Outcomes after per-oral endoscopic myotomy for Zenker's diverticula (Z-POEM) and correlation with impedance planimetry (FLIP).

INTRODUCTION: Zenker's diverticulum (ZD) is a false pulsion diverticulum of the cervical esophagus. It is typically found in older adults and manifests with dysphagia. The purpose of this study is to describe our experience with Per-oral endoscopic myotomy for Zenker's (Z-POEM) and intraoperative impedance planimetry (FLIP). METHODS: We performed a single institution retrospective review of patients undergoing Z-POEM in a prospective database between 2014 and 2022. Upper esophageal sphincter (UES) distensibility index (DI, mm2/mmHg) was measured by FLIP before and after myotomy. The primary outcome was clinical success. Secondary outcomes included technical failure, adverse events, and quality of life as assessed by the gastroesophageal health-related quality of life (GERD-HRQL), reflux severity index (RSI), and dysphagia score. A statistical analysis of DI was done with the paired t-test (p < 0.05). RESULTS: Fifty-four patients underwent Z-POEM, with FLIP measurements available in 30 cases. We achieved technical success and clinical success in 54/54 (100%) patients and 46/54 patients (85%), respectively. Three patients (6%) experienced contained leaks. Three patients were readmitted: one for aforementioned contained leak, one for dysphagia, and one post-operative pneumonia. Three patients with residual dysphagia underwent additional endoscopic procedures, all of whom had diverticula > 4 cm. Following myotomy, mean DI increased by 2.0 ± 1.7 mm2/mmHg (p < 0.001). In those with good clinical success, change in DI averaged + 1.6 ± 1.1 mm2/mmHg. Significant improvement was found in RSI and GERD-HRQL scores, but not dysphagia score. CONCLUSION: Z-POEM is a safe and feasible for treatment of ZD. We saw zero cases of intraoperative abandonment. We propose that large diverticula (> 4 cm) are a risk factor for poor outcomes and may require additional endoscopic procedures. An improvement in DI is expected after myotomy, however, the ideal range is still not known.

Endoluminal treatment for Zenker's diverticulum - a population-based observational study.

BACKGROUND: Zenker's diverticulum is a false diverticulum arising in the oesophago-pharyngeal junction. It may cause symptoms like dysphagia and regurgitation. In Central Norway, treatment is centralized to St. Olavs hospital, either as an endoscopic stapled oesophago-diverticulostomy procedure at the Department of Gastrointestinal Surgery or as laser diverticulostomy at the Department of Ear, Nose and Throat Surgery, depending on diverticulum size. METHODS: Retrospective, population-based, study from 2001-2020 on patients treated for Zenker's diverticulum, at the time with a rigid endoscopic approach. Patients were identified through the in-hospital register for operations. The two treatment groups were compared on relevant pre-, intra-, and postoperative variables by review of the individual patient records. RESULTS: 78 consecutive patients, 36 at Dept. of Ear, Nose and Throat Surgery and 42 at Dept. of Gastrointestinal Surgery, were treated with a total of 104 interventions. Crude incidence for a surgery-demanding Zenker's diverticulum was 0.57 per 100 000 per year. The Dept. of Ear, Nose and Throat Surgery administered significantly less often prophylactic antibiotics than the Dept. of Gastrointestinal Surgery (p < 0.001), administered more frequently intraoperative dexamethasone (p < 0.001), and had significantly more postoperative infections (19.6% vs 3.4%, p = 0.01). No procedure-related mortality was registered. Although no standardized follow-up took place, at a median of 119 months elapsed, observed clinical recurrence was 35% for the endostapler treatment and 51% for the laser treatment procedure. CONCLUSION: Both rigid endoscopic stapled oesophago-diverticulostomy and laser diverticulostomy are safe treatments for Zenker's diverticulum, however with a substantial risk of recurrence.

