Effectiveness and safety of stag beetle knife (SB knife) in management of Zenker's diverticulum: a systematic review and meta-analysis.

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%.

Smoking impacts outcomes in transcervical Zenker's diverticulectomy.

PURPOSE: There is sparse literature discussing the impact of smoking on postoperative outcomes following surgical treatment of Zenker's diverticulum. In this study, we seek to characterize differences in the management and outcomes of open Zenker's diverticulectomy based on patient smoking status. METHODS AND MATERIALS: This paper is a retrospective cohort review. The 2005-2018 American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database was queried for patients undergoing open Zenker's diverticulectomy. Chi-square and multivariable logistic regression were performed to determine statistical associations between postoperative outcomes and smoking status. RESULTS: Of the 715 identified patients, 70 (9.8 %) were smokers and 645 (91.2 %) were non-smokers. Smokers were younger than non-smokers (mean 63.9 vs. 71.7 years, p < 0.001) and more likely to have a prolonged operative time (20.0 % vs. 11.6 %, p = 0.044). On multivariable regression analysis controlling for demographics and comorbidities, smokers had greater odds than non-smokers for developing overall postoperative complications (OR: 2.776, p = 0.013), surgical infections (OR: 3.194, p = 0.039), medical complications (OR: 3.563, p = 0.011), and medical infections (OR: 1.247, p = 0.016). Smokers also had greater odds for requiring ventilation/intubation (OR: 8.508, p = 0.025) and having a prolonged postoperative stay (OR: 2.425, p = 0.030). CONCLUSION: In a cohort of patients undergoing transcervical Zenker's diverticulectomy, smokers are at increased risk for overall complications, medical complications, medical infections, surgical infections, prolonged postoperative stay, and ventilation/intubation.

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.

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.

Retroperitoneal urothelial carcinoma arising after bladder diverticulectomy: a case report.

BACKGROUND: Urothelial carcinoma arises from the inner urothelial membrane of the renal pelvis, ureter, and bladder and often causes macrohematuria. Here, we report a rare case in which the patient developed non-symptomatic urothelial carcinoma anatomically outside the bladder wall 17 years after bladder diverticulectomy. CASE PRESENTATION: An 82-year-old male patient previously underwent gastrectomy for stomach cancer and partial hepatectomy for intrahepatic cholangiocarcinoma. Follow-up computed tomography revealed a tumor in the retroperitoneal space, where a bladder diverticulum was removed 17 years earlier. Multiparametric magnetic resonance imaging suggested that the tumor was malignant with rectal invasion. Subsequent computed tomography-guided percutaneous biopsy revealed that the tumor was urothelial carcinoma. The patient underwent two courses of neoadjuvant chemotherapy followed by pelvic exenteration with pelvic lymph node dissection. He is currently receiving adjuvant therapy with an immune checkpoint inhibitor and has had no recurrence for 3 months. CONCLUSIONS: Multiparametric magnetic resonance imaging is a helpful tool for predicting both tumor malignancy and invasion before a pathologically confirmed diagnosis. Although this case is rare, urologists should be aware of the occurrence of urothelial carcinoma after bladder diverticulectomy in cases of incomplete resection of the diverticulum.

Small bowel diverticula in elderly patients: a case report and review article.

BACKGROUND: Small intestine diverticula are rare findings that were mostly reported in the elderly population as asymptomatic findings. However, they can also present with a wide range of symptoms (bloating, early satiety, chronic abdominal discomfort, and diarrhea/steatorrhea) or complications (gastrointestinal bleeding, small bowel obstruction, acute diverticulitis, or perforation) which in turn warrant medical treatment or urgent surgical intervention. CASE PRESENTATION: This is a case report of an 84-year-old female who presented with an acute surgical abdomen. An exploratory laparotomy revealed complicated small bowel diverticula with a jejunal diverticulum perforation, for which a diverticulectomy was performed. CONCLUSIONS: Throughout this paper, we are aiming to outweigh the consideration of the possibility of complicated small bowel diverticula as a differential in the evaluation of any acute abdomen, especially in the elderly, which warrants emergency surgical management.

