Efficacy and Safety of Peroral Endoscopic Myotomy in the Treatment of Zenker's Diverticulum: A Single-Center Experience.

BACKGROUND/AIMS: The efficacy and safety of Zenker's peroral endoscopic myotomy (Z-POEM), a current method in the treatment of Zenker's diverticulum (ZD), have been demonstrated in a limited number of studies and case reports. This study aimed to report our experience with the Z-POEM method. MATERIALS AND METHODS: Patients with ZD who were treated with Z-POEM between January 2019 and March 2023 and had a followup period of at least 3 months were included in the study. Our primary endpoint was clinical success. A Kothari-Haber score (KHS) of 2 or less at 1 month postoperatively was defined as clinical success. Our secondary endpoints were adverse events and recurrence rates. RESULTS: In total, 20 patients (males, 65%; mean age, 63 ± 14.4 years) were treated with Z-POEM. The mean ZD septum length was 33.7 (±11.04) mm. The technical success rate was 100% (20/20), and the clinical success rate was 95% (19/20). In 1 case with a large ZD (septum length of 60 mm), the mucosal septum, which was thought to cause partial persistence of symptoms, was treated by endoscopic septotomy. The mean KHS decreased significantly after Z-POEM (preoperative KHS: 7.3 and postoperative KHS: 0.15, P < .0001). The median follow-up period was 10 months (interquartile range, 3-39). No recurrence was observed in any case. Intraprocedural mild subcutaneous emphysema was observed in 4 (20%) cases. Emphysema regressed spontaneously in the postoperative period without any treatment. CONCLUSION: Zenker's peroral endoscopic myotomy is a successful and reliable method in the treatment of ZD, with low recurrence rates.

[Endoscopic treatment of recurrent Zenker diverticulum and postoperative esophageal stricture]. / Endoskopicheskaya krikofaringoezofagomiotomiya v lechenii patsientki s retsidivnym divertikulom Tsenkera i posleoperatsionnoi strikturoi pishchevoda.

Zenker diverticulum is a rare disease accounting for 1.5-5% of esophageal diverticula. For a long time, surgical treatment of Zenker pharyngoesophageal diverticula implied open diverticulectomy via cervical approach. However, this intervention is characterized by high postoperative morbidity and recurrence rate. Oral endoscopic minimally invasive cricopharyngoesophagomyotomy has become widespread over the past 10 years. We present a 55-year-old female who underwent endoscopic treatment for recurrent Zenker diverticulum and postoperative esophageal stricture. We obtained favorable result in a patient with recurrent Zenker diverticulum after previous open surgeries complicated by esophageal stricture. Endoscopic management eliminated recurrent diverticulum and esophageal stricture, as well as improved the quality of life. Endoscopic approach is preferable for pharynoesophageal diverticula compared to traditional surgical diverticulectomy. Obvious advantages of this technique are stable functional result, low incidence of complications and mortality, short-term postoperative period with fast rehabilitation. Extended myotomy is essential for successful oral endoscopic cricopharyngoesophagomyotomy.

Surgical Outcomes in Zenker Diverticula: A Multicenter, Prospective, Longitudinal Study.

OBJECTIVE: To compare improvement in patient-reported outcomes (PROM) in persons undergoing endoscopic and open surgical management of Zenker diverticula (ZD). METHODOLOGY: Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgery for ZD. Patient survey, radiography reports, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were abstracted from a REDCap database, which summarized means, medians, percentages, and frequencies of. Outcome based on operative intervention (endoscopic vs. open) was compared using t-test, Wilcoxon rank sum test or chi-square test, as appropriate. RESULTS: One hundred and forty-seven persons were prospectively followed. The mean age (SD) of the cohort was 68.7 (11.0). Overall, 66% of patients reported 100% improvement in EAT-10; 81% of patients had greater than 75% improvement; and 88% had greater than 50% improvement. Endoscopic was used for n = 109 patients, and open surgical intervention was used for n = 38. The median [interquartile range, IQR] EAT-10 percent improvement for endoscopic treatment was 93.3% [72, 100], and open was 100% [92.3, 100] (p = 0.05). The incidence of intraoperative complications was 3.7% for endoscopic and 7.9% for open surgical management. The median [IQR] in follow-up was 86 and 97.5 days, respectively. CONCLUSION: Both endoscopic and open surgical management of ZD provide significant improvement in patient-reported outcomes. The data suggest that open diverticulectomy may provide a modest advantage in symptomatic improvement compared to endoscopic management. The data suggest that the postoperative complication rate is higher in the open surgical group. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:97-102, 2024.

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.

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%.

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)

Modern approaches to treating Zenker's diverticulum.

