Presented at the Meeting of the Middle Section of the American Laryngological, Rhinological and Otological Society, Inc., Cincinnati, Ohio, January 23, 2000.
Objective To evaluate the efficacy and safety of endoscopic stapled diverticulotomy in the treatment of patients with Zenker's diverticulum.
Study Design Cohort study.
Methods Fourteen elderly patients (11 men and 3 women) with Zenker's diverticulum were evaluated in a community hospital setting from July 1996 to November 1999. Before surgery patients had significant dysphagia, regurgitation, cough, or aspiration pneumonia. The common septum between the diverticulum and cervical esophagus was visualized with a Weerda diverticuloscope. While using videoendoscopic monitoring, the septum was divided and the edges simultaneously sealed with a linear endoscopic stapler. Average operative time was 31 minutes.
Results The operation was successfully performed in 11 of 14 patients. In the three unsuccessful cases, one patient's pouch was too small to staple and the other two patients had a septum that was difficult to visualize with the diverticuloscope. There was no significant postoperative morbidity or mortality. Patients started a liquid diet on the first postoperative day and resumed a soft diet a week later. They were usually discharged on the first postoperative day. Most patients reported significant improvement with resolution of dysphagia and regurgitation.
Conclusions Compared with the traditional open technique, the endoscopic stapled diverticulotomy technique is safe, quick, and effective and requires a shorter length of stay in the hospital. Therefore it has become our treatment of choice for elderly, high-risk patients with a large (>2 cm) hypopharyngeal (Zenker's) diverticulum.
During the past 100 years, various surgical techniques have been described for the treatment of the hypopharyngeal (Zenker's) diverticulum. In 1917, Mosher 1 first performed an endoscopic diverticulotomy, although a fatality attributable to mediastinal infection dampened his enthusiasm for this approach. In 1960 Dohlman and Mattsson 2 successfully used the endoscopic approach to divide the common septum with cautery; later, Van Overbeek 3 used CO2 laser successfully. Concerns about possible salivary leak with mediastinal infection have delayed acceptance of this approach. However, various open approaches (i.e., diverticulectomy and diverticulopexy with myotomy) have also had complications; a 37% postoperative medical and surgical complication rate recently was reported by Feeley et al. 4
In 1993 Collard et al. 5 in Belgium and Martin-Hirsch and Newbegin 6 in England independently described the first use of the endoscopic stapling technique, which simultaneously divides the septum and seals the cut edges to produce a common channel—an esophagodiverticulostomy. Extensive use of this procedure in England 7–9 and Italy 10 has shown less morbidity than open procedures. Recently this technique has been developed in the United States by Scher and Richtsmeier. 11,12
We were seeking a safe, minimally invasive procedure that might avoid complications in the elderly patient with Zenker's diverticulum. We describe our favorable experience with the endoscopic stapled diverticulostomy (ESD) procedure for the treatment of patients with a Zenker's diverticulum.
MATERIALS AND METHODS
From July 1996 to November 1999, 14 patients were evaluated for treatment of dysphagia related to Zenker's diverticulum. All patients had an esophagram before surgery except for one patient, whose disease was diagnosed by laryngoscopy while he was in the intensive care unit. After surgery patients who were asymptomatic usually did not have an esophagram performed. Patients with residual symptoms were evaluated with an esophagram.
The surgical procedure of ESD is performed with the patient under general anesthesia. A Weerda diverticuloscope (Storz, Culver City, CA) (Fig. 1) is placed to visualize from anterior to posterior the esophagus, the common septum, and the diverticulum. Retained material is suctioned from the diverticulum. The 0° or 30° telescope, which is connected to the video camera, is used to visualize the septum and diverticulum. The Endopath endoscopic linear cutter (Ethicon Endo-Surgery, Inc., Cincinnati, OH) (Fig. 2) can be modified by shortening the anvil or lower blade (Fig. 3), which allows the incision and rows of staples to extend to the bottom of the diverticulum, thus leaving a low residual septum.
The stapler is passed through the diverticuloscope and down to the septum so that the cartridge blade is in the esophagus and the anvil blade is in the diverticulum. When proper position of the blades is confirmed by video camera, the blades are approximated and the stapler is activated, which simultaneously cuts the common wall and seals the edges of the incision with three rows of staples. The stapler is removed and, if the diverticulum is large, another stapler cartridge is placed and applied in a similar fashion. After the diverticulotomy is completed, the new common channel of the cervical esophagus and diverticulum is examined. Care is taken to avoid leaving a residual septum, which may lead to persistent symptoms.
