Difficult Decisions in Thoracic Surgery - part 7 pdf

38 Lengthening Gastroplasty for Managing Gastroesophageal Reflux Disease and Stricture Sandro Mattioli and Maria Luisa Lugaresi laparothoracoscopic techniques for lengthening gastropla

38

Lengthening Gastroplasty for Managing

Gastroesophageal Reflux Disease

and Stricture

Sandro Mattioli and Maria Luisa Lugaresi

laparothoracoscopic techniques for lengthening gastroplasty associated with a fundoplication have been designed in order to replace the open procedures.6,9–11 Techniques of laparoscopic tubu-larization of the lesser gastric curvature by a wedge resection of the gastric fundus have also been published.12–14

With the lack of tactile appreciation of the viscera, laparoscopic surgery has increased the need to identify the anatomy of the GE junction and more precisely its position with respect to the diaphragmatic hiatus Minimally invasive surgery has revitalized the debate regarding the diagno-sis and treatment of short esophagus and stric-ture; today, as in the past, even the very existence

of the short esophagus is discussed Many geons currently recognize cases of short esopha-gus that are managed with dedicated surgical techniques9,10,12,13,15–26; others deny it is a clinical entity or state they have not seen one, even in large case series.27–59 Traditionally, the short esophagus was coupled with pan mural esopha-gitis and stricture4,14,60–64 in patients affected by severe GERD and mucosal esophagitis Recent data indicate a decreasing frequency of peptic stenosis in the GERD population,65–67 but also the not uncommon existence of true short esophagus

sur-in the absence of esophageal stricture.12,13,26,68,69

Further knowledge has been acquired on the negative role of hiatus hernia,70–72 and particu-larly regarding the effect of a permanent intra-thoracic location of the lower esophageal sphincter

barrier The conceptual differentiation between the intrathoracic position of the GE junction,

