endosc 2020; 35:3896-3904. [PMID: 32748264 DOI: 10.1007/s00464-020-07861-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/28/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND In peroral endoscopic myotomy for Zenker's diverticulum (Z-POEM), the cricopharyngeus muscle is divided within a submucosal tunnel started in the hypopharynx. We aimed to evaluate the safety and preliminary outcomes in patients who underwent a modified version of the Z-POEM where the tunnel is made directly overlying the cricopharyngeus, the mucosal incision and muscular interruption (MIMI) approach, and to compare these with patients who underwent a non-tunneled flexible endoscopic approach. METHODS All patients with ZD who were treated by flexible endoscopy at our institution between January 2015 and February 2020 were identified by a retrospective chart review. Dysphagia symptoms were assessed using a validated scoring system. RESULTS Nineteen patients with ZD underwent MIMI (mean age 76.1 years, 68.1% male) and seven patients underwent non-tunneled flexible endoscopic approach (mean age 64.4 years, 85.7% male) during the study period. Mean ZD size was 2.8 cm in the MIMI group and 1.9 cm in the non-tunneled group (p = 0.03). Clinical success was achieved in 17/19(89.5%) MIMI patients and 7/7(100%) of non-tunneled flexible endoscopic patients (p = 0.101). Dysphagia scores improved in both groups, although this difference was only significant in the MIMI group (p ≤ 0.001). Recurrence occurred in 2/17(11.7%) MIMI patients and 3/7(42.9%) non-tunneled flexible endoscopic patients (p = 0.096). There were 4 complications, including one pharyngeal perforation requiring open surgical repair in a patient with a small ZD with an associated cricopharyngeal bar in the MIMI group. Median length of follow-up was 290 [142; 465] days in the MIMI group and 1056 [258; 1206] days in the non-tunneled group (p = 0.094). CONCLUSIONS MIMI is a technically feasible and effective treatment for ZD. Care should be taken in patients with a cricopharyngeal bar and small ZD, as this may increase the risk of perforation. Larger studies with long-term follow-up are needed to determine if MIMI reduces the risk of symptom recurrence when compared to non-tunneled flexible endoscopic approaches.
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Bajaj JS, Brenner DM, Cai Q, Cash BD, Crowell M, DiBaise J, Gallegos-Orozco JF, Gardner TB, Gyawali CP, Ha C, Holtmann G, Jamil LH, Kaplan GG, Karsan HA, Kinoshita Y, Lebwohl B, Leontiadis GI, Lichtenstein GR, Longstreth GF, Muthusamy VR, Oxentenko AS, Pimentel M, Pisegna JR, Rubenstein JH, Russo MW, Saini SD, Samadder NJ, Shaukat A, Simren M, Stevens T, Valdovinos M, Vargas H, Spiegel B, Lacy BE. Major Trends in Gastroenterology and Hepatology Between 2010 and 2019: An Overview of Advances From the Past Decade Selected by the Editorial Board of The American Journal of Gastroenterology. Am J Gastroenterol 2020; 115:1007-1018. [PMID: 32618649 DOI: 10.14309/ajg.0000000000000709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- J S Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
| | - D M Brenner
- Northwestern University, Chicago Illinois, USA
| | - Q Cai
- Emory University, Atlanta, Georgia, USA
| | - B D Cash
- McGovern Medical School, Houston, Texas, USA
| | - M Crowell
- Mayo Clinic, Scottsdale, Arizona, USA
| | - J DiBaise
- Mayo Clinic, Scottsdale, Arizona, USA
| | | | - T B Gardner
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - C P Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - C Ha
- Inflammatory Bowel Diseases Center, Cedars-Sinai Medical Center, Los Angeles CA, USA
| | - G Holtmann
- University of Queensland, Brisbane, Australia, USA
| | - L H Jamil
- Beaumont Health-Royal Oak, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USA
| | - G G Kaplan
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - H A Karsan
