Zenker's diverticulum surgery: Difference between revisions
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==Overview== | ==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 [[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 is the [[endoscopic]] stapling i.e. closing of the [[diverticulum]] via a stapler inserted through a tube in the mouth. This may be performed through a fiberoptic endoscope. Other non-surgical treatment modalities exist, such as endoscopic laser, which recent evidence suggests it less effective than stapling. | [[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 [[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 is the [[endoscopic]] stapling i.e. closing of the [[diverticulum]] via a stapler inserted through a tube in the mouth. This may be performed through a fiberoptic [[endoscope]]. Other non-surgical treatment modalities exist, such as [[endoscopic]] [[laser]], which recent evidence suggests it less effective than stapling. | ||
==Surgery== | ==Surgery== | ||
*If small and asymptomatic, no treatment is necessary. | *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. | *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 the pharyngeal pouch, J Laryngol Otol. 2004 Aug;118(8):601-6</ref><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> (i.e. closing of the diverticulum via a stapler inserted through a tube in the mouth). | *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 the pharyngeal pouch, J Laryngol Otol. 2004 Aug;118(8):601-6</ref><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> (i.e. closing of 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>. | *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 are endoscopic laser, recent evidence suggesting that it is 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> | *Other non-surgical [[Treatment IND|treatment]] modalities are endoscopic laser, recent evidence suggesting that it is 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 ZD are as follows: | *Various surgeries performed for the ZD are as follows: | ||
**''Rigid endoscopic diverticulotomy'' | **''Rigid [[endoscopic]] diverticulotomy'' | ||
**''Flexible endoscopic diverticulotomy'' | **''Flexible [[endoscopic]] diverticulotomy'' | ||
'''Rigid Endoscopic Diverticulotomy''' | '''Rigid Endoscopic Diverticulotomy''' | ||
-Four types of procedures are performed using rigid scope | -Four types of [[Procedure|procedures]] are performed using rigid scope | ||
'''1.''Endoscopic electrocautery'''''<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> | '''1.''Endoscopic electrocautery'''''<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 lesions and is performed via an endoscope. | *This is suitable for smaller lesions and is performed via an endoscope. | ||
*A double-lipped esophagoscope is used and the wall between the diverticulum and | *A double-lipped esophagoscope is used and the wall between the [[diverticulum]] and [[esophageal]] wall is exposed. | ||
*The hypopharyngeal bar is divided with diathermy or laser. | *The [[Hypopharynx|hypopharyngeal]] bar is divided with [[diathermy]] or [[laser]]. | ||
*Shorter duration of anaesthesia. | *Shorter duration of [[Anesthesia|anaesthesia]]. | ||
*More rapid resumption of oral intake. | *More rapid resumption of oral intake. | ||
*Shorter hospital stay. | *Shorter hospital stay. | ||
*Quicker recovery. | *Quicker recovery. | ||
Complications | Complications | ||
*Sub-cutaneous emphysema | *Sub-cutaneous [[emphysema]] | ||
*Mediastinitis | *[[Mediastinitis]] | ||
*Aspiration from the pouch | *[[Aspiration]] from the pouch | ||
'''2.''Endoscopic CO2 Laser Technique''<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>''' | '''2.''Endoscopic CO2 Laser Technique''<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. | *This technique offers high energy and high focused beam. | ||
*Very minimal tissue trauma. | *Very minimal tissue trauma. | ||
*It also provides a better visualization of the diverticular bridge and easier control of the operation. | *It also provides a better visualization of the [[diverticular]] bridge and easier control of the operation. | ||
Complications | Complications | ||
*Mediastinitis | *[[Mediastinitis]] | ||
*Sub-cutaneous emphysema | *[[Subcutaneous|Sub-cutaneous]] [[emphysema]] | ||
'''3''.Endoscopic Stapling''<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>''' | '''3''.Endoscopic Stapling''<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, | * This cuts and seal the edge of the wound simultaneously, | ||