A lengthening gastroplasty consists of the

forma-tion of a gastric tube by vertically stapling the

proximal stomach from the angle of His parallel

to the lesser gastric curvature This procedure is

designed to elongate the esophageal tube as part

of surgical treatment of complicated cases of

gas-troesophageal refl ux disease (GERD) in which

the esophagus is irreversibly shortened, thus

the gastroesophageal (GE) junction cannot be

re positioned into the abdomen without excessive

tension

This technique was proposed in 1957 by J.L

Collis for the treatment of complicated cases of

GERD as an alternative to esophageal resection.1,2

A few years later, Collis, after following up the

patients operated upon, reported 59% with GERD

at barium swallow and 50% with specifi c

published the results of a series of 24 patients in

whom a Collis gastroplasty had been performed

in combination with a modifi ed Belsey anti-refl ux

procedure.4 The concept of the Pearson operation

was to elongate the esophagus in order to perform

an effective intra-abdominal anti-refl ux

fundo-plication, avoiding any tension on the sutures

placed through the distal esophagus, the gastric

fundus, and the diaphragmatic hiatus Based on

the same concept, the combination of a Collis

gastroplasty with the Nissen fundusplication was

proposed by Orringer and Sloan (transthoracic

and Cameron7 (uncut Collis–Nissen; thoracic and

(abdomi-nal Collis–Nissen) Innovative laparoscopic and

true short esophagus unequivocally ascertained

only in the operating room,9,25,26,77–79 may be a

sig-nifi cant step of the clarifi cation of controversies

The consideration of factors predicting the ex

is-tence of true esophageal shortening,17,23–26,68,77,80

the precise intraoperative localization of the

position of cardia with respect to diaphragmatic

hiatus,14,68,77,81 the knowledge of surgical

physiol-ogy of anti-refl ux operations, the correct choice

and performance of the surgical technique, and

adequate experience in open and minimally

invasive esophageal surgery are at the present

time the key factors in the surgical therapy

of complicated cases of GERD in whom the

lengthening gastroplasty may be indicated The

above-mentioned issues are discussed in this

chapter

38.1 The Short Esophagus:

Definition, Predictors, Diagnosis,

Surgical Techniques, and Results

38.1.1 Definition

The defi nition of short esophagus was fi rstly

adopted by radiologists to describe the

intratho-racic position of the GE junction and to classify

this condition among the various types of hiatus

hernia, taking into consideration the

morphol-ogy of the thoracic esophagus (straight or

redun-dant) and of the gastric fundus (axial displacement,

funnel type, paraesophageal).82–87 Surgeons

gen-erally base the diagnosis of short esophagus on

the inability to reduce the GE junction below the

diaphragm intraoperatively Other surgeons deny

the existence of short esophagus, stating they

always are able to reposition the GE junction

prevalence of short esophagus in open surgery

case series, mainly expressed in terms of

nonre-ducibility, range widely from 0% to 60% (Table

38.1) The scattering of data strongly suggests

that the clinical research was biased by

method-ological errors such as the subjective identifi

ca-tion of the GE juncca-tion and the equally subjective

quantifi cation of the tension needed to be applied

to the distal esophagus in order to reposition an

adequate segment into the abdomen.14,26,77,80,81,92

In the last decade, the widespread diffusion of minimally invasive surgery has again produced controversial effects on the perception of sur-geons with respect to short esophagus: besides a generalized attitude to ignore the problem within

increasing interest has become evident among surgeons who pay specifi c attention to the issue (Table 38.2) The recent literature unequivocally tries to overcome the low grade of reliability of the historical data, instead referring to more objective methods aimed at localizing precisely the GE junction.26,68,77,81 The current defi nition of short esophagus accepted by the majority of the groups interested in the argument,9,10,14,17,26,92–96

includes several major concepts: (1) the short esophagus is diagnosed only intraoperatively; (2) only after extensive mobilization of the medias-tinal esophagus9–14,17,23–26,68,77,80,81,92,93,97,98; and (3) when the intra-abdominal portion of the esopha-

tension applied.9,11,13,14,17,23–26,68,77,80,81,92,98 Horwath and coworkers77 subdivide short esophagus in: (1) true, nonreducible short esophagus; (2) true but reducible short esophagus; and (3) apparent short esophagus Preoperative radiologic and endo-scopic studies in the three groups placed the GE junction across or above the hiatus In the fi rst category the GE junction cannot be reduced for

at least 2.5 to 3cm below the diaphragm, while in the second category this length of the intra-

ture 1964–1995.

Reference Year Patients Surgery Esophagus (%)

Nygard 122 1964 102 Open 40.2% Collis 123 1968 420 Open 18%

Gatzinsky 124 1979 140 Open 37% Maillet 125 1980 800 Open 10% Moghissi 126 1983 245 Open 39.2% Pearson 115 1987 430 Open 60%

Mattioli 26 2004a 149 Open 29% Abbreviation: nr, not reported.

a 1980–1991.

38 Lengthening Gastroplasty for Managing Gastroesophageal Reflux Disease and Stricture 307

abdominal esophagus is achieved In the third category, the esophagus has a normal length but

is accordioned into the distal mediastinum.77

38.1.2 Predictive Factors

Among patients undergoing surgery for GERD,

up to 40% have developed complications such

as macroscopic esophagitis, Barrett’s esophagus, peptic esophageal stricture, or acquired short esophagus.14,60–62 Esophageal stricture is the clin-ical fi nding most commonly related with esopha-geal shortening14,24,68,80; it may occur in 1% to 5%14,63,64 of patients with longstanding severe esophagitis Other abnormalities that should raise the suspicion of a short esophagus include the radiologic diagnosis of a large, nonreducible hiatal hernia in the upright position, a hiatal

of less than 35cm from the incisors as determined

by endoscopy.13,17,77 The presence of a ageal hiatal hernia is considered to be highly pre-dictive of the presence of short esophagus.24,78,80

