Both Endoscopic and External Approaches Needed for ZD

Is the transcervical approach indicated in the treatment of Zenker’s diverticulum (ZD) and, if so, to what extent?

Background: According to the literature, the only existing curative approach to ZD is surgical treatment. While the endoscopic-microscopic method is now established as the treatment of choice, studies have not shown if and to what extent traditional external surgical approaches are needed.

Study design: Retrospective clinical study.

Setting: Department of Otorhinolaryngology, Head and Neck Surgery, University of Erlangen, Nuremberg Medical School, Erlangen, Germany.

Synopsis: The study compared endoscopic laser-assisted diverticulotomy (ELAD) with traditional external surgical approaches in terms of surgical time, duration of hospitalization, incidence of complications, recurrence rate and long-term follow-up. Researchers studied the medical files and operative charts of 182 patients. Of these, ELAD was performed in 101 patients (65.2 percent), and primary transcervical surgery was performed in 54 patients (34.8 percent). The authors noted that ELAD was attempted in 146 patients (94.2 percent) and completed in 101.

An intraoperative switch to an open approach was necessary in 45 (30.8 percent) of the planned ELAD cases. Reasons included inadequate endoscopic exposure of the diverticulum, individual anatomy of the diverticulum sac, insufficient protection of the diverticulum sac by the dorsal esophageal wall, or accidental intraoperative invasion of the mediastinum. Surgical time, duration of hospitalization and occurrence of minor complications were significantly lower after endoscopic approach; however, recurrence rate showed a statistically significant difference in favor of the open approach. Including the recurrences, 38.7 percent could be cured only by transcervical techniques. The authors noted that their results could be influenced by factors such as the surgeons’ experience and patient preference.

Bottom Line: Although the endoscopic approach was the treatment of first choice, the fact that open techniques were necessary in nearly 40 percent of the cases indicates a substantial role for those in the treatment of ZD.

Citation: Koch M, Mantsopoulos K, Velegrakis S, et al. Endoscopic laser-assisted diverticulotomy versus open surgical approach in the treatment of Zenker’s diverticulum. Laryngoscope. 2011;121(10):2090-2094.

—Reviewed by Sue Pondrom