* Low incidence of perforation and bleeding. | * Low incidence of [[perforation]] and [[bleeding]]. | ||
* Thermal damage to the recurrent laryngeal nerve can be prevented with this procedure. | * Thermal damage to the recurrent laryngeal nerve can be prevented with this procedure. | ||
'''4.''Endoscopic Harmonic Scalpel''''' | '''4.''Endoscopic Harmonic Scalpel''''' | ||
'''Flexible Endoscopic Diverticulotomy''' | '''Flexible Endoscopic Diverticulotomy''' | ||
* The procedure is done with an extended neck under sedation, general anesthesia is not required. | * 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 stabilized without overextension of the neck. | * The septum between the [[diverticulum]] and [[esophageal]] [[lumen]] can be visualized by the hood, [[endoscopic]] cap, and overtube and stabilized without overextension of the neck. | ||
* The knifes used for the incision are as follows | * The knifes used for the incision are as follows | ||
** Needle-knife | ** Needle-knife | ||
** Hook-knife | ** Hook-knife | ||
** Argon plasma coagulation | ** [[Argon plasma coagulation]] | ||
** Monopolar forceps | ** 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> | '''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) | *[[Emphysema]] (Mediastinal/Cervical) | ||
*Esophageal perforation | *[[Esophageal]] [[perforation]] | ||
*Dental Injury | *[[Dental|Dental Injury]] | ||
*Bleeding | *[[Bleeding]] | ||
* | * | ||
*Mediastinitis | *[[Mediastinitis]] | ||
*Leak | *Leak | ||
*Recurrent laryngeal nerve injury | *[[Recurrent laryngeal nerve]] injury | ||
*Infection | *[[Infection]] | ||
==References== | ==References== | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:
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 the endoscopic stapling i.e. closing of the diverticulum via a stapler inserted through a tube in the mouth. This may be performed through a fiberoptic endoscope. Other non-surgical treatment modalities exist, such as endoscopic laser, which recent evidence suggests it less effective than stapling.
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[1][2] (i.e. closing of the diverticulum via a stapler inserted through a tube in the mouth).
- This may be performed through a fibreoptic endoscope[3].
- Other non-surgical treatment modalities are endoscopic laser, recent evidence suggesting that it is less effective than stapling.[4]
- Various surgeries performed for the ZD are as follows:
- Rigid endoscopic diverticulotomy
- Flexible endoscopic diverticulotomy
Rigid Endoscopic Diverticulotomy
-Four types of procedures are performed using rigid scope
1.Endoscopic electrocautery[5][6]
- This is suitable for smaller 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 hypopharyngeal bar is divided with diathermy or laser.
- Shorter duration of anaesthesia.
- More rapid resumption of oral intake.
- Shorter hospital stay.
- Quicker recovery.
Complications
- Sub-cutaneous emphysema
- Mediastinitis
- Aspiration from the pouch
2.Endoscopic CO2 Laser Technique[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[9]
- 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 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 stabilized without overextension of the neck.
- The knifes used for the incision are as follows
- Needle-knife
- Hook-knife
- Argon plasma coagulation
- Monopolar forceps
Complications of the Endoscopic procedures[10]
- Emphysema (Mediastinal/Cervical)
- Esophageal perforation
- Dental Injury
- Bleeding
- Mediastinitis
- Leak
- Recurrent laryngeal nerve injury
- Infection
References
- ↑ PMID 15453934 Endoscopic stapling of the pharyngeal pouch, J Laryngol Otol. 2004 Aug;118(8):601-6
- ↑ 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
- ↑ 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
- ↑ PMID 16954989 The Endoscopic Management of Zenker Diverticulum: CO2 Laser versus Endoscopic Stapling, Laryngoscope. 2006 Sep;116(9):1608-11
- ↑ 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.
- ↑ 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.
- ↑ "Surgical Treatment of Zenker's Diverticulum - FullText - Digestive Surgery 2013, Vol. 30, No. 3 - Karger Publishers".
- ↑ "Endoscopic electrocautery dilation of benign anastomotic colonic strictures: a single-center experience. - PubMed - NCBI".
- ↑ "Outcome and quality of life after open surgery versus endoscopic stapler-assisted esophagodiverticulostomy for Zenker's diverticulum. - PubMed - NCBI".
- ↑ "www.karger.com".