Revision Zenker Diverticulum: Laser Versus Stapler Outcomes Following Initial Endoscopic Failure

Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, Yale University School of Medicine, Yale Physicians Building, 4th Floor, 800 Howard Ave, New Haven, CT 06510, USA.
The Annals of otology, rhinology, and laryngology (Impact Factor: 1.09). 04/2013; 122(4):247-53. DOI: 10.1177/000348941312200406
Source: PubMed


We used a retrospective chart review to analyze revision endoscopic carbon dioxide (CO2) laser and staple repairs of recurrent Zenker diverticulum (ZD).
The medical records of patients with recurrent ZD after primary endoscopic repair were selected. The chart data included method of repair (CO2 laser or stapler), demographics (age and sex), defect size (in centimeters), preoperative and postoperative symptoms, and complications. Patients' dysphagia was graded on a modified Functional Oral Intake Scale from 1 to 4 (1 being normal intake and 4 being severely limited intake or gastrostomy tube dependence). Regurgitation was also graded on a 1-to-4 scale (1 being no regurgitation and 4 being aspiration).
A total of 148 consecutive patients with ZD were treated with endoscopic repair between 2000 and 2010. Twelve of these patients had revisions after failed primary endoscopic management procedures, all done with the stapler. Eight revision surgeries were performed by CO2 laser, and 4 by stapler repair. No difference was noted in patient age or defect size (laser, 3.06-cm defects; stapler, 2.75-cm defects). The length of hospital stay and the time to oral intake for the patients who had a revision stapler procedure were significantly greater (p values of 0.029 and 0.009) than those for the patients in the primary stapler procedure group. Better postoperative regurgitation scores were noted for patients who had a CO2 laser procedure.
Secondary endoscopic repair for ZD recurrence is an effective treatment method. Better symptom outcomes were observed with secondary CO2 laser repair than with stapler revision. Patients with revision stapling had longer hospital stays and a longer time to oral intake than did patients with primary staple repairs.

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    ABSTRACT: To evaluate outcomes following endoscopic management of Zenker's diverticula using a carbon dioxide laser (CO2) or stapler-assisted technique, a systematic review and meta-analysis were conducted. Seven retrospective, uncontrolled case series including 391 procedures met selection criteria. No higher quality studies were identified. Outcomes favoring the stapler technique included a shorter duration of nil per os (NPO) status (2 studies), length of hospitalization (LOH, 2 studies), and fewer postoperative fevers and abnormal chest x-rays (1 study). Outcomes favoring the CO2 technique included greater improvement in postoperative dysphagia and regurgitation scores (2 studies) and a lower revision rate (1 study). Meta-analysis demonstrated increased nondental complications in the CO2 group (odds ratio 3.81; 95% confidence interval, 1.37-10.59; P = .01) but no difference in duration of NPO (P = .06), LOH (P = .07), overall complications (P = .08), dental complications (P = .57), major complications (P = .38), or revision surgery (P = .82). Implications are limited by the quality of studies identified.
    No preview · Article · Feb 2014 · Otolaryngology Head and Neck Surgery
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    ABSTRACT: The purpose of the present study is to evaluate long-term outcome and patients' satisfaction after endoscopic therapy of Zenker's diverticulum (ZD) and to analyze the results of the stapler technique in comparison with the application of the carbon dioxide (CO2) laser. A retrospective cohort study with outcome analysis of patients undergoing endoscopic cricopharyngeal myotomy with either stapler or CO2 laser between October 2000 and December 2010 by a single surgeon was performed. Patient's medical charts were reviewed with respect to symptoms before intervention, intra and post operative complications, reasons for the choice of endoscopic technique, and postoperative relief of symptoms. Long-term follow-up was acquired by a standardized self-assessment questionnaire. Seventy-four patients (51 men, 23 women) with a median age at operation of 74 years (range 45-93 years) were enrolled in this study. Forty-five patients underwent endoscopic repair of a ZD with stapler, 29 patients with CO2 laser. The mean follow-up was 4.7 years. We did not observe significant differences for intra and post operative complications, hospital stay, time until normal oral food intake, need for revision, and long-term subjective symptom relief between the two groups. Overall complication (12 %) and recurrence rate (11 %) for the endoscopic techniques were low. Endoscopic surgery had also a high success rate in recurrence cases (87.5 %). According to our study, the most important factor for the success rate of endoscopic treatment was the intraoperative exposure of the ZD. The endoscopic minimally invasive approach is a safe and effective treatment modality and can be considered as the treatment of choice for primary and recurrent ZD. The intraoperative exposure is decisive for the technique applied and the long-term success.
    No preview · Article · Mar 2014 · Archives of Oto-Rhino-Laryngology
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    ABSTRACT: The treatment of choice of Zenker's diverticulum is the rigid endoscopic mucomyotomy. At our ENT department, we usually perform an endoscopic mucosal suture after the myotomy. We diagnosed 49 patients and treated 39 patients between 2003 and 2013 due to a Zenker's diverticulum. We used the classification of Brombart to determine the size of the diverticulum. Surgery was performed as an endoscopic LASER mucomyotomy with mucosal sutures or as an open approach with diverticulectomy and myotomy. Patients were phoned to ask for their complaints postoperatively. The symptoms were classified using a visual scale from 0 (no complaint) until 10 (same or more complaints than before the surgery). The distribution of the diverticulum's size was: 6 patients Brombart I, 11 patients Brombart II, 14 patients Brombart III and 18 patients Brombart IV. 10 patients did not undergo surgery. With 33 patients, we performed an endoscopic operation and 6 patients underwent an open approach. The scale of postoperative complaints was the following: 20 patients (0/10), 12 patients (1/10 or 2/10), 3 patients (3/10), 1 patient (6/10) and 1 patient (10/10). None of the patients suffered from severe complications such as mediastinitis. In 85 % of the cases, an endoscopic approach could be performed. Postoperatively, 94 % of the patients did not have any or just mild complaints. The risk of severe complications or recurrence of the diverticulum is low. The mucosal suture might reduce the risk of infections.
    No preview · Article · Aug 2014 · Archiv für Klinische und Experimentelle Ohren- Nasen- und Kehlkopfheilkunde
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