Zenker's diverticulum surgery: Difference between revisions

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{{Zenker's diverticulum}}
{{Zenker's diverticulum}}
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==Overview==
==Overview==
[[Surgery]] is the most definitive therapy for the [[Zenker's diverticulum]] (ZD). If small and [[asymptomatic]], no [[Treatment IND|treatment]] is necessary. Larger, [[symptomatic]] cases of [[Zenker's diverticulum]] have been traditionally treated by [[neck]] surgery to [[Resection|resect]] the [[diverticulum]] and [[incise]] the [[cricopharyngeus muscle]]. However, in recent times non-surgical [[endoscopic]] techniques have gained more importance, and the currently preferred [[Treatment IND|treatment]] is [[endoscopic]] stapling i.e. closing of the [[diverticulum]] via a stapler inserted through a tube in the [[oral cavity]]. This may be performed through a [[Fiberoptic intubation|fiberoptic endoscope]]. Other non-surgical [[Treatment IND|treatment]] [[Modality|modalities]] exist, such as [[endoscopic]] [[laser]], but recent [[evidence]] has shown it to be less effective than stapling.


==Surgery==  
==Surgery==  
If small and asymptomatic, no treatment is necessary. Larger, symptomatic cases of Zenker's diverticulum have been traditionally treated by neck [[surgery]] to resect the [[diverticulum]] and incise the [[cricopharyngeus]] muscle. However, in recent times non-surgical endoscopic techniques have gained more importance (as they allow for much faster recovery), and the currently preferred treatment is endoscopic stapling<ref>PMID 15453934 Endoscopic stapling of pharyngeal pouch, J Laryngol Otol. 2004 Aug;118(8):601-6</ref><ref>PMID 12782805 Endoscopic staple diverticulostomy for Zenker's diverticulum: review of literature and experience in 159 consecutive cases, Laryngoscope. 2003 Jun;113(6):957-65</ref> (i.e. closing off the diverticulum via a stapler inserted through a tube in the mouth). This may be performed through a fibreoptic endoscope<ref>PMID 15966520 Fiberoptic endoscopic-assisted diverticulotomy: a novel technique for the management of Zenker's diverticulum, Ann Otol Rhinol Laryngol. 2005 May;114(5):347-51</ref>. Other non-surgical treatment modalities exist, such as endoscopic laser, which recent evidence suggests it less effective than stapling.<ref>PMID 16954989 The Endoscopic Management of Zenker Diverticulum: CO2 Laser versus Endoscopic Stapling, Laryngoscope. 2006 Sep;116(9):1608-11</ref>
*If small and [[asymptomatic]], no [[Treatment IND|treatment]] is necessary.  
*Larger, [[symptomatic]] cases of [[Zenker's diverticulum]] have been traditionally treated by neck [[surgery]] to resect the [[diverticulum]] and incise the [[cricopharyngeus]] [[muscle]].  
*However, in recent times non-surgical [[endoscopic]] techniques have gained more importance as they allow for much faster recovery, and the currently preferred treatment is [[endoscopic]] stapling (i.e. closing of the [[diverticulum]] via a stapler inserted through a tube in the mouth).<ref>PMID 12782805 Endoscopic staple diverticulostomy for Zenker's diverticulum: a review of literature and experience in 159 consecutive cases, Laryngoscope. 2003 Jun;113(6):957-65</ref><ref>PMID 15453934 Endoscopic stapling of the pharyngeal pouch, J Laryngol Otol. 2004 Aug;118(8):601-6</ref>
*This may be performed through a fibreoptic [[endoscope]]<ref>PMID 15966520 Fiberoptic endoscopic-assisted diverticulotomy: a novel technique for the management of Zenker's diverticulum, Ann Otol Rhinol Laryngol. 2005 May;114(5):347-51</ref>.  
*Other non-surgical [[Treatment IND|treatment]] [[Modality|modalities]] exist, such as [[endoscopic]] [[laser]], but recent [[evidence]] has shown it to be less effective than stapling.<ref>PMID 16954989 The Endoscopic Management of Zenker Diverticulum: CO2 Laser versus Endoscopic Stapling, Laryngoscope. 2006 Sep;116(9):1608-11</ref>
*Various [[surgeries]] performed for the [[Zenker's diverticulum|ZD]] are as follows:
**''Rigid [[endoscopic]] diverticulotomy''
**''Flexible [[endoscopic]] diverticulotomy''
 