After surgery the patient is observed overnight in the hospital. If there is no fever, chest pain, or back pain, the patient is started on a diet of liquids the evening of the day of surgery or the morning of the first postoperative day. Usually, the patient is discharged on the day after surgery if there are no other illnesses requiring further hospitalization. The patient resumes a soft diet 1 week later.
Between July 1996 and November 1999, 14 patients (11 men and 3 women) were considered for ESD (Table I). Their average age was 69.2 years (age range, 57–94 y). The average operative time was 31 minutes. One patient had undergone a previous open procedure with recurrent symptoms 1 year later. He was treated endoscopically with good results. Two patients could not undergo ESD because of inadequate visualization of the common septum with the diverticuloscope. Both received an open procedure and did well. One patient's diverticulum was considered too small (<2 cm) for stapling. Two patients had sufficient residual symptoms after their first procedure to warrant a second revision procedure, which was successful for both. One patient had undergone an abdominal aortic aneurysm repair when, after surgery, he experienced recurrent aspiration requiring prolonged intubation. A previously undiagnosed case of Zenker's diverticulum was noticed at the time of repeat intubation. The patient was successfully treated with ESD, which allowed extubation and, eventually, a full recovery.
Table Table 1.. Summary of Patients Evaluated for Endoscopic Stapled Diverticulostomy (ESD).
OR = operating room; LOS = length of stay; AAA = abdominal aortic aneurysm; C = complete; I = improved.
Eleven patients underwent ESD. Symptom relief is described in Table II. All patients who were treated with ESD either had complete relief or were improved enough to not wish any further treatment. Eight patients reported complete symptom relief; the other three patients were improved. There were no postoperative infections or deaths. Most patients were discharged on the first postoperative day, resuming a liquid diet the first day and soft diet a week later (Table III). Of the three patients who were not treated with ESD, two have had open procedures with complete relief of their symptoms. At the time of this writing, one untreated patient with a small diverticulum is undergoing evaluation for further treatment.
Table Table 2.. Symptom Relief for Zenker's Diverticulum.
Total patients = 14; total patients treated by ESD = 11; 2 patients had revision procedure with complete relief.
Table Table 3.. Perioperative Results for ESD.
When a patient develops symptoms related to a case of Zenker's diverticulum, there are generally two surgical options—an open procedure or an endoscopic approach. Most patients with Zenker's diverticulum are elderly, and they usually have coexisting medical illnesses. A procedure that provides relief of symptoms with low morbidity and a short hospital stay is preferred. For the external or open approach, Feeley et al. 4 described a 38% complication rate. This can be compared with a zero complication rate as reported by Peracchia et al. 10 in 95 patients and in our study of 14 patients. Our experience in a community hospital setting supports the previous reports from England and Italy showing the safety and efficacy of the endosurgical stapling procedure.
A short length of hospital stay and early resumption of diet are definite advantages of the endoscopic approach. Van Eeden et al. 13 compared the open-procedure and ESD groups of patients and found a shorter length of stay for the ESD group. Symptom relief is also excellent with the stapling technique, with most studies reporting improvement of symptoms in 83% to 88% of patients. 9,12,13 Our study shows that, of the patients treated endoscopically, most had complete relief of symptoms and the others improved. Another advantage of ESD is that, if a revision procedure is required, it can be performed easily with good results. 14
The rate of complications with the ESD procedure is low. Our small series of patients had no postoperative fever, infection, or fistula. Other series have also reported a low morbidity rate, with Peracchia et al. 10 reporting zero morbidity and mortality in the largest cohort study of 95 patients. Scher and Richtsmeier 12 reported a 13.8% complication rate in 36 patients, which included one mucosal tear (treated endoscopically), one postoperative fever, two dental injuries, and one transient vocal cord paralysis. This is a lower complication rate compared with Feeley's 38% complication rate using open techniques.
Disadvantages of the endoscopic technique are few. Incomplete exposure of the common septum and diverticulum because of unfavorable anatomy makes it difficult or impossible to properly position the diverticuloscope. These patients are usually best treated with an open approach. Prominent upper incisors, limited mouth opening, inability to extend the neck, and a too-distal diverticulum can make it difficult to proceed with ESD. As was the case with one of our patients, a small hypopharyngeal (Zenker's) diverticulum (<2 cm) can be technically difficult to treat endoscopically. However, Scher and Richstmeier 12 have described the use of traction sutures allowing endosurgical treatment of the small diverticulum.
Compared with the traditional open techniques, the endoscopic stapling technique for the treatment of the patient with Zenker's diverticulum is safe, quick, and effective and requires a shorter length of stay in the hospital. Therefore it has become our initial treatment of choice for most patients with Zenker's diverticulum of medium to large size.