A giant cause of recurrent fever

A 73-year-old male patient presented to the Emergency Department with history of weight loss, dysphagia, and recurrent fever. The initial chest radiograph showed a mediastinal hypotransparency and to the complaints of dysphagia the patient did a barium swallow test that revealed a giant Zenker diverticulum. Apart from mildly elevated inflammatory markers and despite the extensive investigation of recurrent fever, no other relevant features were found either in blood analysis, microbiological cultures or computerized tomography. He was submitted to surgical intervention, with no recurrence of fever afterwards. It was assumed that food debris and possible microaspirations were responsible for the recurrence of fever and elevation of inflammatory markers. The patient eventually died due to late complications of surgery. Although recurrent fever is frequently linked to systemic disease, the presence of such a giant diverticulum was probably causing an inflammatory response that is usually not seen in these conditions. (AU)

Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative.

OBJECTIVES: The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication. METHODS: Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi-institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management. RESULTS: There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases (n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases (p = 0.002); postoperative diet was not different between open and endoscopic (p = 0.26). CONCLUSIONS: Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction. LEVEL OF EVIDENCE: Level III Laryngoscope, 134:2678-2683, 2024.

Management of the Zenker diverticulum: multicenter retrospective comparative study of open surgery and rigid endoscopy versus flexible endoscopy.

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.

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

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

Cricopharyngeus Muscle Dysfunction and Hypopharyngeal Diverticula (e.g., Zenker): A Multicenter Study.

OBJECTIVE: To describe demographics and imaging and compare findings and symptoms at presentation in a large cohort of persons with cricopharyngeus muscle dysfunction (CPMD) with and without hypopharyngeal diverticula. METHODOLOGY: Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeal Hypertonicity (POUCH) Collaborative. Patient survey, comorbidities, radiography, laryngoscopy findings, and patient-reported outcome measures (e.g., Eating Assessment Tool [EAT-10]) data were abstracted from a REDCap database and summarized using means, medians, percentages, and frequencies. Diagnostic categories were compared using analysis of variance. RESULTS: A total of 250 persons were included. The mean age (standard deviation [SD]) of the cohort was 69.0 (11.2). Forty-two percent identified as female. Zenker diverticula (ZD) was diagnosed in 85.2%, 9.2% with CPMD without diverticula, 4.4% with a Killian Jamieson diverticula (KJD), and 1.2% traction-type diverticula. There were no differences between diagnostic categories in regard to age, gender, and duration of symptoms (p = 0.25, 0.19, 0.45). The mean (SD) EAT-10 score for each group was 17.1 (10.1) for ZD, 20.2 (9.3) for CPMD, and 10.3 (9.4) for KJD. Patients with isolated CPMD had significantly greater EAT-10 scores compared to the other diagnostic groups (p = 0.03). CONCLUSION: ZD is the most common, followed by CPMD without diverticula, KJD, and traction-type. Patients with isolated obstructing CPMD may be more symptomatic than persons with ZD or KJD. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1349-1355, 2023.

Peroral endoscopic myotomy and septotomy for Zenker diverticulum.

Zenker diverticulum (ZD) is the most common hypopharyngeal diverticulum seen often in septuagenarian and octogenarian males. Oropharyngeal dysphagia is the most common presenting symptom. Treatment of ZD has been advancing with the introduction of a wide variety of accessory devices, primarily focusing on obliteration of the septum by complete transection of the cricopharyngeus muscle to recreate the common cavity and restore normal pharyngo-esophageal bolus outflow. This review aimed to provide an overview of the various surgical and endoscopic treatment options for ZD, while focusing specifically on Zenker peroral endoscopic myotomy.

[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.

Upper Esophageal Dysphagia.

Esophageal dysphagia presents acutely, most frequently as a food impaction, or in a progressive fashion. Anatomic changes are frequently responsible. Although the history may be suggestive, diagnosis is made from imaging or endoscopic studies. In asymptomatic cases, observation is most appropriate. Treatment is frequently accomplished endoscopically. Strictures, cricopharyngeal hyperfunction, and Zenker diverticulum are potential etiologic causes. For the purpose of this article focused on upper esophageal dysphagia, delineation between the upper and lower parts is the crossing of the aortic arch but also includes the most distal aspects of the hypopharynx including the inferior pharyngeal constrictors and upper esophageal sphincter.