Transurethral enucleation of the prostate combined with laparoscopic bladder diverticulectomy.

OBJECTIVE: We present a one-session procedure for treating bladder diverticula combined with benign prostatic hyperplasia (BPH). MATERIAL AND METHODS: Between January 2015 and April 2019, transurethral plasmakinetic enucleation of the prostate (TUEP) followed by laparoscopic bladder diverticulectomy (LD) were performed in 12 patients at our institution, in four of them combined with bladder stone(s) and in one patient combined with diverticular tumor. Clinical data were retrospectively collected. RESULTS: The mean size of the prostate was 137.3 ± 96.3 (65.5-403.3) ml. The mean maximal diameter of the diverticulum was 8.0 ± 2.7 (3.2-12.0) cm. The mean total operation time was 214.2 ± 69.0 (120-300) min, and the mean enucleation time was 23.2 ± 6.4 (12-35) min. The mean intraoperative blood loss was 52.1 ± 14.9 (30-80) ml. The average pre- and post-operative maximum flow rate was 5.1 ± 1.4 (2.4-8.5) ml/s and 12.8 ± 2.3 (9.6-17.1) ml/s. Except for urinary infection in one patient, no other severe peri- or postoperative complications were observed. CONCLUSIONS: TUEP accompanied by LD in one session provides an effective and minimally invasive surgical treatment for bladder diverticula combined with BPH, with or without bladder stones, and permits reasonable operation time and rapid discharge.

Meckel's Diverticulum - Clinical Presentation and Pitfalls in Diagnosis in the Pediatric Age Group in Singapore.

Purpose: The purpose of this study was to study the presentation of patients who underwent Meckel's diverticulectomy (MD) and utility of pertechnetate Meckel's scan in the diagnosis of MD. Methods: The clinical presentation of a retrospective cohort of patients who underwent MD from January 2007 to December 2019 was studied. The modes of presentation, treatment, and the diagnostic utility of pertechnetate Meckel's scans were evaluated. False-positive and false-negative scans were reviewed. The presence of gastric mucosa on histology of Meckel's was correlated with presentation as gastrointestinal bleeding and positive scan results. Results: Ninety-nine patients underwent MD. Thirty-five out of 263 (13.3%) Meckel's scans done were positive. There was a male preponderance (86.9%). The peak age of presentation was 0-4 years (rectal bleeding or intestinal obstruction). Only a third of the patients with Meckel's diverticulum Meckel's had a preoperative diagnosis of Meckel's. The sensitivity/specificity of Meckel's scan was higher in patients presenting with painless rectal bleeding. Seven patients were false positive (weak tracer uptake or ectopic uptake) and five were false negative. Two patients with false-negative Meckel's scan, having gastrointestinal bleeding had gastric mucosa on histology of Meckel's. Conclusion: Meckel's diverticulum has a male predominance. Meckel's scan has a high sensitivity in the children presenting with fresh painless rectal bleeding but is of limited use in the diagnosis of Meckel's diverticulum in other forms of presentations. False-positive scans can be anticipated in the presence of weak or ectopic uptake. False-negative scans can occur even in the presence of bleeding and in spite of the presence of gastric mucosa in the Meckel's diverticulum. Laparoscopy is a useful tool in diagnosis and treatment.

[Esophageal squamous cell carcinoma localized in pharyngeal-esophageal diverticulum]. / Redkii sluchai ploskokletochnogo raka pishchevoda s lokalizatsiei v glotochno-pishchevodnom divertikule.

Squamous cell carcinoma in Zenker's diverticulum was first described in 1933. No large studies have yet been conducted due to rarity of this disease. There are a lot of unresolved issues regarding diagnosis and treatment of this pathology. In the literature, there are only few reports on cancer of Zenker diverticulum. It is only known that clinical symptoms are not specific, and diagnosis of carcinoma is traditionally correlated with age and male sex. Despite esophageal localization of primary tumor, its development can take up to 10 years. The authors report squamous cell carcinoma in Zenker diverticulum, discuss the main difficulties of morphological verification of this disease and choice of surgical approach.