- Atlanta Gastroenterology Associates and Emory University, Atlanta, Georgia, USA
| | - Y Kinoshita
- Steel Memorial Hirohata Hospital and Himeji Brain and Heart Center, Himeji, Japan
| | - B Lebwohl
- Columbia University Irving Medical Center, New York, New York, USA
| | | | | | - G F Longstreth
- Kaiser Permanente Southern California, San Diego, California, USA
| | - V R Muthusamy
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | - M Pimentel
- Inflammatory Bowel Diseases Center, Cedars-Sinai Medical Center, Los Angeles CA, USA
| | - J R Pisegna
- Department of Veterans Affairs, VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA Los Angeles, California, USA
| | - J H Rubenstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - M W Russo
- Carolinas Medical Center-Atrium Health, Charlotte, North Carolina, USA
| | - S D Saini
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan, USA
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - A Shaukat
- Minneapolis Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota, USA
| | - M Simren
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - T Stevens
- Cleveland Clinic, Cleveland, Ohio, USA
| | - M Valdovinos
- Instituto Nacional de Ciencias Médicas y Nutricion S.Z., Mexico City, Mexico
| | - H Vargas
- Mayo Clinic, Scottsdale, Arizona, USA
| | - B Spiegel
- Inflammatory Bowel Diseases Center, Cedars-Sinai Medical Center, Los Angeles CA, USA
| | - B E Lacy
- Mayo Clinic, Jacksonville, Florida, USA
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Juin C, Barret M, Belle A, Abouali E, Leblanc S, Oudjit A, Dohan A, Coriat R, Chaussade S. Endoscopic treatment of Zenker's diverticulum by complete septotomy: initial experience in 19 patients. Endosc Int Open 2020; 8:E885-E890. [PMID: 32617393 PMCID: PMC7297605 DOI: 10.1055/a-1153-8985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/25/2020] [Indexed: 11/03/2022] Open
Abstract
Background and study aims Endoscopic treatment of Zenker's Diverticulum (ZD) using a flexible endoscope and a diverticuloscope consists of myotomy of the cricopharyngeus muscle, sparing the lower part of the diverticular septum. However, recurrence occurs in up to 54 % of patients at 4 years. We assessed the feasibility and safety of a complete septotomy in endoscopic treatment of ZD. Patients and methods We conducted a retrospective analysis of a prospectively collected database at a single referral center. All consecutive patients treated by complete resection of the diverticular wall were included. The endoscopic technique used a distal attachment cap and division of the ZD septum using a Dual Knife or a Triangle Tip knife in endocut mode, until the esophageal muscularis propria was seen and no residual diverticulum remained. Symptoms were evaluated using the Augsburger questionnaire. Results Nineteen patients, 10 of whom were men with mean age 79 ± 12 years, were treated by complete septotomy for a symptomatic ZD with a median size of 2.5 cm (range 1-5 cm). The clinical success rate was 100 % and the complication rate was 10 % (one pneumonia and one atrial fibrillation). Median hospital stay was 2 days (range 1-3 days). On Day 1 esophagogram, no extraesophageal contrast leakage was seen, periesophageal CO 2 was still visible in two patients, and complete ZD regression was seen in 63 % of patients. The 6-month clinical success rate was 100 %, with two patients lost to follow-up, and a median symptom score of 0 (range 0-4). After a mean ± SD follow-up of 9 ± 5 months, the clinical success rate was 94 % (16/17). Conclusion Complete endoscopic septotomy is a feasible and safe therapeutic modality in patients with symptomatic ZD that does not require use of a diverticuloscope, and with good short-term efficacy. The complete regression of the diverticulum observed on Day 1 in 63 % of patients could be a marker of long-term clinical success.