(75/94) of patients with a large paraesophageal hernia required a lengthening procedure for short esophagus Of lesser importance, but still thought to play a role, is a history of severe esoph-agitis or Barrett’s esophagus.80 The incidence of reoperative surgery has been shown to be signifi -cantly increased in patients with esophageal stricture following standard Belsey and Nissen repairs.100,101 The risk of gastroplasty was increased 3.8-fold [95% confi dence level (95% CI), 1.0–15.0)

in the presence of esophageal stricture in the study of Urbach and colleagues,24 and by a factor

Urbach observed that for paraesophageal hernia the risk of gastroplasty was increased 4.5-fold (95% CI, 1.4–14.6), 4.3-fold for Barrett’s esopha-gus (95% CI, 1.3–14.3), and 11.6-fold for reopera-tive surgery (95% CI, 2.8–48.4).24 Mittal68 found that, although the presence of Barrett’s esopha-gus or an esophageal stricture was associated with the need for esophageal lengthening, the presence of a large hiatal hernia on barium studies and the preoperative manometric length of the esophagus did not appear to be a statistically signifi cant factor Preoperative esophagraphy,

T ABLE 38.2 Incidence of short esophagus in the surgical

assessment are useful, though not ideal, for

iden-tifying patients in need of an esophageal

length-ening procedure.17,23,24,68 However, it has been

shown that neither a single preoperative

diagnos-tic test nor any combination of tests is completely

accurate in making the diagnosis.23 The

combi-nation of two or more tests resulted in a specifi

c-ity ranging from 63% to 100% but a low sensitivc-ity

In a study on the outcomes of the surgical

treatment of GERD in 319 patients, the

preopera-tive factors predicpreopera-tive of the need for an

esopha-geal lengthening procedure were evaluated.26 The

multivariate analysis showed the following

pre-operative factors as predicting the need of a Collis

procedure: radiologic classifi cation [p = 0.005;

odds ratio (OR) 20.53; 95% CI, 2.47–170.15),

manometry in the upright position performed

after the standard recording in the supine

posi-tion (p = 0.038; OR 5.26; 95% CI, 1.09–25.41), and

the presence of peptic stenosis (p = 0.015; OR 5.18;

95% CI, 1.38–19.44) The radiologic classifi cation

adopted for the study was based on the

assess-ment of the position of the GE junction with

respect to the hiatus and not on the size of the

hernia Three grades of orad migration of the GE

junction were considered: hiatal insuffi ciency,

concentric hiatus hernia, and short esophagus

The classifi cation had been validated with a

manometric–radiologic study, which

demon-strated that the distance (in centimeters) from

the LES inferior margin to the diaphragm was

versus the three grades of migration and between

combina-tion of endoscopy, radiology, and manometry has

been shown to be associated with a high positive

predictive value for short esophagus, the

sensi-tivity and negative predictive value for the

com-bination of these tests are low, and no single

criterion has been shown to be associated with a

high specifi city or predictive value.23,25

38.1.3 Intraoperative Diagnosis

In course of laparoscopic surgery for GERD,

the surgeon may underestimate the presence of

esophageal shortening because of a number of

contributing factors Complete dissection of the

fat pad overlying the GE junction is necessary to

presence of pneumoperitoneum elevates the diaphragm signifi cantly and may give the false impression that an adequate length of intra-abdominal esophagus is achieved.26,92,102 In some reports, a Penrose drain is placed around the distal esophagus and downward tension is applied during the dissection and wrap; this apparent intra-abdominal segment of esophagus may later retract back up into the thoracic cavity when the Penrose drain is removed.92 Finally, many lapa-roscopic surgeons routinely place a weighted bougie into the esophagus, and the downward pressure from the bougie pushes the esophagus distally for a distance up to 2 to 3cm.92 During laparoscopy it is possible to miss the exact posi-tion of the GE junction because the proximal stomach, attracted upward, acquires a funnel like form after years of herniation, the serosa loses brightness, and the wall thins.26 The tubularized proximal stomach is hardly distinguishable from the distal esophagus.98,103 One or more of these factors can lead the surgeon to overestimate the length of intra-abdominal esophagus

