BACKGROUND AND AIM: Minimally invasive endoscopic techniques are the treatment of choice for Zenker's diverticulum (ZD). Our objective was to evaluate the results and efficacy of endoscopic and open approaches, to determine whether postoperative C-reactive protein (CRP) serum levels can be used as a marker to exclude the presence of esophageal leakage, and to identify risk factors for development of postoperative leakage and complications. MATERIALS AND METHODS: Patients who underwent transcervical myotomy and diverticulotomy (TMD) or endoscopic cricopharyngeal myotomy (ECM) with CO2 laser for ZD in years 2008-2021 at our department were included in this retrospective study. RESULTS: Of the 101 patients enrolled, 83 patients underwent ECM and 18 TMD. The procedure time of the endoscopic technique was significantly shorter compared to that of transcervical method (p < 0.001). The median time to oral intake was 6 days for ECM and 10.5 days in the TMD group (p < 0.001). There was a 13% (n = 11) and 16.7% (n = 3) symptomatic recurrence rate and 3.6% (n = 3) and 16.7% (n = 3) major complications rate for ECM and TMD groups, respectively. The incidence of contrast leak (CL) evaluated by postoperative swallow study was 8.9% (9 from 83 patients in the ECM group only). In patients with CL, a significant increase in CRP levels on postoperative day (POD) 2 and 3 was detected when compared to patients without CL. CONCLUSIONS: Endoscopic diverticulotomy with CO2 laser represents a safe and efficient treatment of ZD. Elevation of postoperative CRP serum levels over 123.8 mg/L on POD2 and 98.8 mg/L on POD3 may indicate presence of an esophageal leakage.

Department of Otorhinolaryngology and Head and Neck Surgery University Hospital Motol 1st Faculty of Medicine Charles University 5 Uvalu 84 150 06 Prague Czech Republic

Zobrazit více v PubMed

Bizzotto A, Iacopini F, Landi R, Costamagna G (2013) Zenker’s diverticulum: exploring treatment options. Acta Otorhinolaryngol Ital 33(4):219–229 PubMed PMC

Ferreira LE, Simmons DT, Baron TH (2008) Zenker’s diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. Dis Esophagus 21(1):1–8. https://doi.org/10.1111/j.1442-2050.2007.00795.x PubMed DOI

Koch M, Mantsopoulos K, Velegrakis S, Iro H, Zenk J (2011) Endoscopic laser-assisted diverticulotomy versus open surgical approach in the treatment of Zenker’s diverticulum. Laryngoscope 121(10):2090–2094. https://doi.org/10.1002/lary.22152 PubMed DOI

Albers DV, Kondo A, Bernardo WM, Sakai P, Moura RN, Silva GL, Ide E, Tomishige T, de Moura EG (2016) Endoscopic versus surgical approach in the treatment of Zenker’s diverticulum: systematic review and meta-analysis. Endosc Int Open 4(6):E678-686. https://doi.org/10.1055/s-0042-106203 PubMed DOI PMC

Greene CL, McFadden PM, Oh DS, Chang EJ, Hagen JA (2015) Long-term outcome of the treatment of Zenker’s diverticulum. Ann Thorac Surg 100(3):975–978. https://doi.org/10.1016/j.athoracsur.2015.04.029 PubMed DOI

Chang CW, Burkey BB, Netterville JL, Courey MS, Garrett CG, Bayles SW (2004) Carbon dioxide laser endoscopic diverticulotomy versus open diverticulectomy for Zenker’s diverticulum. Laryngoscope 114(3):519–527. https://doi.org/10.1097/00005537-200403000-00025 PubMed DOI

Yuan Y, Zhao YF, Hu Y, Chen LQ (2013) Surgical treatment of Zenker’s diverticulum. Dig Surg 30(3):207–218. https://doi.org/10.1159/000351433 PubMed DOI

Visser LJ, Hardillo JA, Monserez DA, Wieringa MH, Baatenburg de Jong RJ (2016) Zenker’s diverticulum: Rotterdam experience. Eur Arch Otorhinolaryngol 273(9):2755–2763. https://doi.org/10.1007/s00405-015-3825-0 PubMed DOI

Akashi M, Furudoi S, Hashikawa K, Sakakibara A, Hasegawa T, Shigeta T, Minamikawa T, Komori T (2015) Postoperative abnormal response of C-reactive protein as an indicator for infectious complications after oral oncologic surgery with primary reconstruction. J Otolaryngol Head Neck Surg 44:13. https://doi.org/10.1186/s40463-015-0066-6 PubMed DOI PMC

Santonocito C, De Loecker I, Donadello K, Moussa MD, Markowicz S, Gullo A, Vincent JL (2014) C-reactive protein kinetics after major surgery. Anesth Analg 119(3):624–629. https://doi.org/10.1213/ANE.0000000000000263 PubMed DOI

van Winsen M, McSorley ST, McLeod R, MacDonald A, Forshaw MJ, Shaw M, Puxty K (2021) Postoperative C-reactive protein concentrations to predict infective complications following gastrectomy for cancer. J Surg Oncol 124(7):1060–1069. https://doi.org/10.1002/jso.26613 PubMed DOI

Dutta S, Fullarton GM, Forshaw MJ, Horgan PG, McMillan DC (2011) Persistent elevation of C-reactive protein following esophagogastric cancer resection as a predictor of postoperative surgical site infectious complications. World J Surg 35(5):1017–1025. https://doi.org/10.1007/s00268-011-1002-1 PubMed DOI

Messias BA, Botelho RV, Saad SS, Mocchetti ER, Turke KC, Waisberg J (2020) Serum C-reactive protein is a useful marker to exclude anastomotic leakage after colorectal surgery. Sci Rep 10(1):1687. https://doi.org/10.1038/s41598-020-58780-3 PubMed DOI PMC