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Affiliation(s)
- Charlotte Juin
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Maximilien Barret
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France,University of Paris, France
| | - Arthur Belle
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Einas Abouali
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France,University of Paris, France
| | - Sarah Leblanc
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Ammar Oudjit
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France,University of Paris, France
| | - Anthony Dohan
- University of Paris, France,Department of Radiology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, France
| | - Romain Coriat
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France,University of Paris, France
| | - Stanislas Chaussade
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France,University of Paris, France
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Nabi Z, Reddy DN. Endoscopic management of Zenker’s diverticulum. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020; 9:78-85. [DOI: 10.18528/ijgii200004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 06/28/2025] Open
Affiliation(s)
- Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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40
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Bresteau C, Barret M, Guillaumot MA, Abou Ali E, Belle A, Leblanc S, Oudjit A, Dohan A, Coriat R, Chaussade S. Do we still need a diverticuloscope for the flexible endoscopic septotomy of Zenker's diverticulum? J Gastroenterol Hepatol 2020; 35:630-633. [PMID: 31693762 DOI: 10.1111/jgh.14923] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/13/2019] [Accepted: 10/27/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Zenker's diverticulum (ZD) is the most common type of diverticulum in the esophagus. The endoscopic septotomy of the diverticular wall has become a widely accepted treatment modality, but the recurrence rate is unclear. Our aim was to assess short-term and long-term success rates after flexible endoscopic septotomy for the treatment of ZD. METHODS All consecutive patients treated at our department for a ZD between November 2014 and September 2018 were included. Endoscopic septotomy was conducted using a diverticuloscope or a distal attachment cap. Data were retrospectively analyzed from a prospectively collected database. We collected data concerning patients, endoscopic procedures, and short-term clinical outcomes. All patients were reached by phone between October and December 2018 to assess long-term results. RESULTS Seventy-seven patients were referred to our department for a ZD. Sixty patients were treated using a diverticuloscope and 17 patients with a distal attachment cap. For all 77 patients, the myotomy was technically successful. Three patients treated with a diverticuloscope reported complications. Initial treatment success was 93%. After a mean (±SEM) follow up of 23 ± 2 months, 66% of patients had persistent clinical remission. The rate of long-term treatment success was 72% in treatment-naïve and 50% in previously treated patients (P = 0.13). Treatment success was 68% in patients treated with the diverticuloscope versus 60% in the group treated with a cap (P = 0.75). CONCLUSION The flexible endoscopic septotomy for the treatment of ZD is a safe and effective treatment of ZD, with or without a diverticuloscope.
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Affiliation(s)
- Clément Bresteau
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Maximilien Barret
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris Descartes University, Paris, France
| | - Marie-Anne Guillaumot
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris Descartes University, Paris, France
| | - Einas Abou Ali
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris Descartes University, Paris, France
| | - Arthur Belle
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sarah Leblanc
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Ammar Oudjit
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris Descartes University, Paris, France
| | - Anthony Dohan
- Department of Radiology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris Descartes University, Paris, France
| | - Romain Coriat
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris Descartes University, Paris, France
| | - Stanislas Chaussade
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,Paris Descartes University, Paris, France
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Abstract
The field of third space endoscopy (TSE), also called submucosal endoscopy using a mucosal flap valve, allows secure access to the submucosal and deeper layers of the gastrointestinal tract without the risk of a full-thickness perforation. Since the first description of per-oral endoscopic myotomy (POEM) for the treatment of achalasia cardia 10 years ago, this field has expanded rapidly. Several new procedures, submucosal tunneling endoscopic resection, gastric-POEM, Zenker POEM, per-rectal endoscopic myotomy, diverticular POEM, and recanalization for complete esophageal obstruction (per-oral endoscopic tunneling for restoration of the esophagus), have been performed. All TSE procedures employ a similar technique-after a mucosal incision, a submucosal tunnel is created, a myotomy is performed, or a subepithelial tumor is resected distal to the site of mucosal incision, after which the mucosal incision is closed. Potential indications for TSE include resection of subepithelial tumors in the esophagus, gastroesophageal junction, or stomach; refractory gastroparesis; Zenker diverticulum; Hirschsprung disease or other forms of megacolon; and recanalization for complete esophageal obstruction. Data are currently available for POEM, submucosal tunneling endoscopic resection, and gastric-POEM, although mainly in the form of retrospective studies, and randomized trials and long-term follow-up data are limited. Submucosal endoscopy has an excellent safety profile with very few intraoperative adverse events, the majority being related to insufflation, although bleeding, perforation, and sepsis have been reported. TSE procedures require special training and have demonstrated a learning curve.