Recently, intraoperative endoscopy has been proposed in order to identify the GE junction in relation to the hiatus.26,68,81,103 The reference to the gastric folds as an anatomical–endoscopic land-mark of the GE junction104,105,106 helps to eliminate the subjective component of the evaluation in the presence of short and long Barrett’s esopha-gus.23,26,107 As the gastric folds are normally located at or few millimeters below the Z line, this anatomical reference also eliminates the risk of overdiagnosing the condition of short esopha-gus.26,103 After the endoscopist has placed the tip

of the fi berscope at the level of the gastric folds, the surgeon recognizes the point of passage between the tubular esophagus and the stomach

by means of transillumination68 or by localizing the tip of the scope with a grasping forceps As the length of the open jaws of the forceps is known, the distance between the hiatus and the

GE junction can be estimated.81

The gold standard for determination of short esophagus is intraoperative esophageal mobiliza-tion followed by assessment of length.68 As described by Collis,1 there is a large subset of patients who have true but moderate esophageal shortening, which can be treated by an extended

38 Lengthening Gastroplasty for Managing Gastroesophageal Reflux Disease and Stricture 309

mediastinal dissection Recently, O’Rourke and

transmediastinal dissection in patients with

moderately short esophagus These authors

defi ned an esophageal dissection less than 5cm

into the mediastinum as type I, and an

esopha-geal dissection greater than or equal to 5cm into

the mediastinum as type II On average, a type II

into the mediastinum In cases in which type II

dissection failed to release intra-abdominally

an adequate segment of tension-free esophagus,

a thoracoscopic-assisted Collis gastroplasty was

dissection is the potential for occult injury to

length of the intra-abdominal esophagus after

isolation without tension has the advantage of

overcoming the totally subjective concepts of

moderate or reasonable or adequate tension

applied to pull downward the stomach Any

modality of objective measurement of the applied

tension, although feasible with a dynamometer,

would be unacceptably cumbersome It is

gener-ally agreed that if a minimum of 2.5 to 3 meters of tension–free intra-abdominal esophagus are not obtained after adequate mobilization, a lengthening gastroplasty should be added to the fundoplication.9,11,13,23,25,26,68,77,92,95,102

centi-38.1.4 Surgical Techniques

The techniques of transthoracic and abdominal lengthening gastroplasty, associated with a total or partial fundoplication, are famil-iar to thoracic and esophageal surgeons who have

trans-an adequate training These procedures remain the cornerstones of anti-refl ux surgery, especially for complicated cases and re-operative surgery The minimally invasive Collis–Nissen has gained popularity, mainly in tertiary reference centers via laparoscopic or combined thoraco-laparoscopic approaches In the mid 1990s, two techniques of thoracoscopic gastroplasty and

Swanstrom performed a lengthening gastroplasty

by introducing an endostapler through the right

thoracoscopic approach, and (D) laparoscopic stapled wedge gastroplasty.

technique that reproduced the open one

pro-moted by Steichen [Figure 38.1(B)] The authors

intended to avoid a “double cavity procedure”