A complex modality of achalasia, diverticulum and paraesophageal hernia treated through three-dimensional left thoracoscopy.

Herein, we report a case of a patient with recurrent dysphagia after an open transabdominal hernia repair for a Type IV paraesophageal hernia performed elsewhere. Subsequent work-up and medical records' review revealed the coexistence of a large left epiphrenic diverticulum in combination with achalasia synchronous to the recently repaired paraesophageal hernia. A three-dimensional left thoracoscopic diverticulectomy with a long esophagomyotomy was conducted under endoscopic guidance intraoperatively, with no perioperative complications. At 12 months' follow-up evaluation, the patient presents well with no documented recurrence. Cumulative experience from various medical specialties regarding esophageal motility disorders and endoscopic state-of-the-art techniques, when combined with minimally invasive surgical techniques, provide an effective management of esophageal motility syndromes, overall.

Peroral endoscopic myotomy as treatment for Zenker's diverticulum (Z-POEM): a multi-center international study.

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.

[Transaxillary minimally invasive Zenker's diverticulectomy]. / Transaksillyarnoe endovideokhirurgicheskoe udalenie divertikula Tsenkera.

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.

A multicenter retrospective cohort study comparing urethral diverticulectomy with and without pubovaginal sling.

BACKGROUND: Urethral diverticulum is a rare entity and requires a high suspicion for diagnosis based on symptoms and physical exam with confirmation by imaging. A common presenting symptom is stress urinary incontinence (SUI). The recommended treatment is surgical excision with urethral diverticulectomy. Postoperatively, approximately 37% of patients may have persistent and 16% may have de novo SUI. An autologous fascial pubovaginal sling (PVS) placed at the time of urethral diverticulectomy (UD) has the potential to prevent and treat postoperative SUI. However, little has been published about the safety and efficacy of a concomitant pubovaginal sling. OBJECTIVE: The objective of this study was to compare the clinical presentation, outcomes, complications, and diverticulum recurrence rates in women who underwent a urethral diverticulectomy with vs without a concurrent pubovaginal sling. STUDY DESIGN: This multicenter, retrospective cohort study included women who underwent a urethral diverticulectomy between January 1, 2000, and December 31, 2016. Study participants were identified by Current Procedure Terminology codes, and their records were reviewed for demographics, medical or surgical history, symptoms, preoperative testing, concomitant surgeries, and postoperative outcomes. Symptoms, recurrence rates, and complications were compared between women with and without a concomitant pubovaginal sling. The primary outcome was the presence of postoperative stress urinary incontinence symptoms. Based on a stress urinary incontinence rate of 50% with no pubovaginal sling and 10% with a pubovaginal sling, we needed a sample size of 141 participants who underwent diverticulectomy without a pubovaginal sling and 8 participants with a pubovaginal sling to achieve 83% power with P<.05. RESULTS: We identified 485 diverticulectomy cases from 11 institutions who met the inclusion criteria; of these, 96 (19.7%) cases had a concomitant pubovaginal sling. Women with a pubovaginal sling were older than those without a pubovaginal sling (53 years vs 46 years; P<.001), and a greater number of women with pubovaginal sling had undergone diverticulectomy previously (31% vs 8%; P<.001). Postoperative follow-up period (14.6±26.9 months) was similar between the groups. The pubovaginal sling group had greater preoperative stress urinary incontinence (71% vs 33%; P<.0001), dysuria (47% vs 30%; P=.002), and recurrent urinary tract infection (49% vs 33%; P=.004). The addition of a pubovaginal sling at the time of diverticulectomy significantly improved the odds of stress urinary incontinence resolution after adjusting for prior diverticulectomy, prior incontinence surgery, age, race, and parity (adjusted odds ratio, 2.27; 95% confidence interval, 1.02-5.03; P=.043). It was not significantly protective against de novo stress urinary incontinence (adjusted odds ratio, 0.86; 95% confidence interval, 0.25-2.92; P=.807). Concomitant pubovaginal sling increased the odds of postoperative short-term (<6 weeks) urinary retention (adjusted odds ratio, 2.5; 95% confidence interval, 1.04-6.22; P=.039) and long-term urinary retention (>6 weeks) (adjusted odds ratio, 6.98; 95% confidence interval, 2.20-22.11; P=.001), as well as recurrent urinary tract infections (adjusted odds ratio, 3.27; 95% confidence interval, 1.26-7.76; P=.013). There was no significant risk to develop a de novo overactive bladder (adjusted odds ratio, 1.48; 95% confidence interval, 0.56-3.91; P=.423) or urgency urinary incontinence (adjusted odds ratio, 1.47; 95% confidence interval, 0.71-3.06; P=.30). A concomitant pubovaginal sling was not protective against a recurrent diverticulum (adjusted odds ratio, 1.38; 95% confidence interval, 0.67-2.82; P=.374). Overall, the diverticulum recurrence rate was 10.1% and did not differ between the groups. CONCLUSION: This large retrospective cohort study demonstrated a greater resolution of stress urinary incontinence with the addition of a pubovaginal sling at the time of a urethral diverticulectomy. There was a considerable risk of postoperative urinary retention and recurrent urinary tract infections in the pubovaginal sling group.