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Yang J, Novak S, Ujiki M, Hernández Ó, Desai P, Benias P, Lee D, Chang K, Brieau B, Barret M, Kumta N, Zeng X, Hu B, Delis K, Khashab MA. An international study on the use of peroral endoscopic myotomy in the management of Zenker's diverticulum. Gastrointest Endosc 2020; 91:163-168. [PMID: 31082393 DOI: 10.1016/j.gie.2019.04.249] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 04/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The novel use of peroral endoscopic myotomy (POEM) in the treatment of Zenker's diverticulum (ZD) was recently described in case reports. The aim of this study is to report a multicenter experience with the POEM technique in the management of ZD. METHODS This is a multicenter international retrospective study involving 10 centers. The Zenker's POEM technique was performed using principles of submucosal endoscopy. RESULTS Seventy-five patients (73.3 ± 1.2 years, 33 women) were included with a mean Charleson comorbidity index of 4 ± .2. The mean size of ZD was 31.3 ± 1.6 mm (range, 10-89). The overall technical success rate was 97.3% (73/75). There were 2 technical failures because of the inability to locate the septum and failed tunnel creation. Adverse events occurred in 6.7% (5/75): 1 bleed (mild) conservatively managed and 4 perforations (1 severe, 3 moderate). The mean procedure time was 52.4 ± 2.9 minutes, and mean length of hospital stay was 1.8 ± .2 days. Clinical success was achieved in 92% (69/75) with a decrease in mean dysphagia score from 1.96 to .25 (P < .0001). The median length of follow-up was 291.5 days (interquartile range, 103.5-436). At the 12-month follow-up, 1 patient reported symptom recurrence. CONCLUSIONS Endoscopic management of ZD using the POEM technique is novel and feasible with promising efficacy and safety results. Long-term follow-up is needed to ensure durability of response. In addition, comparative studies with other treatment modalities are warranted.
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Affiliation(s)
- Juliana Yang
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
| | - Stephanie Novak
- Department of Surgery, Section of Minimally Invasive Surgery, North Shore University Health System, Evanston, Illinois, USA
| | - Michael Ujiki
- Department of Surgery, Section of Minimally Invasive Surgery, North Shore University Health System, Evanston, Illinois, USA
| | - Óscar Hernández
- Departamento de Endoscopia, Hospital de Especialidades Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Ciudad de México, México
| | - Pankaj Desai
- Surat Institute of Digestive Sciences, Surat, India
| | - Petros Benias
- Division of Gastroenterology, Department of Medicine, Hofstra Northwell School of Medicine, Northwell Health System, North Shore University Hospital, Manhasset, New York, USA
| | - David Lee
- H.H. Chao Comprehensive Digestive Disease Center, Division of Gastroenterology & Hepatology, Department of Medicine, UC Irvine School of Medicine, Irvine, California, USA
| | - Kenneth Chang
- H.H. Chao Comprehensive Digestive Disease Center, Division of Gastroenterology & Hepatology, Department of Medicine, UC Irvine School of Medicine, Irvine, California, USA
| | - Bertrand Brieau
- Service de gastroentérologie, Hôpital Cochin, Maitre de Conférence des Universités, Praticien Hospitalier Université Paris Descartes, Paris, France
| | - Maximilien Barret
- Service de gastroentérologie, Hôpital Cochin, Maitre de Conférence des Universités, Praticien Hospitalier Université Paris Descartes, Paris, France
| | - Nikhil Kumta
- Division of Gastroenterology, Mount Sinai Medical Center, New York, New York, USA
| | - Xianhui Zeng
- Department of Gastroenterology, West China Hospital, Sichuan University, Sichuan, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Sichuan, China
| | - Konstantinos Delis
- Department of Gastroenterology, Metropolitan Hospital, Neo Faliro, Piraeus, Greece
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA
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Bola S, Ashman A, Winter S. Endoscopic pharyngeal pouch stapling: A retrospective study of 55 patients comparing intubation difficulty and body mass index as factors for success. Clin Otolaryngol 2019; 45:135-138. [DOI: 10.1111/coa.13469] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 06/29/2019] [Accepted: 10/06/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Sumrit Bola
- ENT Registrar Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - Alexander Ashman
- ENT Registrar Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - Stuart Winter
- Consultant Head & Neck Surgeon Oxford University Hospitals NHS Foundation Trust Oxford UK