and its potential complications Awad has

pre-ferred the left thoracoscopic approach for

intro-ducing the articulated endostapler [Figure 38.1(C)].11

The most recent modifi cation of the Collis

gas-troplasty is the stapled wedge gasgas-troplasty

Lin and associates,13 and Hoang and coworkers.14

This technique is performed laparoscopically,

and requires the resection of a wedge of gastric

fundus in order to staple the lesser curvature

ver-tically [Figure 38.1(D)] The wedge gas troplasty

has been developed because, with the fully

lapa-roscopic technique [Figure 38.1(B)], the apex of

38.1.5 Results

With regard to the transthoracic Collis–Belsey

and Collis–Nissen operations, Pearson and

Orringer reported an operative mortality of 0.5%

to 1.1%.109–111 Other authors achieved analogous

results.6,112–114 Complications related to the

length-ening gastroplasty included leaks and fi stulas,

Pearson reported good long-term results in 84.5%

observed good results in 89%.110,111 The long-term

results of the open Collis procedure associated

with anti-refl ux surgery are not uniform, and

sat-isfactory results vary from 59%107,116 to 80%.26

With regard to the minimally invasive Collis–

Nissen, the early results are satisfactory and

compare favorably with previous open surgery

series Mean operative time for Hunter’s series

was 294min,10 and for Swanstrom’s series, it was

257min.16 The average length of stay has been 2

to 3 days.10,11,16,92 No operative mortalities were re

ported.10,11,12,14,16,92,117 Complications ranged from

0% to 50%.10–12,14,16,92,117 Postoperative functional

assessment at 12 months for Hunter’s series

revealed that 11% of patients complained of refl ux

follow-up in Swanstrom’s series revealed no

medium-term follow up, 14% of patients complained of

observed.16 Awad and coworkers reported similar outcome data at a mean follow-up of 17 months: 9% of patients complained of refl ux symptoms

docu-mented a 9% wrap failure rate and a 9% tinal herniation rate.23 Pierre and colleagues118

medias-reported on a group of 112 patients with sophageal hernia who underwent a laparoscopic Collis–Nissen procedure At a median of 18 months of follow-up, the patients satisfaction rate was 93%, 16% required, at least occasionally, anti-secretory medications, and 6% had dyspha-gia warranting dilation Recurrent hiatal hernias.were observed in 2.7%.118

parae-The Collis gastroplasty is a suitable procedure also in case of re-operation after a failed anti-refl ux procedure, as performed in open surgery by

minimally invasive surgery by Luketich in 52.5%.120

Two specifi c causes of malfunction of the ening gastroplasty have been identifi ed The neo-esophagus’ lack of motility may predispose to dilation of the tube or contribute to postoperative dysphagia.13,14,77 Of more potential concern is the production of acid within the neoesophagus pro-ducing localized esophagitis, as was observed in open Collis procedures.13,14,77,107 Jobe and cowork-

patients after laparoscopic lengthening plasty and anti-refl ux fundoplication: in 7 of 15 patients the neoesophagus above the wrap was found to contain parietal cells that continued to secrete acid This was indicated by an abnormal postoperative DeMeester score and it was con-

gastro-fi rmed by positive Congo red testing of the suspected mucosa In order to avoid leaving parietal cells above the fundoplication, Hunter suggests placing the highest stitch of the fundopli-

Collis gastroplasty is conceptually appealing, these problems call into question the liberal

ap plication of this technique during anti-refl ux surgery.13

38.2 Recommendations

All the data of the past and present literature originate from single center reports; no study was

38 Lengthening Gastroplasty for Managing Gastroesophageal Reflux Disease and Stricture 311

randomized; the criteria for inclusion of patients

were not defi ned; the indications for surgical

therapy of GERD were not specifi ed; and the

methods for studying the patients were neither

standardized nor uniform The surgical

tech-niques adopted in the last 10 years are

substan-tially different and have been applied to relatively

small numbers of patients In consequence, the

quality of data of the body of literature available

regarding the arguments treated in the present

chapter is unfortunately low (level of evidence 3

to 4) Nevertheless, every day patients affected by

GERD undergo surgical therapy It is imperative

to draw empirical guidelines for the management

of these patients

Authors who believe that the lengthening

gastroplasty is still the only way to manage true

short esophagus and other complex situations

agree on the following concepts: (1) the

preopera-tive evaluation offers the clinician posipreopera-tive

ele-ments of suspicion on the eventual complexity

of the case, but the diagnosis of short esophagus

can be made only in the operating room with

a combined surgical and endoscopic

measure-ment of the distance between the GE junction

and the diaphragm; (2) only after extensive

mobi-lization of the mediastinal esophagus; and (3)