=== '''Rigid endoscopic diverticulotomy''' ===
Four types of [[Procedure|procedures]] are performed using rigid scope
 
==== '''1.''Endoscopic electrocautery''''' ====
[[Endoscopic]] [[electrocautery]] may be used as a treatment option for Zenker's diverticulum:<ref name="pmid5396435">{{cite journal |vauthors=Costa RC |title=[Use of proteolytic enzymes, isolated or in combination with antibiotics, in orthopedics and in injuries] |language=Portuguese |journal=Rev Bras Med |volume=26 |issue=11 |pages=696–9 |year=1969 |pmid=5396435 |doi= |url=}}</ref><ref name="pmid12215027">{{cite journal |vauthors=Mirza S, Dutt SN, Minhas SS, Irving RM |title=A retrospective review of pharyngeal pouch surgery in 56 patients |journal=Ann R Coll Surg Engl |volume=84 |issue=4 |pages=247–51 |year=2002 |pmid=12215027 |pmc=2504214 |doi= |url=}}</ref>
*This is suitable for smaller [[Lesion|lesions]] and is performed via an [[endoscope]].
*A double-lipped esophagoscope is used and the wall between the [[diverticulum]] and [[esophageal]] wall is exposed.
*The [[Hypopharynx|hypopharyngeal]] bar is divided with [[diathermy]] or [[laser]].
*Shorter duration of [[Anesthesia|anaesthesia]].
*More rapid resumption of [[oral]] intake.
*Shorter hospital stay.
*Quicker recovery.
'''Complications:'''
*[[Subcutaneous|Sub-cutaneous]] [[emphysema]]
*[[Mediastinitis]]
*[[Aspiration]] from the pouch
'''2.''Endoscopic CO2 laser technique'''''
 
Endoscopic CO2 laser technique may also be used as a treatment option for Zenker's diverticulum:<ref name="urlSurgical Treatment of Zenkers Diverticulum - FullText - Digestive Surgery 2013, Vol. 30, No. 3 - Karger Publishers">{{cite web |url=https://www.karger.com/Article/FullText/351433#ref48 |title=Surgical Treatment of Zenker's Diverticulum - FullText - Digestive Surgery 2013, Vol. 30, No. 3 - Karger Publishers |format= |work= |accessdate=}}</ref><ref name="urlEndoscopic electrocautery dilation of benign anastomotic colonic strictures: a single-center experience. - PubMed - NCBI">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmed/25835467 |title=Endoscopic electrocautery dilation of benign anastomotic colonic strictures: a single-center experience. - PubMed - NCBI |format= |work= |accessdate=}}</ref>
*This technique offers high energy and high focused beam.
*Very minimal [[tissue]] [[trauma]].
*It also provides a better visualization of the [[diverticular]] bridge and easier control of the operation.
'''Complications:'''
*[[Mediastinitis]]
*[[Subcutaneous|Sub-cutaneous]] [[emphysema]]
 
'''3''.Endoscopic stapling'''''
 
Endoscopic stapling is one the preferred treatment options for Zenker's diverticulum:<ref name="urlOutcome and quality of life after open surgery versus endoscopic stapler-assisted esophagodiverticulostomy for Zenkers diverticulum. - PubMed - NCBI">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmed/16866864?dopt=Abstract |title=Outcome and quality of life after open surgery versus endoscopic stapler-assisted esophagodiverticulostomy for Zenker's diverticulum. - PubMed - NCBI |format= |work= |accessdate=}}</ref>
* This cuts and seal the edge of the wound simultaneously,
* Low incidence of [[perforation]] and [[bleeding]].
* Thermal damage to the [[recurrent laryngeal nerve]] can be [[Prevention|prevented]] with this [[procedure]].
'''4.''Endoscopic harmonic scalpel'''''
 