Laparoscopic diverticulectomy versus non-operative treatment for uncomplicated right colonic diverticulitis.

BACKGROUND: Right-sided colonic diverticulitis (RCD) is an Asian-centric disease. The optimal treatment for acute uncomplicated RCD remains a controversial area. This study aimed to compare the safety and efficacy of laparoscopic diverticulectomy (LD) with non-operative treatment (NT) in patients with uncomplicated RCD. METHODS: A single-center, prospective, non-randomized controlled study ran from 2009 to 2017. Patients with first episode of uncomplicated RCD were divided into two treatment arms, LD or NT with bowel rest and broad-spectrum antibiotics, based on their choice. The primary outcome was recurrent diverticulitis during follow-up. Secondary outcomes were treatment success and complications. RESULTS: A total of 155 patients were enrolled, with 81 in the NT arm and 74 in the LD arm. Mean follow-up was 49 months. The treatment success rate for the NT arm was 90.1% and for the LD arm, 86.5% (P = 0.480). There was no significant difference in the complication rate between the LD arm, 12.2% and the NT arm, 8.6% (P = 0.472). LD was better than NT in preventing recurrent diverticulitis. Nine patients in the NT arm and none in the LD arm had recurrence (P = 0.003). The number needed to treat to prevent recurrence was nine. CONCLUSION: Non-operative management with bowel rest and antibiotics for uncomplicated RCD is safe and effective. Alternatively, LD is also safe and effective, with the added benefit of preventing recurrences. While both treatments could be reasonably offered for uncomplicated RCD, LD is an appealing option when recurrence is a concern.

The Feasibility, Technique, and Medium-Term Follow-Up of Laparoscopic Transvesical Diverticulectomy.

BACKGROUND: To present our experience and results with the transvesical laparoscopic diverticulectomy, developed by Pansadoro et al. [BJU Int. 2009;103(3):412-24], as treatment of symptomatic bladder diverticula, with a medium-term follow-up. METHODS: Between June 2010 and July 2018, we successfully operated 15 patients (13 male/2 female), aged 32-85 years (mean age 61 years) in 2 centers in Austria, using the aforementioned technique. RESULTS: The median operative time was 297 min (range 83-488 min), and the blood loss was minimal. The median diameter of the diverticula was 94 mm (range 40-110 mm). The transurethral catheter was removed in most patients on day 7 (range 1-26 days), and cystography was performed before catheter removal. Patients were discharged on the ninth postoperative day (range 4-18 days). One case had a Clavien-Dindo grade IIIb complication (ureter injury), and 2 cases had a grade IIIa complication (nephrostomy drainage). After a median follow-up of 19 months, no recurrences were observed. CONCLUSION: The laparoscopic, transvesical diverticulectomy is a feasible and valuable procedure with good outcomes. To avoid complications, the ureter needs to be spared meticulously.

Solitary caecal diverticulitis: Comparison of operative and non operative treatment.