when the intra-abdominal portion of the

tension applied With regard to the surgical

techniques, many insist on the utility of

perform-ing the fundoplication around the proximal

neo-esophagus

38.3 Our Approach

The 25 years of clinical research of the Bologna group on anti-refl ux surgery, specifi cally on diag-nosis, pathophysiology, and treatment of short esophagus, and the continuous attention paid

to the work of others, has led us to progressively mature and share the above-mentioned princi-ples according to our experience We have adopted a series of technical details with the intention of eliminating the reasons for failure, still certainly not negligible, of the Collis proce-dure associated with anti-refl ux surgery.26 At the present time, we believe that the only alternative

to a lengthening gastroplasty for true short esophagus, with or without stricture or parae-sophageal hernia, is long-term medical therapy,

preoperative barium swallow and the radiologic classifi cation in three steps of cranial migration

to adequately inform the patient and to plan the operative procedure

When a concentric hiatus hernia or short esophagus are diagnosed radiologically, we place the patient in the 45° left lateral position on the operating table [Figure 38.2(A)] Rotating the bed

on the left or on the right, the surgeon can fortably perform laparoscopy or laparoscopy-left thoracoscopy; the 10-mm optic port is placed at

[Figure 38.2(A)] The left thoracoscopic approach [Figure 38.2(B)] has been preferred because it permits effective control of the otherwise blind passage of the endostapler into the mediastinum and upper abdomen (if a second optic is not used) The tip of the stapler is clearly visible while walking the stapler tip along the left diaphragm Moreover, with the left thoracic approach, the lower esophagus and hiatus are well displayed The routine marking by clips of the GE junction with the help of the fi berscope is useful in placing the fundoplication in the correct position around the esophagus or the neo-esophagus Intraopera-tive endoscopy requires a few technical details to precisely measure the length of the intraabdomi-nal esophagus: (1) defl ate the stomach to avoid distension of the fundus and the consequent shortening of the submerged esophageal segment; (2) mark the level of the gastric folds while

The diagnosis of short esophagus can be made

only in the operating room with a combined

surgical and endoscopic measurement of the

distance between the GE junction and the

dia-phragm, and only after extensive mobilization

of the mediastinal esophagus When these

conditions are met and the intra-abdominal

portion of the esophagus is shorter than 2 to

appropriate to perform a Collis gastroplasty

(level of evidence 3 to 4; recommendation

grade C)

withdrawing the instrument [Figure 38.2(B,C)]

measure the distance between the anterior apex

of the hiatus (which is more cranial than the

pos-terior aspect) and the clips For measuring the

distance between the clips and the apex of the

diaphragm, we have created an L-shaped ruler

which eliminates the perspective errors caused

by the bidimensional video image [Figure

38.2(C)] In order to avoid the formation of an

amotile acid secreting pouch above the upper

margin of the fundoplication, we consider it

crucial that the neoesophagus is not longer than

approach, the lengthening achieved with one

application of the roticulator endostapler cannot

include the entire neo-esophagus in the 360°

fundoplication To date, the neo-esophagus and the fundoplication always have been placed below the diaphragm without tension

The importance of preserving a soft, shaped gastric fundus to wrap smoothly around the neo-esophagus has been clearly pointed out

balloon-in the past.121 With the EEA laparoscopic plasty (same for the open Collis–Nissen), a long stiff fundus is frequently obtained that cannot softly cover the whole length of the neo-esopha-gus We believe that this was the main reason for some of the poor long-term results we obtained with the abdominal Collis–Nissen with respect to the Pearson operation, in the absence of ischemia

gastro-of the stapled gastric remnant and gastro-of anatomical relapse.26 We extend this concern to the stapled

