Abstract
This study was designed to compare rates of failure, revision and morbidity from endoscopic and open approaches as treatment for pharyngeal pouch. Systematic review was conducted using MEDLINE and PubMed databases. Search terms treatment, Zenker’s, hypopharyngeal, pharyngeal, diverticulum, and pouch. There were no randomised clinical trials. Therefore, cohort and comparative studies with at least 10 patients in each arm, a follow-up of a least 12 months and reporting on all patients were included. Seventy-one studies met inclusion criteria. Diverticulectomy with or without cricopharyngeal myotomy comprised 33 studies (1,990 patients), and endoscopic stapler diverticulotomy was in 22 studies (1,089 patients). Failure of open and endoscopic approaches was 4.2 and 18.4 %, respectively, and corresponding complication rates were 11 and 7 %. Within endoscopic techniques, failure rates were 18.9 % for stapler diverticulotomy and 21.7 % for laser diverticulotomy. Corresponding complication rates were 4.3 and 7.9 %. Flexible endoscopy techniques have a higher failure (29 %) and overall complication rate (14.3 %). Most reported complications for transcervical techniques relate to the recurrent nerve (3.4 %) and salivary fistula (3.7 %) and for endoscopic group emphysema (3.0 %) and mediastinitis (1.2 %). Operation-related deaths were infrequent in both groups, but more frequent with open approach (0.9 vs. 0.4 %). Open approaches have more success but more complications than endoscopic techniques. Taking in account overall complications and failure rates, open approaches and stapler diverticulotomy yield different patterns, but are arguably comparable. In younger patients open approach is preferred, as well in patients with unfavourable anatomic conditions for endoscopic exposure. Flexible endoscopic techniques provide a suitable option for patients who do not tolerate general anaesthesia.
Similar content being viewed by others
References
Martin-Hirsch DP, Newbegin CJ (1993) Autosuture GIA gun: a new application in the treatment of hypopharyngeal diverticula. J Laryngol Otol 107:723–725
Collard JM, Otte JB, Kestens PJ (1993) Endoscopic stapling technique of esophagodiverticulostomy for Zenker’s diverticulum. Ann Thorac Surg 56:573–576
Lang RA, Spelsberg FW, Winter H, Jauch KW, Huttl TP (2007) Transoral diverticulostomy with a modified Endo-GIA stapler: results after 4 years of experience. Surg Endosc 21:532–536
Leong SC, Wilkie MD, Webb CJ (2012) Endoscopic stapling of Zenker’s diverticulum: establishing national baselines for auditing clinical outcomes in the United Kingdom. Eur Arch Otorhinolaryngol 269:1877–1884
Lerut J, El Gariani A, Otte JB, Kestens PJ (1983) Zenker’s diverticulum. Surgical experience in a series of 25 patients. Acta Gastroenterol Belg 46:189–196
Payne WS, King RM (1983) Pharyngoesophageal (Zenker’s) diverticulum. Surg Clin North Am 63:815–824
Luckhaupt H, Rose KG (1984) Behandlung und Behandlungsergebnisse beim Zenkerschen Divertikel. HNO 32:35–37
Welch AR, Stafford F (1985) Comparison of endoscopic diathermy and resection in the surgical treatment of pharyngeal diverticula. J Laryngol Otol 99:179–182
Bowdler DA, Stell PM (1987) Surgical management of posterior pharyngeal diverticula: inversion versus one-stage excision. Br J Surg 74:988–990
Konowitz PM, Biller HF (1989) Diverticulopexy and cricopharyngeal myotomy: treatment for the high-risk patient with a pharyngoesophageal (Zenker’s) diverticulum. Otolaryngol Head Neck Surg 100:146–153
Westmore GA (1990) Staple gun in the surgery of hypopharyngeal diverticula. J Laryngol Otol 104:553–556
Broll R, Kramer T, Kalb K, Bruch HP (1991) Zenker’s diverticulum. Long-term results after surgical therapy. Chirurg 62:668–672