OBJECTIVE: To evaluate the treatment options applied to solitary caecal diverticulitis patients, and to explore the possibility of non-operative treatments. METHODS: The retrospective study was conducted a tertiary referral centre, and comprised data of patients who presented with acute abdominal pain and were diagnosed either preoperatively or intraoperatively as cases of solitary caecal diverticulitis between January 2009 and December 2017. Data on demographics, physical examination findings, laboratory results, treatment modalities and outpatient clinical records was noted, and analysed analysed using SPSS 21. RESULTS: Of the 580 patients whose medical records were reviewed, 11(1.89%) were diagnosed as cases of solitary caecal diverticulitis. Of them, 6(54.5%) patients were treated conservatively, and 5(45.4%) surgically. The disease recurred in 1(9%) patient who was treated conservatively. Among those treated surgically, 1(20%) patient had hemicolectomy, and the rest had appendectomy and/or diverticulectomy and drainage procedures. There were no major complications during the follow- up. CONCLUSIONS: With accurate diagnosis during preoperative period, the spread of the pathology helps to choose the best suitable surgical technique. Appendectomy should be performed to avoid future diagnostic confusion.

[Epiphrenic diverticulum of the lower third of the esophagus after previous antireflux surgery]. / Epifrenal'nyi divertikul nizhnei treti pishchevoda u patsientki posle provedennoi ranee antireflyuksnoi operatsii.

In this article is described a rare postoperative complication: epiphrenal diverticulum of the esophagus of the lower third of the esophagus in patient after antireflux surgery. Brief description of the main stages of surgical treatment. 96 patients with cardiofundal, subtotal or total hiatal hernias underwent operation. There were complications of I-II degree according to Clavien-Dindo in the early postoperative period in 11 patients (11.4%). Complications of IIIb degree were revealed in 2 patients (2.1%) in the early postoperative period and in 1 patient (1.0%) in the late postoperative period (2 months after hospitalization) - epiphrenal diverticulum of the esophagus. Laparotomy, the sagittal diafragmalnaya, diverticulectomy, valisesta pyloroplasty were performed. Postoperative period without complications. The patient's nutrition through the mouth is restored on the 5-th day. No dysphagia and reflux esophagitis were detected radiologically and endoscopically.

Urethral diverticulum in pregnancy: a case report.

INTRODUCTION AND HYPOTHESIS: Urethral diverticulum in pregnancy is a rare finding and difficult to diagnose. The classical triad of dysuria, dyspareunia and dribbling of urine is found in a minority of women. METHODS: A young woman presented during the first trimester of pregnancy with vaginal and suprapubic pain as well as voiding difficulty. Ultrasound demonstrated a 2-cm hypoechoic lesion to the left of the urethra. She went on to have a cystoscopy that demonstrated a diverticulum. She was found to have chlamydia on PCR. RESULTS: Her pregnancy was complicated by recurrent admissions for pain and also an episode of reactive arthritis. She underwent an uncomplicated surgical excision postpartum. CONCLUSIONS: Urethral diverticula should be excluded whenever a patient exhibits unresolved, nonspecific urinary problems. This is an underdiagnosed problem. Pregnancy presents additional challenges, but does not preclude medical or surgical treatment in the patient with significant symptoms.

Semi-prone video-assisted thoracoscopy for the treatment of large infracarinal traction diverticula.

BACKGROUND: Large middle-third esophageal diverticula are rare. Thoracotomy has been proposed as mainstay of treatment; however, minimally invasive resection through lateral or prone position thoracoscopy has been described. METHODS: The technical aspects of the novel semi-prone minimally invasive thoracoscopy (spVATS) in the management of large (> 5 cm) infracarinal traction diverticula are described. Operative outcomes, pre- and postoperative symptoms (Eckardt score) and quality of life (Short-Form 36) are analyzed. RESULTS: Four symptomatic patients underwent spVATS for traction midesophageal diverticula. The median age was 59 years and 75% were males. The median diverticulum size was 7.0 cm (range 5.5-8). The median preoperative Eckardt score was 8.4 (range 5-10), and the overall incidence of respiratory symptoms was 50%. Esophageal manometry was performed in three patients with no evidence of underlying motility disorders. The median operative time was 149 min (range 125-175). No intraoperative complications or open conversions occurred. Postoperative morbidity and mortality were 25% and 0%, respectively. The median hospital length of stay was 7.5 days (range 6-10). The median postoperative follow-up was 22 months (range 5-35). At the last follow-up, there was a significant improvement of patients' symptoms (p = 0.024) and quality of life (p < 0.05) with complete resolution of respiratory symptoms. CONCLUSION: In summary, spVATS seems a valuable approach to treat large midesophageal traction diverticula in centers experienced with minimally invasive esophageal surgery. Further studies are needed to validate the advantages and promising outcomes of the spVATS providing more robust evidence on the treatment of this rare clinical entity.

