The endoscopic management of Zenker diverticulum: CO2 laser versus endoscopic stapling

OBJECTIVE: The purpose of this project was to analyze the endoscopic management of Zenker diverticulum (ZD) using both the CO2 laser and endoscopic stapling techniques. This study compares the two techniques in terms of diverticulum size, onset to oral intake, hospital stay, resolution of symptoms (dysphagia and regurgitation), and complications. STUDY DESIGN: A retrospective consecutive case series was performed at an academic medical center. METHODS: Forty patients underwent an attempted endoscopic resection of the ZD using either the CO2 laser or the endoscopic stapling technique. The two techniques were compared on a variety of parameters, including diverticulum size, hospital stay, onset to oral intake, resolution of symptoms, and complications. Symptom scores were obtained before and after surgery with a patient self-reported scoring report (scale 0-3 for both dysphagia and regurgitation with 0 indicating asymptomatic and 3 severe symptoms). RESULTS: Forty patients underwent an attempted endoscopic management of ZD. Five patients (12.5%) failed endoscopic exposure (four converted to open, one observed). Sixteen patients underwent CO2 laser management and 19 underwent endoscopic stapling. The mean diverticulum size (3.8 cm CO2 laser versus 4.4 cm stapling) was not significantly different for the two groups. Both groups demonstrated a significant decrease in preoperative versus postoperative dysphagia and regurgitation symptoms scores, respectively, CO2 laser dysphagia scores decreasing from 2.75 to 1.38 and the regurgitation score dropping from 1.51 to 0.68, whereas endoscopic stapling dysphagia score decreased from 2.74 to 1.21 and the regurgitation score dropped from 1.37 to 0.53. Overall, 86% of patients demonstrated an onset of liquid intake on postoperative day 1 and the average length of stay was 3.4 days in the CO2 laser group and 1.5 days in the endoscopic stapling (P < .0015). Complications included dental trauma in four patients (two CO2 laser and two stapling) and subcutaneous air in three patients (all three CO2 laser). There were no cases of mediastinitis, recurrent laryngeal nerve injury, fistula, or perioperative death. CONCLUSIONS: The endoscopic management of ZD is a safe and effective technique. The endoscopic stapling technique appears to have an improved efficacy and safety when compared with the CO2 laser technique. The two techniques are compared and contrasted.     

Endoscopic assisted endoluminal stapler-diverticulotomy of Zenker diverticulum

INTRODUCTION: One of the advantages of endoluminal diverticolotomy in Zenker's diverticulum with the staple is the possibility of early rehabilitation. As the stapler allows to close the cut wound margins of the diverticulum threshold simultaneously with a clip suture, the patient can start oral food intake as early as 24 hours after surgery. The overview for the surgeon for correct placement of the clip device is limited due to the physiological narrowness of the pharyngeal tube. PATIENTS AND METHODS: We reduced the danger of malplacement by placing a temporary stomach tube as well as endoscopic control of the position of the stapler at the diverticulum threshold. RESULTS: 61 patients with Zenker's diverticulum stage Brombart I - IV have been successfully treated with this surgery technique since 1998. In two other patients a transcervical diverticulotomy was done because the diverticulum threshold could not be exposed clearly with the spread laryngoscope. In 10 patients a clinically symptomatical recurrent diverticulum (Brombart stage II) could be safely removed by a repeated endoscopically assisted stapler diverticulotomy. CONCLUSION: The advanced endoscopically assisted endoluminal stapler diverticulotomy in Zenker's diverticulum is convenient for the patient allowing prompt food intake and showing low morbidity and no mortality.     

Current trends in management of Zenker diverticulum

Zenker's diverticulum is a relatively common problem encountered by head and neck surgeons. Careful review of the available literature regarding its pathogenesis indicates that Zenker diverticulum likely occurs as a result of increased intrabolus pressures during swallowing secondary to cricopharyngeal spasm. Rational treatment for Zenker diverticulum therefore addresses cricopharyngeal spasm. The traditional approach to diagnosis and management of Zenker diverticulum has been based on standard techniques and principles. For example, diverticulectomy with concurrent cricopharyngeal myotomy is an acceptable form of treatment with a high success rate. However, recent advances in endoscopic stapling and carbon dioxide laser technologies have added new options to the therapeutic armament of the otolaryngologist. For appropriately selected patients, endoscopic staple-assisted diverticulostomy is a minimally invasive, safe, and effective procedure associated with shorter hospital stays, more rapid postoperative recovery, decreased time to resumption of oral intake, and high levels of patient satisfaction.     

Measures for reducing the rate of complications in endoscopic surgery of Zenker's diverticulum

In the treatment of the pharyngeal pouch diverticulectomy and endoscopic diverticulotomy are generally accepted. The latter can lead to severe bleeding and mediastinitis. --Therefore the authors have extended the preoperative diagnostic procedure to include a DSA of the aortic arch. The simultaneous contrast filling of the pouch enables the exact position of the blood vessels relative to the bar to be established. --With the spreadable diverticuloscope developed by the authors, the use of a CO2 laser and an operating microscope, optimum endoscopic working conditions are assured. Postoperative sealing of the wound margin with fibrin reduces the likelihood of postoperative bleeding and mediastinitis, the risk of which have been further reduced by antibiotic prophylaxis and tube feeding for eight days. During and after the treatment of ten patients not a single complication has arisen.     

