Radu Pescarus, MD1, Eran Shlomovitz, MD2, Maria Cassera, BSc3, Ahmed Sharata, MD3, Kevin M Reavis, MD3, Christy M Dunst, MD3, Lee L Swanstrom, MD3. 1Hopital Sacre-Coeur, Universite de Montreal, 2University Health Network, University of Toronto, 3The Oregon Clinic, Portland, Oregon
Zenker’s diverticulum (ZD) is rare upper esophageal pathology that is most prevalent in the 6th and 7th decade. It is thought to be caused by a lack of coordination between the contractions of the pharynx and the upper esophageal sphincter. Three different therapeutical options are available (1) open transcervical approach, (2) rigid endoscopy and (3) flexible endoscopy. Our hypothesis is that a free handed endoscopic cricomyotomy represents a safe and effective treatment of ZD as well as cricopharyngeal spasm.
A retrospective analysis of all patients that underwent a flexible endoscopic cricomyotomy at our institution between 10/2008-05/2014 was performed. Pre-operative and post-operative (1 month and long-term follow-up) symptoms scores, demographic information and clinical outcomes were collected. Briefly, using a high definition endoscope, the ZD is carefully identified and a nasogastric tube is introduced. The common wall is divided using needle knife cautery with the help of an endoscopic cap. Clips are used to close the mucosal defect starting with the apex.
Thirty patients underwent a flexible endoscopic myotomy for a ZD (26 patients) or isolated cricopharyngeal spasm (4 patients). 6/30 (20%) had a history of previous open or stapled trans-oral myotomy and 4/30 (13.3%) underwent a concomitant foregut procedure. Mean length of stay was 1.5 days (range: 1-11 days). Mean operative time was 68 minutes (range: 28-149 min). There were no intra-operative adverse events. One patient presented with a post-operative leak and one patient presented with a retained clip. Both were treated endoscopically. Residual weekly dysphagia was noted in 2/30 (7%) patients and recurrent weekly dysphagia in 4/30 (13%). No patients underwent a repeat myotomy; however, 2/30 (7%) required an endoscopic bougie dilatation post-operatively. With regards to clinical outcomes, there was statistically significant improvement in both short-term (1 month) and long-term (average 16.9 months; range 1-68.2 months) dysphagia (p<0.001; p<0.0001), regurgitation (p=0.006; p=0.002) and aspiration (p=0.032; p=0.017).
Flexible endoscopic cricomyotomy offers durable relief of dysphagia, regurgitation and aspiration in ZD and isolated cricopharyngeal spasm patients. It appears to have a good safety profile with symptomatic recurrence occurring in up to 13% of cases.