Maurer KP, Junginger T, Kaltenborn H (1991) Results of surgical therapy of cervical diverticulum. Chirurg 62:673–676
Molins L, Lluis J, Galofre M (1992) Zenker’s diverticulum. The clinical manifestations and treatment. Rev Esp Enferm Dig 81:313–315
Morton RP, Bartley JRF (1993) Inversion of Zenker’s diverticulum: the preferred option. Head Neck 15:253–256
Laccourreye O, Menard M, Cauchois R, Huart J, Jouffre V, Brasnu D, Laccourreye H (1994) Esophageal diverticulum: diverticulopexy versus diverticulectomy. Laryngoscope 104:889–892
Laing MR, Murthy P, Ah-See KW, Cockburn JS (1995) Surgery for pharyngeal pouch: audit of management with short- and long-term follow up. J R Coll Surg Edinb 40:315–318
Lippert BM, Werner BA (1995) Results and surgical experiences in web transsection of hypopharyngeal (Zenker) diverticulum with the CO2 laser. HNO 43:605–610
Witterick IJ, Gullane PJ, Yeung E (1995) Outcome analysis of Zenker’s diverticulectomy and cricopharyngeal myotomy. Head Neck 17:382–388
Hecker A, Junginger T (1996) Esophageal diverticulum— perioperative risks and long-term follow-up. Zentralbl Chir 121:201–206
Ochando Cerdan F, Moreno Gonzalez E, Hernandez Garcia D, Gomez Sanz R, Loinaz Segurola C, Rico Selas P, Abradelo de Usera M, Castellon Pavon C (1998) Diagnostic and treatment of Zenker’s diverticulum: review of our series pharyngo-esophageal diverticula. Hepatogastroenterology 45:447–450
Crescenzo DG, Trastek VF, Allen MS, Deschamps C, Pairolero PC (1998) Zenker’s diverticulum in the elderly: is operation justified? Ann Thorac Surg 66:347–350
Fraczek M, Karwowski A, Krawczyk M, Paczkowski PM, Pawlak B, Pszenny C (1998) Results of surgical treatment of cervical esophageal diverticula. Dis Esophagus 11:55–57
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 109:858–861
Zbaren P, Schar P, Tschopp L, Becker M, Hausler R (1999) Surgical treatment of Zenker’s diverticulum: transcutaneous diverticulectomy versus microendoscopic myotomy of the cricopharyngeal muscle with CO2 laser. Otolaryngol Head Neck Surg 121:482–487
Leporrier E, Salamé E, Gignoux M, Ségol P (2001) Zenker’s diverticulum: diverticulopexy versus diverticulectomy. Ann Chir 126:42–45
Dennis S, Mal RK (2002) Pharyngeal pouch surgery in Weston-super-Mare from 1974 to 1999. CME Bull Otolaryngol Head Neck Surg 6:35
Gutschow CA, Hamoir M, Rombaux P, Otte JP, Goncette L, Collard JM (2002) Management of pharyngoesophageal (Zenker’s) diverticulum: which technique? Ann Thorac Surg 74:1677–1683
Colombo-Benkmann M, Unruh V, Krieglstein C, Senninger N (2003) Cricopharyngeal myotomy in the treatment of Zenker’s diverticulum. J Am Coll Surg 196:370–378
Jougon J, Le Taillandier-de-Gabory L, Raux F, Delcambre F, Mac Bride T, Velly JF (2003) Plea in favour of external approach of Zenker’s diverticulum: 73 cases reported. Ann Chir 128:167–172
Chang CWD, Burkey BB, Netterville JL, Courey MS, Garret CG, Bayles SW (2004) Carbon dioxide laser endoscopic diverticulotomy versus open diverticulectomy for Zenker’s diverticulum. Laryngoscope 114:519–527
Wirth D, Kern B, Guenin MO, Montali I, Peterli I, Ackermann C, von Flue M (2006) Outcome and quality of life after open surgery versus endoscopic stapler-assisted esophagodiverticulostomy for Zenker’s diverticulum. Dis Esophagus 19:294–298
Bonavina L, Bona D, Abraham M, Saino G, Abate E (2007) Long-term results of endosurgical and open surgical approach for Zenker diverticulum. World J Gastroenterol 13:2586–2589
Smejkal M, Smejkal P, Pazdro A, Harustiak T, Pafko P (2007) Our experience with diverticulectomy in symptomatic Zenker’s diverticulum. Zentralbl Chir 132:504–508
Brigand C, Bajcz K, Elamrani H, Dan S, Meyer SRC (2008) Suspension diverticulopexy for Zenker’s diverticulum. J Chir 145:341–345
