Results of a Tailored Approach to Zenker's Diverticulum: A Single VA Experience

Abstract

The transoral division of the esophageal–diverticula septum with a linear stapler, with CO₂ laser, or with harmonic scalpel under rigid endoscopy has revolutionized the surgical management of Zenker's diverticula. Nevertheless, the open approach still plays a role in select cases. Our goals are to illustrate the techniques and the results of our tailored approach to the surgical management of Zenker's diverticula in U.S. veterans.

Introduction

The introduction of minimally invasive procedures, such as the transoral division of the esophageal–diverticula septum with a linear stapler, CO₂ laser, and harmonic scalpel under rigid endoscopy, has revolutionized the surgical management of Zenker's diverticula.¹ Benefits of these endoscopic techniques include the absence of a visible scar, shorter operative time, reduced hospital length of stay, faster resumption of oral feeding, and overall decreased patient discomfort postoperatively.² The traditional open transcervical approach, however, can still play a role in select cases.^3,4 Our goals are to illustrate the techniques and the results of our tailored approach to the surgical management of Zenker's diverticula in U.S. veterans treated in a single center and to explain our rationale for choice in technique.

Methods

A retrospective review was undertaken on all consecutive patients treated for Zenker's diverticula from January 2010 to November 2015 at VA Boston. The cohort comprised all open and endoscopic (endoscopic stapler or CO₂ laser) procedures. Patient variables and surgical outcomes were abstracted: sex, age, American Society of Anesthesiologists (ASA) classification, diverticulum size, failure rate, need for repeat intervention, complications, time to oral intake, and length of stay.

Description of the surgical technique

Open and endoscopic approaches have been described previoulsy.⁴ A brief description of the surgical steps is given hereunder.

Open approach

After the skin incision is made along the anterior border of the sternocleidomastoid muscle, subplatysmal flaps are elevated with lateral retraction of the sternocleidomastoid and medial retraction of the strap muscles. Once access to the carotid sheath is gained, this is retracted laterally to get access to the Zenker's diverticulum. The recurrent laryngeal nerve is found in the tracheoesophageal groove and is identified and preserved. The diverticulum is carefully pulled and its neck is dissected off from the muscle fibers. At this point, a cricopharyngeal myotomy at the inferior neck of the diverticulum is extended onto the muscularis propria of the cervical esophagus for a few millimeters. Once the myotomy is completed distally, if the diverticulum is small—usually less than 2 cm—we complete that myotomy by extending it 1 or 2 cm cephalad onto the inferior pharyngeal constrictor. However, if the diverticulum is greater than 2 cm, we also perform a stapled diverticulectomy with a stapler (Endopath^® 35 mm ETS Articulating Linear Cutter [Ethicon™] with a blue cartridge). A water leak test is performed and a #10 flat Jackson–Pratt drain is placed. Finally, the platysma and the skin are reapproximated and closed.

Endoscopic approach

The first step consists in performing a rigid cervical esophagoscopy to assess the accessibility to the diverticulum, after which we insert the Weerda diverticuloscope (Karl Storz™) and we position it with the anterior blade within the esophageal lumen and the posterior blade within the diverticulum. The valves of the diverticuloscope are then widened to isolate the septum for its entire length. We then insert a zero-degree 5 mm scope to confirm adequate positioning. Then we insert the endoscopic stapler Endopath 35 mm ETS Articulating Linear Cutter (Ethicon) with a blue cartridge and orient it so that the longer lip with the cartridge lies within the esophageal lumen, whereas the shorter lip is placed within the diverticulum. Once the adequate positioning of the stapler is confirmed with the telescope, the stapler is fired and the division of the esophageal–diverticula septum that includes the cricopharyngeal muscle is accomplished. An internal cricopharyngeal myotomy is performed in this manner. When the preoperative barium swallow demonstrated a diverticulum too small for our stapler, we have used a Carl Zeiss OPMI Sensera microscope with a CO₂ laser micromanipulator (CO₂ laser is hemostatic with minimal thermal injury) employing a working distance of 400 mm and at a setting of 5–10 W laser to divide the esophageal–diverticula septum.

Results

All patients (n = 12) were male with a median age of 70 years (range 54–93 years) and all presented with dysphagia. Four patients underwent open surgery and 8 underwent septum transection by rigid endoscopy with stapler or CO₂ laser (Table 1). Median follow-up was 24 months. Failure rates for open surgery and endoscopy were 0% and 25%, respectively (2 patients, both with diverticula greater than 3 cm in size). One patient in the endoscopic group required a repeat procedure to achieve resolution of persistent dysphagia. Neck hematomas complicated 50% of open cases with one requiring operative intervention that resulted in vocal cord paresis. Comparing mean values, patients undergoing open surgery had larger diverticula (4 cm versus 2 cm), a longer duration to oral feeding (2 day versus 1 day), and a longer hospital length of stay (3 day versus 1 day). All patients with an ASA class >3 underwent endoscopy. Mortality was zero.

Table 1.

Patient Characteristics and Outcomes of U.S. Veterans Undergoing Surgical Treatment of Zenker's Diverticula at VA Boston

	Open (n = 4)	Endoscopic (n = 8)
Age, mean (SD), years	66 (4)	78 (12)
ASA, median (range)	3	3 (2–4)
Size, mean (SD), cm	4 (1.5)	2 (1.1)
Failure rate, n (%)	—	2 (25)
Complications, n (%)	2 (50)	—
Time to diet, mean (SD), days	2 (1)	1 (0)
Hospital stay, mean (SD), days	3 (3)	1 (0)

ASA, American Society of Anesthesiologists physical status classification; HLOS, hospital length of stay; SD, standard deviation.

Conclusions

There is no consensus regarding the optimal surgical intervention for the resection of Zenker's diverticula and there are no randomized controlled studies comparing the different open and endoscopic approaches. Hence, to date, no strong evidence exists to prove one procedure superior. This is, in part, due to the heterogeneity of inclusion criteria, sample size, length of follow-up, and attrition rates in other studies. The results of our study, the largest single-center case series of Zenker's diverticula in U.S. veterans, parallel those of nonveterans, as they demonstrate an improved functional outcome in those who underwent open surgery but more complications in those who underwent endoscopic surgery.^5,6 Therefore, our approach individualizes the surgical treatment of patients by offering an open repair to younger patients and to those at lower surgical cardiovascular risk. Conversely, endoscopic repair is offered to higher risk patients and to those for whom the open repair is contraindicated given its effectiveness, shorter operative duration, and low complication rate. Similarly, as highlighted by the higher failure rate in those who underwent endoscopic treatment, we believe that larger diverticula are ideally treated by the open approach, whereas smaller diverticula may be better addressed by endoscopic procedures.

Finally, granted that formal treatment guidelines linking patient characteristics to the presence and size of diverticula and to specific interventions are unlikely to be generated without level I evidence, we acknowledge that our treatment algorithm is based on results similar to those highlighted in other case series of whom we share a similar small number of cases.

Footnotes

Disclosure Statement

No competing financial interests exist.

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