Rigid Endoscopic Cricopharyngeal Myotomy Is Feasible, Safe and Highly Effective in the Treatment of Symptomatic Zenker’s Diverticulum

Tanveer Zamani, MD, FRCSI, Matthew Plank, PAC, James Dove, BA, Marie Hunsinger, RN, Anthony T Petrick, MD, FACS, FSSO. Geisinger Medical center, Danville PA

INTRODUCTION: Conventional surgical approaches to the treatment of Zenker’s diverticulum (ZD) are effective but risk perforation and nerve injury. Rigid and flexible endoscopic approaches to the treatment of ZD have been described using cutting and energy delivery. These are associated with a significant rate of perforation. We report our 12- year experience with rigid endoscopic stapling (RES) for the treatment of Zenker’s diverticulum.

METHODS: Cricopharyngeal myotomy (CPM) for the treatment of symptomatic ZD by rigid endo-stapling (RES) device was planned in 24 patients between October 1, 2002 and May 31, 2014. Procedures were performed by a single surgeon at Geisinger Medical Center. Data was collected as a retrospective cohort study. Demographic data included age, gender, and comorbidities. Outcomes data included conversion rates, complications, length of stay (LOS), change in ZD-related symptoms and recurrence. A standardized dysphagia score system (0 to 4) was used as a tool by which the patients quantified symptomatic improvement.

RESULTS: Of the 24 patients with symptomatic ZD, 13 were men and 11 were women with a mean age of 81.5 years (57-89). One patient underwent conversion to an open CPM and pexy and was excluded from analysis. All patients had general anesthesia. For the remaining 23 patients, mean LOS was 2.1 days. Two patients had LOS of greater than 2 days (5, 16 days). One due to advanced age and need for supervised home care. This patient had no complications. The second patient had recurrent aspiration. Three patients had anatomy that precluded endoscopic stapling including the patient that had an open procedure. Four patients (17.4%) had complications (Table 1). Of the 21 patients who had successful RES, there were 2 minor complications (5%). There were NO esophageal leaks. All 21 patients undergoing successful RES showed symptomatic improvement within 2 weeks. At last follow up (mean= 6.8 months; range 0.5-12 months) complete symptom resolution was documented in 18 patients (85.7%). Recurrence occurred in 3 (14.3%) patients and all 3 patients had a repeat RES with complete resolution of symptoms.

Complications Pt (n)/24 Cause
Aborted (Anatomy) 1 Limited neck extension prevented exposure
Aborted(Aspiration) 1 Associated with complex esophageal motility disorder
Aborted bleeding 1 Laceration of gum to frenulum.
Minor post-op bleeding 1 Lateral tongue superficial laceration
Fracture of dental bridge 1 Trauma related to Weerda laryngoscope

CONCLUSIONS: When performed by an experienced surgeon, CPM using a RES technique is feasible and safe. Compared to CPM by flexible endoscopy with the use of energy for cutting the cricopharyngeus, our study reports lower rates of recurrence and esophageal leak. Major complications including perforation, abscesses or vocal cord paralysis were not observed. The technique is more limited by patient factors than the flexible endoscopic technique, but was successfully completed in 87.5% of patients. In these patients RES seems to be safer and more effective.

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