Zenker's diverticulum surgery
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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
- Endoscopic diverticulotomy- the two types of endoscopic diverticulotomy are rigid endoscopic diverticulotomy and flexible endoscopic diverticulotomy.
Rigid Endoscopy
-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 oesophageal 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]
- The high energy, high focus beam, and less tissue trauma.
- It also provides a better visualization of the diverticular bridge and easier control of the operation.
Compliations
- Mediastinitis
- Sub-cutaneous emphysema
3.Endoscopic Stapling
- 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 Endoscopy
- 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
- Emphysema (Mediastinal/Cervical)
- Esophageal perforation
- Dental Injury
- Bleeding
- Mucosal tear
- 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".