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Presentation and Management of Killian Jamieson Diverticulum: A Comprehensive Literature Review. Ann Otol Rhinol Laryngol 2019; 129:394-400. [DOI: 10.1177/0003489419887403] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective: To examine the clinical presentation, diagnostic evaluation, and management of Killian–Jamieson diverticula (KJD) through literature review. Methods: A comprehensive literature review was conducted through December 2018 using keywords Killian–Jamieson diverticula/diverticulum. Data extracted included clinical presentation, imaging characteristics, surgical management, and postoperative care. Sources: PubMed and Google Scholar. Results: Sixty-eight cases of KJD in 59 reports (29M:39F; median 58 years old) were identified for review. The most common presentation was dysphagia (n = 39), suspected thyroid nodule (n = 24) and globus (n = 14). The majority of KJD (n = 51) occur on the left, with rare reports of right side (n = 11) and bilateral (n = 5) presentation. Thirty-two cases describe surgical management: 22 utilizing a transcervical approach, with (n = 13) or without (n = 9) cricopharyngeal myotomy; and 10 reported endoscopic surgery. Diverticula managed transcervically averaged 3.8 cm in size in comparison to average 2.8 cm in the endoscopic group. Time to diet initiation after transcervical surgery averaged 4 days versus 2 days after endoscopic surgery. Complications were reported in 2/68 cases; both were diverticula recurrence after endoscopic surgery. Conclusion: Killian–Jamieson diverticula is a rare diagnosis that should be considered in the evaluation of dysphagia, globus, and also suspected thyroid nodule. When patient symptoms warrant intervention, a transcervical approach, with or without cricopharyngeal myotomy, is most commonly utilized. In recent years, an endoscopic approach has been presented as an alternative for smaller diverticula. Further understanding of the optimal treatment and postoperative management for KJD requires larger cohorts. Level of Evidence: 4
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Nabi Z, Ramchandani M, Jagtap N, Darisetty S, Reddy DN. Endoscopic treatment of Zenker's diverticulum using a new triangle tip knife. Ann Gastroenterol 2019; 32:650-653. [PMID: 31700244 PMCID: PMC6826068 DOI: 10.20524/aog.2019.0393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 05/11/2019] [Indexed: 01/01/2023] Open
Abstract
Background: Zenker’s diverticulum (ZD) is a rare disease that affects elderly subjects. The mainstay of management is endoscopic myotomy of the cricopharyngeal septum. In this series, we aimed to evaluate the feasibility and efficacy of cricopharyngeal myotomy with a new electrosurgical knife in patients with ZD. Methods: Consecutive patients with ZD who underwent flexible endoscopic myotomy with the new triangle tip knife J (TTJ) were included in the study. The study outcomes included technical and clinical success, procedure duration, and adverse events. Results: A total of 7 patients [median age 57 (range 40-87) years] underwent cricopharyngeal myotomy with the TTJ knife. The median size of the ZD was 4 (range 3-5) cm. The procedure was successfully completed in all the patients with a median operative time of 12 (range 8-16) min. There were no major adverse events. Minor bleeding was noticed in 3 patients and was successfully managed using the same knife. Clinical resolution of symptoms was noticed in all the patients at follow up. Conclusion: Cricopharyngeal myotomy can be performed safely and efficiently with the new TTJ knife.
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Affiliation(s)
- Zaheer Nabi
- Gastroenterology Department, Asian Institute of Gastroenterology, Hyderabad, India
| | - Mohan Ramchandani
- Gastroenterology Department, Asian Institute of Gastroenterology, Hyderabad, India
| | - Nitin Jagtap
- Gastroenterology Department, Asian Institute of Gastroenterology, Hyderabad, India
| | - Santosh Darisetty
- Gastroenterology Department, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Gastroenterology Department, Asian Institute of Gastroenterology, Hyderabad, India
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2007-2019: a "Third"-Space Odyssey in the Endoscopic Management of Gastrointestinal Tract Diseases. ACTA ACUST UNITED AC 2019; 17:202-220. [PMID: 31037613 DOI: 10.1007/s11938-019-00233-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW The main scope of this review article is to introduce readers to the innovative field of third-space endoscopy and offer a closer look at its history, milestones, and procedure spectrum while discussing ongoing and future challenges arising from its increasing adoption worldwide. RECENT FINDINGS Over the past few years, third-space endoscopy has been utilized in various diagnostic and interventional procedures performed throughout the gastrointestinal tract: obliteration of Zenker's diverticulum, myotomy for achalasia, gastroparesis or Hirschsprung's disease, biopsy or removal of subepithelial tumors, stricture management, post-per-oral endoscopic myotomy endoscopic fundoplication, and mediastino-, thoraco-, and peritoneoscopy. Third-space endoscopic interventions have revolutionized the management of esophageal motility disorders, gastroparesis, and gastrointestinal tract subepithelial tumors. Despite the high efficacy and safety of such interventions, some common (e.g., the high level of necessary endoscopic skill) and unique for each procedure (e.g., post-procedure gastroesophageal reflux or poor outcomes in patient subgroups) challenges still remain. Through a dedicated endoscopic training, a rigorous pre-procedure patient evaluation and selection, and the application of modified or new techniques, challenges can be overcome thus establishing existing procedures and paving the way for additional breakthroughs in the field of third-space endoscopy.