Simic A, Radovanovic N, Stojakov D, Bjelovic M, Kotarac M, Sabljak P, Skrobic O, Pesko P (2009) Surgical experience of the national institution in the treatment of Zenker’s diverticula. Acta Chir Iugosl 56:25–33
Mantsopoulos K, Psychogios G, Kunzel J, Zenk J, Iro H, Koch M (2012) Evaluation of the different transcervical approaches for Zenker diverticulum. Otolaryngol Head Neck Surg 146:725–729
Lerut T, van Raemdonck D, Guelinckx P, Dom R, Geboes K (1992) Zenker’s diverticulum: is a myotomy of the cricopharyngeus useful? How long should it be? Hepatogastroenterology 39:127–131
Morse CR, Fernando HC, Ferson PF, Landreneau RJ, Luketich JD (2007) Preliminary experience by a thoracic service with endoscopic transoral stapling of cervical (Zenker’s) diverticulum. J Gastrointest Surg 11:1091–1094
Baldwin DL, Toma AG (1998) Endoscopic stapled diverticulotomy: a real advance in the treatment of hypopharyngeal diverticulum. Clin Otolaryngol 23:244–247
Narne S, Cutrone C, Bonavina L, Chella B, Peracchia A (1999) Endoscopic diverticulotomy for the treatment of Zenker’s diverticulum: results in 102 patients with staple-assisted endoscopy. Ann Otol Rhinol Laryngol 108:810–815
Luscher MS, Johansen LV (2000) Zenker’s diverticulum treated by the endoscopic stapling technique. Acta Otolaryngol Suppl 543:235–238
Jaramillo MJ, McLay KA, McAteer D (2001) Long-term clinico-radiological assessment of endoscopic stapling of pharyngeal pouch: a series of cases. J Laryngol Otol 115:462–466
Raut VV, Primrose WJ (2002) Long-term results for endoscopic stapling diverticulotomy for pharyngeal pouches. Otolaryngol Head Neck Surg 127:225–229
Stoeckli SJ, Schmid SS (2002) Endoscopic stapler-assisted diverticulo-esophagostomy for Zenker’s diverticulum: patient satisfaction and subjective relief of symptoms. Surgery 131:158–162
Chang C, Payyapilli R, Scher R (2003) Endoscopic Staple Diverticulostomy for Zenker’s diverticulum: review of literature and experience of 159 consecutive cases. Laryngoscope 113:957–965
Manni JJ, Kremer B, Rinkel RN (2004) The endoscopic stapler diverticulotomy for Zenker’s diverticulum. Eur Arch Otorhinolaryngol 261:68–70
Aly A, Devitt PG, Watson DI, Jamieson GG, Bessell JR, Chew A, Krishnan S (2004) Endoscopic stapling for pharyngeal pouch: does it make the cut? ANZ J Surg 74:116–121
Casso Cd, Lalam M, Ghosh S, Timms M (2006) Endoscopic stapling diverticulotomy: an audit of difficulties, outcome and patient satisfaction. Otolaryngol Head Neck Surg 134:288–293
Tsikoudas A, Eason D, Kara N, Brunton JN, Mountain RE (2006) Correlation of radiological findings and clinical outcome in pharyngeal pouch stapling. Ann Otol Rhinol Laryngol 115:721–726
Lang RA, Spelsberg FW, Naumann A, Dellian M, Jauch KW, Huttle TP (2007) Zenker’s diverticulum treated by transoral diverticulostomy: technique and results. Zentralbl Chir 132:451–456
Folia M, Chanteret C, Duvillard C, Romanet P (2008) Zenker’s diverticulum: technique and results of endoscopic treatment with Endo-Gia stapler 30. Rev Laryngol Otol Rhinol 129:101–105
Lieder A, Nasseri F, Sharma A, Jani P (2008) Safety and efficacy of endoscopic pharyngeal pouch stapling in a large UK study. Clin Otolaryngol 33:127–130
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 12:2057–2064
Wasserzug O, Zikk D, Raziel A, Cavel O, Fleece D, Szold A (2010) Endoscopically stapled diverticulostomy for Zenker's diverticulum: results of a multidisciplinary team approach. Surg Endosc 24:637–641
Verhaegen V, Feuth T, van den Hoogen F, Marres H, Takes R (2011) Endoscopic carbon dioxide laser diverticulostomy versus endoscopic staple-assisted diverticulostomy to treat Zenker’s diverticulum. Head Neck 33:154–159