Open Versus Endoscopic Surgery of Zenker's Diverticula: A Systematic Review and Meta-analysis.

Most Zenker's diverticula (ZD) cohort studies are single-institution retrospective observational studies of recurrence rates. There is a gap in the literature regarding patient-reported outcomes after ZD surgery. This study was conducted to compare if open transcervical diverticulectomy (OD) is better than endoscopic laser diverticulectomy (ELD) or endoscopic stapler-assisted diverticulectomy (ESD). The study design is of systematic review and meta-analysis. The following databases were searched: SCOPUS, EMBASE, PubMed, and Word of Science through December 2017. The quality of the studies was evaluated using 22-item STROBE checklist with 3 independent physician reviewers. The Inter-rater reliability was calculated both as a percent and utilizing Cohen's Kappa. For the meta-analysis, Cohen's d for an effect size was calculated for all studies comparing dysphagia results before and after surgery. A total of 865 patients were treated across 11 selected publications, of which 106 patients were treated OD, 310 ELD, and 449 with an ESD approach. Patient-reported dysphagia outcomes were reported as Cohen's d (confidence interval): OD, ELD, and ESD were 1.31 (0.88, 1.74), 1.91 (1.62, 2.20), and 2.45 (2.04, 2.86), respectively. The pooled effect of all studies for dysphagia was 2.22 (1.85, 2.59) and regurgitation 2.20 (1.80, 2.59). We did not prove that OD has superior outcomes compared to ESD and ELD. Any method of surgical intervention yields a large effect (i.e., improvement in dysphagia and regurgitation) comparing patient-reported symptoms before and after surgery. Future research, currently underway, includes a prospective, multi-institutional study comparing standardized outcomes between treatments of ZD including symptom resolution, complications, and recurrences using validated measures to define long-term outcomes.Level of Evidence 3.

Is Myotomy Plus Diverticulopexy Suitable for Symptomatic Zenker's Diverticula?

The aim of the study was to prospectively evaluate the outcome of myotomy plus diverticulopexy over short and long-terms. A prospectively collected consecutive series (2007-2017) of 37 patients undergoing myotomy plus diverticulopexy was analyzed for clinical condition, operative information, peri-operative events, and follow-up by means of interview and physical examination. Diverticulopexy was scheduled regardless of the diverticulum's features and patient condition, other than operability. There was no choice or selection between possible treatment options. Patients were evaluated pre-operatively, at post-operative day 30 and after 1 year. Follow-up aimed at assessing the subjective condition following treatment. During the interview, patients were asked to self-assess their ability to swallow before and after surgery. No patient had peri-operative events, complications associated with the procedure, wound infection or impaired swallowing. All patients could start drinking the day after operation, could return to solid diet on post-operative day 2 and be discharged on post-operative days 3-4. Barium swallowing was not necessary before discharge. Full solid diet was resumed according to patient's compliance from post-operative day 2 (some patients refused solid diet soon after the operation even if asymptomatic). Follow-up ranged between 1 and 8 years. No patient was lost at follow-up. No disease recurrence was observed. Finally, no patient needed or sought for a clinical examination between the follow-up calls. Patients reported at least 50% improvement of symptomatology after 1 year. Diverticulopexy appears to be clinically safe, methodologically reproducible, and an effective procedure; it avoids suturing and offers good outcome results along with high patient satisfaction.