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Pharyngeal pouch: comparison of surgical treatment with botulinum toxin injection to the cricopharyngeus. The Journal of Laryngology & Otology 2019; 133:125-128. [PMID: 30722793 DOI: 10.1017/s0022215119000124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pharyngeal pouch surgical treatments can be carried out via an endoscopic or open approach. Injection of botulinum toxin into the cricopharyngeus was first described as an alternative treatment to the more invasive surgical procedures performed for cricopharyngeal dysfunction. It has not been previously described as a treatment option for pharyngeal pouch. OBJECTIVES To compare operative time, average stay, complication rates and symptom control between endoscopic laser diverticulotomy, botulinum toxin injection and open procedures for pharyngeal pouch patients. METHODS The medical records for 66 pharyngeal pouch procedures, carried out on 47 patients treated between 2011 and 2017, were identified and reviewed. RESULTS The mean operative time was 21 minutes for botulinum toxin injection, 38 for endoscopic laser diverticulotomy and 104 for open surgery. The mean hospital stay was 0.6 days for botulinum toxin injection, 4.7 for endoscopic laser diverticulotomy and 4 for open surgery. The improvement in Reflux Symptom Index scores was statistically significant for both endoscopic laser diverticulotomy and botulinum toxin injection. Botulinum toxin injection had a 0 per cent complication rate. CONCLUSION Botulinum toxin injection is a safe and effective treatment for pharyngeal pouch.
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Chang KJ. Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey. World J Gastroenterol 2019; 25:1-41. [PMID: 30643356 PMCID: PMC6328959 DOI: 10.3748/wjg.v25.i1.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 02/06/2023] Open
Abstract
In this paper, I reviewed the emerging field of endoscopic surgery and present data supporting the contention that endoscopy can now be used to treat many foregut diseases that have been traditionally treated surgically. Within each topic, the content will progress as follows: "lessons learned", "technical considerations" and "future opportunities". Lessons learned will provide a brief background and update on the most current literature. Technical considerations will include my personal experience, including tips and tricks that I have learned over the years. Finally, future opportunities will address current unmet needs and potential new areas of development. The foregut is defined as "the upper part of the embryonic alimentary canal from which the pharynx, esophagus, lung, stomach, liver, pancreas, and part of the duodenum develop". Foregut surgery is well established in treating conditions such as gastroesophageal reflux disease (GERD), achalasia, esophageal diverticula, Barrett's esophagus (BE) and esophageal cancer, stomach cancer, gastric-outlet obstruction, and obesity. Over the past decade, remarkable progress in interventional endoscopy has culminated in the conceptualization and practice of endoscopic foregut surgery for various clinical conditions summarized in this paper. Regarding GERD, there are now several technologies available to effectively treat it and potentially eliminate symptoms, and the need for long-term treatment with proton pump inhibitors. For the first time, fundoplication can be performed without the need for open or laparoscopic surgery. Long-term data going out 5-10 years are now emerging showing extended durability. In respect to achalasia, per-oral endoscopic myotomy (POEM) which was developed in Japan, has become an alternative to the traditional Heller's myotomy. Recent meta-analysis show that POEM may have better results than Heller, but the issue of post-POEM GERD still needs to be addressed. There is now a resurgence of endoscopic treatment of Zenker's diverticula with improved technique (Z-POEM) and equipment; thus, patients are choosing flexible endoscopic treatment as opposed to open or rigid endoscopy options. In regard to BE, endoscopic submucosal dissection (ESD) which is well established in Asia, is now becoming more mainstream in the West for the treatment of BE with high grade dysplasia, as well as early esophageal cancer. In combination with all the ablation technologies (radiofrequency ablation, cryotherapy, hybrid argon plasma coagulation), the entire spectrum of Barrett's and related dysplasia and early cancer can be managed predominantly by endoscopy. Importantly, in regard to early gastric cancer and submucosal tumors (SMTs) of the stomach, ESD and full thickness resection (FTR) can excise these lesions en-bloc and endoscopic suturing is now used to close large defects and perforations. For treatment of patients with malignant gastric outlet obstruction (GOO), endoscopic gastro-jejunostomy is now showing better results than enteral stenting. G-POEM is also emerging as a treatment option for patients with gastroparesis. Obesity has become an epidemic in many western countries and is becoming also prevalent in Asia. Endoscopic sleeve gastroplasty (ESG) is now becoming an established treatment option, especially for obese patients with body mass index between 30 and 35. Data show an average weight loss of 16 kg after ESG with long-term data confirming sustainability. Finally, in respect to endo-hepatology, there are many new endoscopic interventions that have been developed for patients with liver disease. Endoscopic ultrasound (EUS)-guided liver biopsy and EUS-guided portal pressure measurement are exciting new frontiers for the endo-hepatologists.