Recipi A, Pagano N, Fumagalli U, Peracchia A, Narne S, Malesci A, Rosati R (2011) Transoral treatment of Zenker diverticulum: flexible endoscopy versus endoscopic stapling. A retrospective comparison of outcomes. Dis Esophagus 24:235–239
Flikweert DC, van der Baan S (1992) Endoscopic treatment of pharyngeal pouches: electrocoagulation versus carbon dioxide (CO2) laser. Clin Otolaryngol Allied Sci 17:122–124
Kuhn FA, Bent JP (1992) Zenker’s diverticulotomy using the KTP/532 laser. Laryngoscope 102:946–950
van Overbeek JJ (1994) Meditation on the pathogenesis of hypopharyngeal (Zenker’s) diverticulum and a report of endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol 103:178–185
Bradwell RA, Bieger AK, Strachan DR, Homer JJ (1997) Endoscopic laser myotomy in the treatment of pharyngeal diverticula. J Laryngol Otol 111:627–630
Flamenbaum M, Becaud P, Genes J, Cassan P (1997) Endoscopic treatment of Zenker’s diverticulum using CO2 laser. 17 cases. Gastroenterol Clin Biol 21:950–954
Gehanno P, Delattre J, Depondt J, Guedon C, Barry B (1999) Endoscopic surgical treatment of Zenker hypopharyngeal diverticuli. Apropos of 59 cases. Ann Otolaryngol Chir Cervicofac 116:245–249
Krespi Y, Kacker A, Remacle M (2002) Endoscopic treatment of Zenker’s diverticulum using CO2 laser. Otolaryngol Head Neck Surg 127:309–314
Hoffmann M, Scheunemann D, Rudert HH, Maune S (2003) Zenker’s diverticulotomy with the carbon dioxide laser: perioperative management and long-term results. Ann Otol Rhinol Laryngol 112:202–205
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 121:2090–2094
Von Doersten PG, Byl FM (1997) Endoscopic Zenker’s diverticulotomy (Dohlman procedure): forty cases reviewed. Otolaryngol Head Neck Surg 116:209–212
Ishioka S, Sakai P, Maluf Filho F, Melo JM (1995) Endoscopic incision of Zenker’s diverticula. Endoscopy 27:433–437
Evrard S, Le Moine O, Hassid S, Deviere J (2003) Zenker’s diverticulum: a new endoscopic treatment with a soft diverticuloscope. Gastrointest Endosc 58:116–120
Rabenstein T, May A, Michel J, Manner H, Pech O, Gossner L, Ell C (2007) Argon plasma coagulation for flexible endoscopic Zenker’s diverticulotomy. Endoscopy 39:141–145
Costamagna G, Iacopini F, Tringali A, Marchese M, Spada C, Familiari P, Mutignani M, Bella A (2007) Flexible endoscopic Zenker’s diverticulotomy: cap-assisted technique vs. diverticuloscope-assisted technique. Endoscopy 39:146–152
Vogelsang A, Preiss C, Neuhaus H, Schumacher B (2007) Endotherapy of Zenker’s diverticulum using the needle-knife technique: long-term follow-up. Endoscopy 39:131–136
Al-Kadi AS, Maghrabi AA, Thomson D, Gillman LM, Dhalla S (2010) Endoscopic treatment of Zenker diverticulum: results of a 7-year experience. J Am Coll Surg 211:239–243
Case DJ, Baron TH (2010) Flexible endoscopic management of Zenker diverticulum: the Mayo Clinic experience. Mayo Clin Proc 85:719–722
Seth R, Rajasekaran K, Lee WT, Lorenz RR, Wood BG, Kominsky A, Scharpf J (2014) Patient reported outcomes in endoscopic and open transcervical treatment of Zenker’s diverticulum. Laryngoscope 124:119–125
Bloom JD, Bleier BS, Mirza N, Chalian AA, Thaler ER (2010) Factors predicting endoscopic exposure of Zenker’s diverticulum. Ann Otol Rhinol Laryngol 119:736–741
Ong CC, Elton PG, Mitchell D (1999) Pharyngeal pouch endoscopic stapling—are post-operative barium swallow radiographs of any value? J Laryngol Otol 113:233–236
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Verdonck, J., Morton, R.P. Systematic review on treatment of Zenker’s diverticulum. Eur Arch Otorhinolaryngol 272, 3095–3107 (2015). https://doi.org/10.1007/s00405-014-3267-0
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00405-014-3267-0