Comparison of techniques for transsphenoidal pituitary surgery

BACKGROUND: The aim of this study was to compare three different techniques for transsphenoidal pituitary surgery: (1) sublabial transseptal approach with microscopic resection, (2) transnasal transseptal approach with endoscopic resection, and (3) endoscopic approach with endoscopic resection. METHODS: We performed a retrospective review of 50 pituitary surgeries performed by the same neurosurgeon. Demographic, radiographic, and clinical data were collected. RESULTS: Fifteen patients underwent sublabial approach with microscopic tumor resection, 21 patients underwent the transnasal approach with endoscopic resection, and 14 patients underwent the completely endoscopic technique. There were a total of 20 complications in the sublabial group, 13 transnasal complications, and 6 endoscopic complications. Cerebrospinal fluid leak incidence was 53% in the sublabial approaches, 47% transnasal, and 28% in the endoscopic patients. Diabetes insipidus was encountered in 33% of sublabial approaches, 5% of transnasal approaches, and 7% of endoscopic approaches. Lumbar drains were required in 40% of sublabial approaches, 38% of transnasal approaches, and 7% of endoscopic approaches. Nasal packing was used in 100% of sublabial and transnasal approaches and 0% of endoscopic approaches. Mean recurrence rate and follow-up was sublabial in 6.6% (50 months), transnasal in 9.5% (11 months), and endoscopic in 0% (7 months). Average hospital stay for sublabial approaches, transnasal approaches, and endoscopic approaches was 8.3, 6.2, and 3.4 days, respectively (p < 0.05). CONCLUSION: Transsphenoidal pituitary surgery has evolved over the past several decades, because advances in technology have been the catalyst for minimally invasive surgeries. Less invasive approaches, such as the transnasal approach with endoscopic resection of tumor and the completely endoscopic .technique have less morbidity and a shorter hospital stay than traditional sublabial approaches. Continued follow-up is needed to confirm long-term benefits and similar recurrence rates.     

Transoral endoscopic surgery: new surgical techniques for oropharyngeal cancer

Surgery of oropharyngeal cancer has evolved from large, open transcervical and transmandibular approaches to minimally invasive transoral endoscopic techniques. Transoral laser microsurgery and transoral robotic surgery allow complete oncologic resection through the mouth with minimal cosmetic deformity and optimal speech and swallow function. With a significant increase in the incidence of oropharyngeal cancers, there is a growing role for up-front surgery, especially in young, healthy patients with human papillomavirus-associated squamous cell carcinoma. This article explores the development of transoral endoscopic surgery, its role in the multidisciplinary treatment of patients with oropharyngeal cancer, and oncologic and functional outcomes.     

Hypopharyngeal diverticulum after cervical spine surgery; The role of endoscopic management

Purpose

The purpose of this study was to assess the role of minimally invasive endoscopic diverticulostomy in patients who develop hypopharyngeal diverticulum after cervical spine surgery/fixation.

Materials and methods

This is a retrospective case series of seven patients who underwent endoscopic management of a symptomatic hypopharyngeal diverticulum. The patients were analyzed for diverticulum size, pre-operative and post-operative dysphagia and regurgitation scores, and complications. The overall success with the endoscopic approach was compared to the prior experience with traditional Zenker's diverticulum.

Results

Of the seven patients with hypopharyngeal diverticulum, four were successfully managed with minimally invasive endoscopic diverticulostomy (57%). These four patients all demonstrated clinically significant improvement in both dysphagia and regurgitation scores at a minimum of 6 months postoperatively. Complications were minimal and consisted of one case with postoperative subcutaneous air. There were no cases of fistula, mediastinitis, or nerve injury.

Conclusions

Minimally invasive endoscopic diverticulotomy can be successfully applied to patients who develop hypopharyngeal diverticulum after cervical spine surgery/fixation.     

The endoscopic stapler diverticulotomy for Zenker's diverticulum

This paper describes the surgical procedure of the endoscopic stapler treatment of Zenker's diverticulum and analyzes the results of 24 consecutive operated patients. In three patients the endoscopic exposure of the diverticulum was not possible. Twenty-one patients underwent endoscopic stapler treatment without any peri- or postoperative complications. The follow-up period was 4 to 29 months (average 18 months). The average total time for surgery was 25 min. Postoperatively, a nasogastric feeding tube was not necessary: all patients resumed oral intake 12 h after surgery. Discharge from the hospital followed the 2nd postoperative day. All patients had complete or nearly complete resolution of symptoms at the 4-month follow-up. Recurrent complaints were an indication for repeat of the contrast barium esophagram. Two patients revealed a residual diverticulum 7 and 11 months after treatment. In comparison with results and complication rates in the literature of the external, transcutaneous techniques and endoscopic diverticulotomy procedures, the endoscopic stapler treatment of Zenker's diverticulum is a safe, (cost-)effective and minimally invasive method and to be considered as the initial treatment of choice.     

鼻内镜下鼻整形手术技术教学经验

鼻位于面部中央,位置显著而独立,是面部美学结构的关键,在整个面部美学形态和立体结构中都起着举足轻重的作用。鼻的整形再造手术可以追溯到公元前600年,早在古印度时期就有所记载。在当时的古印度,切除鼻子被当成是惩治人的一种常用手段,因此导致了这种手术的兴起。     

Basic surgical techniques and variations of endoscopic sinus surgery

This article gives complete information on the care of the endoscopic sinus surgery patient. Indications and preoperative evaluations necessary for endoscopic sinus surgery are described. The technique of functional endoscopic sinus surgery is covered in detail. Postoperative care and complications are also described. Various procedures for patients with extensive or unusual disease are discussed.