PURPOSE OF REVIEW: Zenker's diverticulum is the most common hypopharyngeal diverticulum. Patients with Zenker's diverticulum may require surgical treatment, which can be performed via an open surgical or endoscopic approach. A new endoscopic technique that is now being used for Zenker's diverticulum is Zenker Per Oral Endoscopic Myotomy (ZPOEM). ZPOEM has demonstrated promising results, and may have certain advantages over the other endoscopic treatments. The purpose of this review article is to evaluate the various surgical and endoscopic treatment options for Zenker's diverticulum, while specifically focusing on ZPOEM. RECENT FINDINGS: Endoscopic approaches have become the first-line therapy for Zenker's diverticulum, replacing the traditional open approach, because of the less invasive nature of the endoscopic procedures, improved rates of morbidity, and quicker recovery times. Recent studies evaluating ZPOEM have demonstrated that it is technically feasible and highly efficacious. In addition, it has a low rate of clinical recurrence and adverse events. When compared with other endoscopic techniques for treating Zenker's diverticulum, ZPOEM appears to have improved outcomes. SUMMARY: ZPOEM has been recently implemented in the algorithm of Zenker's diverticulum management. Further comparative and prospective studies focusing on long-term follow-up are still needed; however, ZPOEM appears to be an excellent option for patients suffering from Zenker's diverticulum.

Comparison of Zenker's per-oral endoscopic myotomy (Z-POEM) with standard flexible endoscopic septotomy for Zenker's diverticulum: a prospective study with 2-year follow-up.

BACKGROUND: Flexible endoscopic therapy of Zenker's diverticulum using submucosal tunneling (Z-POEM) similar to esophageal Per-Oral Endoscopic Myotomy (POEM) is becoming increasingly common. However, data comparing Z-POEM with traditional flexible endoscopic septotomy (FES) are sparse. The aim of this study was to compare outcomes of Z-POEM with traditional FES over a medium-term follow-up period. METHODS: This was a prospective study of patients who underwent Z-POEM for treatment of Zenker's diverticulum between 2018 and 2020 at a tertiary academic medical center compared to prior patients who had FES (between 2015 and 2018). Procedural characteristics and clinical outcomes (technical and clinical success, and adverse events) were compared between patients who underwent each treatment. RESULTS: A total of 28 patients underwent ZD therapy during the study period. 13 patients (mean age 70 years; 77% male) underwent Z-POEM and 15 patients (mean age 72 years; 73% male) underwent traditional FES. The mean Zenker's diverticulum size was 2.4 ± 0.6 cm in the ZPOEM group vs 2.5 ± 0.8 cm in the FES group. The mean procedure time was similar between groups: 43.9 min (range 26-66) in the Z-POEM group and 60.2 min (range 25-92) in the traditional FES group (t = 1.74 p = 0.19). Overall technical success was seen in 100% of patients. There was one adverse event in the FES group (dehydration resulting in near-syncope) (1/28, 3.6%). Overall clinical success was seen in 92.8% (26/28) of patients and was not significantly different between groups (Z-POEM; 13/13, 100% vs FES; 13/15, 86.7%, t = - 1.36 p = 0.18). CONCLUSION: This prospective study suggests that ZPOEM is an effective technique for the treatment of Zenker's diverticulum with no significant differences in clinical outcomes or adverse event rates when compared to traditional FES.

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.

Per-oral endoscopic myotomy is a safe and effective treatment for Zenker's diverticulum: a retrospective multicenter study.

Zenker per-oral endoscopic myotomy (ZPOEM) has become a promising technique for Zenker's diverticulum (ZD). The aim of this study was to add to the limited body of literature evaluating the safety and efficacy of ZPOEM. A prospectively maintained database was retrospectively reviewed to identify patients who underwent ZPOEM at two separate institutions between January 2020 and January 2022. Demographics, preoperative and postoperative clinical data, intraoperative data, adverse events, and length of stay were analyzed. A total of 40 patients (mean age 72.5 years, 62.5% male) were included. Average operative time was 54.7 minutes and average length of stay was 1.1 days. There were three adverse events, and only one was related to the technical aspects of the procedure. Patients showed improvement in the Functional Oral Intake Scale (FOIS) scores at 1 month (5 vs 7, p < 0.0001). The median FOIS scores remained 7 at both 6 and 12 months, although this improvement was not statistically significant at these time intervals (p = 0.46 and 0.37, respectively). Median dysphagia scores were decreased at 1 (2.5 vs 0, p < 0.0001), 6 (2.5 vs 0, p < 0.0001), and 12 months (2.5 vs 0, p = 0.016). The number of patients reporting ≥1 symptom was also decreased at 1 (40 vs 9, p < 0.0001) and 6 months (40 vs 1, p = 0.041). Although the number of patients reporting ≥1 symptom remained consistent at 12 months, this was not statistically significant (40 vs 1, p = 0.13). ZPOEM is a safe and highly effective treatment for the management of ZD. .

Postoperative Complications and Reoperative Surgery in the Treatment of Patients With Zenker Diverticulum.