Suspected malignant degeneration in a Zenker's diverticulum: should we biopsy it?

We report the case of an 89-year-old female who presented with progressive weight loss, oropharyngeal dysphagia and food regurgitation.

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

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

Cap-Assisted Endoscopic Septotomy of Zenker's Diverticulum: Early and Long-Term Outcomes.

INTRODUCTION: Multiple therapeutic modalities including surgery and rigid and flexible endoscopy have been adopted to manage Zenker's diverticulum (ZD). Minimally invasive flexible endoscopic septotomy (FES) techniques have been increasingly favored over the past 20 years; however, long-term data are still scanty. The aim of this study is to evaluate early and long-term outcomes of FES for naive ZD in a single-center setting. METHODS: From 2010 to 2017, ZD patients treated with FES were included in a prospectively maintained database (NCT03948438). Those who had already been treated surgically or endoscopically were excluded from the analysis. The Dakkak and Bennett dysphagia scale was used to rate the dysphagia. Persistent complete or near-complete resolution of symptoms (Dakkak and Bennett 0 or 1) was defined as clinical success. Postprocedural adverse events were reported according to ASGE lexicon. RESULTS: Overall, 256 consecutive patients were treated. Mean pouch size was 29.8 ± 11.3 mm. The procedure was successfully completed in all scheduled patients, with an early clinical success of 96.1%. Adverse events occurred in 3.5% (9/256) of patients. Eight of them were mild/moderate with no fatal events, whereas one patient required surgery. Recurrences occurred in 31.3% (80/256) of treated patients after a mean time of 9 ± 3 months and 95% of recurrences were treated by a second FES. At an average follow-up of 5.5 years, 95.3% of patients were asymptomatic after a mean number of 1.3 procedures. DISCUSSION: FES is a safe and effective treatment modality for patients with ZD. Recurrence rate is significant; however, endoscopic reintervention is associated with long-term relief of dysphagia.

Correlating Dysphagia Severity with Fluoroscopic Parameters in Patients with Zenker's Diverticulum.

Zenker's diverticulum (ZD) is an uncommon condition characterized by formation of a pseudodiverticulum in the hypopharynx that presents with considerable variability in swallowing symptomatology. Identifying radiographic features of ZD most associated with clinical impact could prove useful in counseling patients and predicting treatment response. This study was a retrospective case series of patients undergoing videofluoroscopic swallowing studies (VFSS) for Zenker's diverticulum at a tertiary dysphagia center. Anatomic parameters identified on VFSS of patients with ZD were correlated with subjective perception of swallowing using Eating Assessment Tool (EAT-10) scores. Upper esophageal sphincter (UES) opening at the point of maximal distention, area of diverticulum on the lateral view, height of the diverticulum, and entrance angle of the esophagus were measured. We identified 40 patients with ZD (52.5% male, mean age = 71.2 years). Narrow UES opening was significantly correlated with dysphagia severity (r = - 0.3445, p = 0.035). Largest area of diverticulum (r = 0.0188, p = 0.87), diverticulum height (r = 0.1435, p = 0.45), and esophageal entrance angle (r = 0.1677, p = 0.42) were not correlated with EAT-10 scores. Maximum UES opening size was predictive of severity of swallowing dysfunction in patients with ZD. Size of ZD and the angle of bolus entry in patients with ZD are not predictive of swallowing dysfunction. Understanding the predictors of swallowing dysfunction will assist in counseling patients on postoperative expectations.

Benign Tracheoenteric Fistula to a Zenker's Diverticulum With Complete Esophageal Obstruction.

A fistula between a Zenker's diverticulum and the trachea has only been reported once, in 1983. Here, we report a case of a fistula between a large Zenker's diverticulum and the trachea with complete occlusion of the esophagus. The fistula was repaired, first by an esophageal myotomy, followed by proximal resection of the diverticulum, completion of the esophageal myotomy, transection of the fistula, and repair of the trachea. The surgical repair provided complete resolution of symptoms without complications.

30-Day Postoperative Outcomes Following Transcervical Zenker's Diverticulectomy in the Elderly: Analysis of the NSQIP Database.

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.