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Affiliation(s)
- Kenneth J Chang
- H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA 92868, United States
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49
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Ching HH, Kahane JB, Reeve NH, Wang RC. The Plication Technique to Enhance the Endoscopic Approach to Zenker's Diverticulum. Otolaryngol Head Neck Surg 2018; 159:799-801. [PMID: 29966497 DOI: 10.1177/0194599818785892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endoscopic stapler approaches to Zenker's diverticulum often yield a persistent diverticulum and recurrent dysphagia up to 20%. A novel technique to reduce the postoperative diverticulum is described. Eight consecutive patients with Zenker's diverticulum who underwent endoscopic stapler diverticulotomy had adjunctive endoscopic plication of the diverticulum wall to functionally reduce the residual diverticulum size. On postoperative esophagram, there was no visible diverticulum in 4 of 7 patients (57%). The remaining 3 patients had a reduction in common wall of 76%, 50%, and 40% with a mean postoperative size of 1.0 cm. All patients had resolution or significant improvement in dysphagia. There were no complications or recurrences at a mean follow-up of 6.3 months. As an adjunct to endoscopic treatment of Zenker's diverticulum, the plication technique can reduce diverticulum size. Further studies will determine if the plication technique affects long-term recurrence of endoscopic stapler approaches.
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Affiliation(s)
- Harry H Ching
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Nevada Las Vegas School of Medicine, Las Vegas, Nevada, USA
| | - Jacob B Kahane
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Nevada Las Vegas School of Medicine, Las Vegas, Nevada, USA
| | - Nathaniel H Reeve
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Nevada Las Vegas School of Medicine, Las Vegas, Nevada, USA
| | - Robert C Wang
- 1 Department of Otolaryngology-Head and Neck Surgery, University of Nevada Las Vegas School of Medicine, Las Vegas, Nevada, USA
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Ishaq S, Sultan H, Siau K, Kuwai T, Mulder CJ, Neumann H. New and emerging techniques for endoscopic treatment of Zenker's diverticulum: State-of-the-art review. Dig Endosc 2018; 30:449-460. [PMID: 29423955 DOI: 10.1111/den.13035] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 02/04/2018] [Indexed: 02/06/2023]
Abstract
Zenker's diverticulum (ZD), or pharyngeal pouch, is an anatomical defect characterized by herniation of the posterior pharyngeal wall through Killian's dehiscence, and may result in dysphagia and regurgitation. Multiple therapeutic modalities including surgery, rigid and flexible endoscopy have been developed to manage ZD. Although surgical management with open and endoscopically assisted techniques have historically been the mainstay of ZD treatment, minimally invasive flexible endoscopic techniques, carried out under conscious sedation, are increasingly favored. Over the last two decades, the advent of new accessories and techniques have changed the landscape of endotherapy for ZD, with the current armamentarium including, but not limited to, endoscopic stapling, CO2 laser, argon plasma coagulation, needle knife, bipolar forceps, hook knife, clutch cutter, stag beetle knife, and submucosal tunneling endoscopic septum division. We hereby review the latest evidence to support the endoscopic management of ZD.
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Affiliation(s)
- Sauid Ishaq
- Department of Gastroenterology, Russell Hall Hospital, Dudley, UK.,Birmingham City University, Birmingham, UK.,St George's University, Grenada, West Indies
| | - Haleema Sultan
- Department of Gastroenterology, Russell Hall Hospital, Dudley, UK
| | - Keith Siau
- Department of Gastroenterology, Russell Hall Hospital, Dudley, UK.,Joint Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK
| | - Toshio Kuwai
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure, Japan
| | - Chris J Mulder
- Department of Gastroenterology and Hepatology, VU Medical Center, Amsterdam, Netherlands
| | - Helmut Neumann
- Department of Interdisciplinary Endoscopy, University Hospital Mainz, Mainz, Germany
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