Hering S, Wiegand S (2019) Systemic inflammatory response after endoscopic surgery of Zenker’s diverticulum. Acta Otorhinolaryngol Ital 39(4):230–234. https://doi.org/10.14639/0392-100X-1576 PubMed DOI PMC

Plzak J, Zabrodsky M, Lukes P (2014) Zenker’s diverticulum: carbon dioxide laser endoscopic surgery. Biomed Res Int 2014:516231. https://doi.org/10.1155/2014/516231 PubMed DOI PMC

Jammer I, Wickboldt N, Sander M, Smith A, Schultz MJ, Pelosi P, Leva B, Rhodes A, Hoeft A, Walder B, Chew MS, Pearse RM, European Society of A, the European Society of Intensive Care M, European Society of A, European Society of Intensive Care M (2015) Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures. Eur J Anaesthesiol 32(2):88–105. https://doi.org/10.1097/EJA.0000000000000118 PubMed DOI

Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213. https://doi.org/10.1097/01.sla.0000133083.54934.ae PubMed DOI PMC

Wheeler WI (1886) Pharyngocele and dilatation of pharynx, with existing diverticulum at lower portion of pharynx lying posterior to the Œsophagus, cured by pharyngotomy, being the first case of the kind recorded. Dublin J Med Sci 82(5):349–356. https://doi.org/10.1007/BF02970535 DOI

Mosher HP (1917) Webs and pouches of the esophagus: their diagnosis and treatment. Surg Gynecol Obstet 25:175–187

Johnson CM, Postma GN (2016) Zenker diverticulum-which surgical approach is superior? JAMA Otolaryngol Head Neck Surg 142(4):401–403. https://doi.org/10.1001/jamaoto.2015.3892 PubMed DOI

Keck T, Rozsasi A, Grun PM (2010) Surgical treatment of hypopharyngeal diverticulum (Zenker’s diverticulum). Eur Arch Otorhinolaryngol 267(4):587–592. https://doi.org/10.1007/s00405-009-1079-4 PubMed DOI

Saetti R, Silvestrini M, Peracchia A, Narne S (2006) Endoscopic stapler-assisted Zenker’s diverticulotomy: which is the best operative facility? Head Neck 28(12):1084–1089. https://doi.org/10.1002/hed.20431 PubMed DOI

Murer K, Soyka MB, Broglie MA, Huber GF, Stoeckli SJ (2015) Zenker’s diverticulum: outcome of endoscopic surgery is dependent on the intraoperative exposure. Eur Arch Otorhinolaryngol 272(1):167–173. https://doi.org/10.1007/s00405-014-2959-9 PubMed DOI

Courson AM, Landry AM, Lott DG, Hinni ML (2013) Open staple diverticulectomy for a large recurrent Zenker’s diverticulum: still a valid procedure. Ann Otol Rhinol Laryngol 122(12):729–733. https://doi.org/10.1177/000348941312201201 PubMed DOI

Feeley MA, Righi PD, Weisberger EC, Hamaker RC, Spahn TJ, Radpour S, Wynne MK (1999) Zenker’s diverticulum: analysis of surgical complications from diverticulectomy and cricopharyngeal myotomy. Laryngoscope 109(6):858–861. https://doi.org/10.1097/00005537-199906000-00003 PubMed DOI

Shah RN, Slaughter KA, Fedore LW, Huang BY, Deal AM, Buckmire RA (2016) Does residual wall size or technique matter in the treatment of Zenker’s diverticulum? Laryngoscope 126(11):2475–2479. https://doi.org/10.1002/lary.25975 PubMed DOI

Barton MD, Detwiller KY, Palmer AD, Schindler JS (2016) The safety and efficacy of endoscopic Zenker’s diverticulotomy: a cohort study. Laryngoscope 126(12):2705–2710. https://doi.org/10.1002/lary.26046 PubMed DOI

Berger MH, Weiland D, Tierney WS, Bryson PC, Weissbrod PA, Shah PV, Shah RN, Buckmire RA, Verma SP (2021) Surgical management of recurrent Zenker’s diverticulum: a multi-institutional cohort study. Am J Otolaryngol 42(1):102755. https://doi.org/10.1016/j.amjoto.2020.102755 PubMed DOI

Adam SI, Paskhover B, Sasaki CT (2012) Laser versus stapler: outcomes in endoscopic repair of Zenker diverticulum. Laryngoscope 122(9):1961–1966. https://doi.org/10.1002/lary.23398 PubMed DOI

Witterick IJ, Gullane PJ, Yeung E (1995) Outcome analysis of Zenker’s diverticulectomy and cricopharyngeal myotomy. Head Neck 17(5):382–388. https://doi.org/10.1002/hed.2880170504 PubMed DOI

Ong CC, Elton PG, Mitchell D (1999) Pharyngeal pouch endoscopic stapling–are post-operative barium swallow radiographs of any value? J Laryngol Otol 113(3):233–236. https://doi.org/10.1017/s0022215100143646 PubMed DOI

Berzofsky CE, Holiday RA, Pitman MJ (2012) Variability of postoperative esophagrams after endoscopic cricopharyngeal myotomy: technique dependence. Ann Otol Rhinol Laryngol 121(3):145–150. https://doi.org/10.1177/000348941212100301 PubMed DOI

Rizzetto C, Zaninotto G, Costantini M, Bottin R, Finotti E, Zanatta L, Guirroli E, Ceolin M, Nicoletti L, Ruol A, Ancona E (2008) Zenker’s diverticula: feasibility of a tailored approach based on diverticulum size. J Gastrointest Surg 12(12):2057–2064. https://doi.org/10.1007/s11605-008-0684-7 (discussion 2064–2055) PubMed DOI