'''Flexible Endoscopic Diverticulotomy'''
* The [[procedure]] is done with an extended [[neck]] under [[sedation]], general [[anesthesia]] is not required.
* The septum between the [[diverticulum]] and [[esophageal]] [[lumen]] can be visualized by the hood, [[endoscopic]] cap, and overtube and [[Stabilization|stabilized]] without overextension of the [[neck]].
* The knives used for the [[incision]] are as follows
** Needle-knife
** Hook-knife
** [[Argon plasma coagulation]]
** Monopolar [[forceps]]
'''Complications of the Endoscopic procedures'''<ref name="urlwww.karger.com">{{cite web |url=https://www.karger.com/Article/Pdf/351433 |title=www.karger.com |format= |work= |accessdate=}}</ref>
*[[Emphysema]] ([[mediastinal]]/[[cervical]])
*[[Esophageal]] [[perforation]]
*[[Dental|Dental Injury]]
*[[Bleeding]]
*[[Mediastinitis]]
*Leak
*[[Recurrent laryngeal nerve]] injury
*[[Infection]]


==References==
==References==

Latest revision as of 02:40, 7 December 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Ajay Gade MD[2]]

Overview

Surgery is the most definitive therapy for the Zenker's diverticulum (ZD). If small and asymptomatic, no treatment is necessary. Larger, symptomatic cases of Zenker's diverticulum have been traditionally treated by neck surgery to resect the diverticulum and incise the cricopharyngeus muscle. However, in recent times non-surgical endoscopic techniques have gained more importance, and the currently preferred treatment is endoscopic stapling i.e. closing of the diverticulum via a stapler inserted through a tube in the oral cavity. This may be performed through a fiberoptic endoscope. Other non-surgical treatment modalities exist, such as endoscopic laser, but recent evidence has shown it to be less effective than stapling.

Surgery

Rigid endoscopic diverticulotomy

Four types of procedures are performed using rigid scope

1.Endoscopic electrocautery

Endoscopic electrocautery may be used as a treatment option for Zenker's diverticulum:[5][6]

Complications:

2.Endoscopic CO2 laser technique

Endoscopic CO2 laser technique may also be used as a treatment option for Zenker's diverticulum:[7][8]

  • This technique offers high energy and high focused beam.
  • Very minimal tissue trauma.
  • It also provides a better visualization of the diverticular bridge and easier control of the operation.

Complications:

3.Endoscopic stapling

Endoscopic stapling is one the preferred treatment options for Zenker's diverticulum:[9]

4.Endoscopic harmonic scalpel

Flexible Endoscopic Diverticulotomy

Complications of the Endoscopic procedures[10]

References

  1. ↑ PMID 12782805 Endoscopic staple diverticulostomy for Zenker's diverticulum: a review of literature and experience in 159 consecutive cases, Laryngoscope. 2003 Jun;113(6):957-65
  2. ↑ PMID 15453934 Endoscopic stapling of the pharyngeal pouch, J Laryngol Otol. 2004 Aug;118(8):601-6
  3. ↑ PMID 15966520 Fiberoptic endoscopic-assisted diverticulotomy: a novel technique for the management of Zenker's diverticulum, Ann Otol Rhinol Laryngol. 2005 May;114(5):347-51
  4. ↑ PMID 16954989 The Endoscopic Management of Zenker Diverticulum: CO2 Laser versus Endoscopic Stapling, Laryngoscope. 2006 Sep;116(9):1608-11
  5. ↑ Costa RC (1969). "[Use of proteolytic enzymes, isolated or in combination with antibiotics, in orthopedics and in injuries]". Rev Bras Med (in Portuguese). 26 (11): 696–9. PMID 5396435.
  6. ↑ Mirza S, Dutt SN, Minhas SS, Irving RM (2002). "A retrospective review of pharyngeal pouch surgery in 56 patients". Ann R Coll Surg Engl. 84 (4): 247–51. PMC 2504214. PMID 12215027.
  7. ↑ "Surgical Treatment of Zenker's Diverticulum - FullText - Digestive Surgery 2013, Vol. 30, No. 3 - Karger Publishers".
  8. ↑ "Endoscopic electrocautery dilation of benign anastomotic colonic strictures: a single-center experience. - PubMed - NCBI".
  9. ↑ "Outcome and quality of life after open surgery versus endoscopic stapler-assisted esophagodiverticulostomy for Zenker's diverticulum. - PubMed - NCBI".
  10. ↑ "www.karger.com".

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