Importance: The association of the surgical approach, surgical specialty, and other factors with the outcomes of surgical treatment of Zenker diverticulum (ZD) have been debated in the literature. Objectives: To explore the outcomes of 3 different surgical methods used in the management of ZD and determine the associations between patient characteristics, such as preoperative comorbidities and treatment outcomes. Design, Setting, and Participants: This retrospective, population-based cohort study examined patient records of patients who underwent surgical treatment for ZD from the Care Register for Healthcare database in Finland between January 1996 and December 2015. Data review and analysis were completed in 2021. Exposure: Surgical treatment for ZD. Main Outcome and Measures: Complications of surgical procedures used in the management of ZD. Results: In this study, 1044 patients (median [IQR] age, 70.0 [22.0-98.0] years; 416 female individuals [39.8%]) surgically treated for ZD were identified. Most patients (606 [58.0%]) had no preoperative comorbidities. A total of 67 (6.4%) complications were recorded, with a mortality rate of 0.9%. The likelihood of complications was associated with patient age (t [1042] = 2.28; Cohen d, 0.29; 95%, CI 0.04, 0.54), surgical approach (Cramer V = 0.14 [95% CI 0.07-0.21]), and surgical specialty (Cramer V, 0.16; 95% CI, 0.06-0.28). The median (IQR) length of stay in association with the primary surgical intervention was 3.0 (0-85.0) days. Length of stay was associated with patient age (Cramer V, 0.14; 95% CI, 0.06-0.25), especially in patients older than 90 years, surgical approach (F [2, 466.2] = 26.9; ηp2 = 0.08; 95% CI, 0.05-0.11), and surgical specialty (F [4, 22.1] = 11.0; ηp2 = 0.07; 95% CI, 0.04-0.10). Reoperation was associated with the initial surgical approach (Cramer V, 0.18; 95% CI, 0.12-0.23) and surgical specialty (Cramer V, 0.14; 95% CI, 0.09-0.21). Conclusions and Relevance: The results of this cohort study suggest that the outcomes of surgical management depended on the surgical approach, surgical specialty, and patient age. Overall, surgical treatment may be considered safe and may be considered for all patients with symptomatic ZD.

Concurrent Killian-Jamieson and Zenker's Diverticula.

Pharyngoesophageal diverticula are rare causes of dysphagia. Zenker's diverticulum is the most common type, followed by Killian-Jamieson diverticulum. A 44-year-old male presented to our clinic with a longstanding history of dysphagia and globus sensation. Bilateral pharyngoesophageal diverticula were confirmed by imaging CT and esophagogastroscopy. He underwent transcervical resection, and a right Killian-Jamieson diverticulum was observed during surgery. The left diverticulum was found to originate above the cricopharyngeus muscle and was labeled as Zenker's diverticulum. Bilateral pharyngoesophageal diverticula are rare, and physicians should be aware of the variable clinical presentations and management options for pharyngoesophageal diverticula.

Objective Fluoroscopic Outcomes After Endoscopic Staple Versus Laser Zenker's Diverticulotomy.

OBJECTIVE: Endoscopic Zenker's diverticulotomy (EZD) is typically performed via stapling (endoscopic staple diverticulotomy; ESD) or CO2 laser (endoscopic laser diverticulotomy; ELD). Conflicting reports exist on which approach provides optimal outcomes. This investigation compared objective fluoroscopic data between ESD and ELD. METHODS: A retrospective review of all patients undergoing primary EZD at a tertiary center between January 1, 2014 and January 10, 2022 was performed. Patients undergoing ESD and ELD were matched by preoperative diverticulum size. Primary outcome measures were postoperative diverticulum size and change in diverticulum size from pre- to postoperative swallowing fluoroscopy. Secondary outcome measures were the Eating Assessment Tool (EAT-10) score, penetration aspiration scale (PAS), pharyngeal constriction ratio (PCR), and pharyngoesophageal segment opening (PESo). RESULTS: Thirteen matched pairs with complete fluoroscopic data were identified. The mean (±SD) age of the cohort was 74.0 (±8.5) years. There were no age or gender differences between groups (p > 0.05). The mean pre-operative ZD size was 1.98 (±0.69) cm for ESD and 1.97 (±0.72) cm for ELD; the mean postoperative size was 0.84 (±0.62) cm for ESD and 0.34 (±0.27) cm for ELD (p < 0.05). Mean diverticulum size improved by 1.14 (±0.59) cm after ESD and 1.62 (±0.59) cm after ELD (p < 0.05). There were no significant differences in postoperative EAT-10, PAS, PCR, or PESo between groups. CONCLUSION: The data suggest that endoscopic laser Zenker's diverticulotomy results in a greater improvement in diverticulum size than endoscopic staple diverticulotomy. The data did not suggest a difference in postoperative dysphagia symptom scores or other objective fluoroscopic parameters between staple and laser diverticulotomy. LEVEL OF EVIDENCES: Level 3 Laryngoscope, 133:3057-3060, 2023.

Comparing Open Versus Rigid Endoscopic and Flexible Endoscopic Techniques for the Treatment of Zenker's Diverticulum.

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.