A

B

C

procedure: (A) position of the patient on the operative bed, the

chest is rotated 45 ° to the right side, the optic port is placed 5 cm

above the ombilicus in the mid line, the thoracoscopic port

(12 mm) is placed in the posterior axillary line 5th to 7th interspace

according to the size of the chest; (B) the tip of the fiberscope is

in correspondence of the gastric folds; (C) the L-shaped ruler; (D) the neoesophagus, and (E) the floppy Nissen is anchored to the esophagus at the level of the native GE junction.

38 Lengthening Gastroplasty for Managing Gastroesophageal Reflux Disease and Stricture 313

drastically reduce the volume of the gastric

fundus To prevent the formation of a gastric

pouch above the fundoplication we fi x the wrap

laterally to the native cardia with two stitches

placed at the apex of the gastroplasty [Figure

38.2(E)] To avoid the intraoperative splitting of

bougie to calibrate the gastroplasty We have not

yet registered any cases of troubling dysphagia

In summary, when treating complex cases

of GERD, surgeons must optimize the pre- and

intra-operative recognition of the anatomical and

pathophysiological situation and must possess

the experience and skill necessary to adequately

perform very complex surgical procedures

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Lengthening Gastroplasty for Managing Giant Paraesophageal Hernia

Kalpaj R Parekh and Mark D Iannettoni

plasty in the management of giant geal hernias

paraesopha-39.1 Preoperative Evaluation

The true incidence of the short esophagus in a giant paraesophageal hernia remains unknown This is mainly because there is no single test that can accurately assess the degree of esophageal shortening preoperatively Mittal and colleagues3

analyzed the accuracy of preoperative ment in predicting the true incidence of short esophagus at the time of surgery The criteria used for diagnosis of short esophagus preopera-tively in their study included (1) hiatal hernia

assess-5cm or larger on upright esophagogram, (2) large paraesophageal hernia (>5cm), (3) stricture for-mation or Barrett’s esophagus as evaluated by endoscopy, and (4) manometric esophageal length two standard deviations below their laboratory mean for height Using these criteria they identi-

fi ed 39 patients as having a preoperative sis of short esophagus However, intraoperatively, only eight patients required an esophageal length-ening procedure The remaining 31 patients did not require an esophageal lengthening proce-dure, and intra-operative mobilization was suf-

diagno-fi cient to allow the gastroesophageal junction to lie below the diaphragmatic crus They concluded that, in their experience, the most sensitive pre-operative test was an endoscopic fi nding of either

a stricture or Barrett’s esophagus for predicting the need for lengthening Another study from the same institution showed similar results, with the

The herniation of stomach into the thorax has

been classifi ed into four major types The sliding

hiatus hernia (type I), which is the commonest

type and accounts for 95% of all cases, has the

gastroesophageal (GE) junction as the leading

point of the hernia.1 The GE junction is herniated

into the thorax in this type of hernia The pure

paraesophageal hernia (type II), which is

ex-tremely rare, is characterized by a GE junction

that maintains its intra-abdominal position while

the fundus herniates into the chest through the

anterolateral hiatus The majority of the

parae-sophageal hernias (type III) are a combination of

the above two types, in which the GE junction is

herniated along with the fundus into the thorax

Finally, type IV hernias are those in which other

organs like colon, small intestine, and spleen are

also present in the sac

Paraesophageal hernias are likely to

incarcer-ate or strangulincarcer-ate and may also present with a

volvulus of the stomach, and hence often need to

be operated on electively when diagnosed

Con-troversy exists about the role of surgery, the

approach (transthoracic or transabdominal), and

the need for esophageal lengthening during

repair Esophageal shortening is a result of

long-standing gastroesophageal refl ux disease wherein

chronic irritation and injury leads to fi brosis and

scarring of the esophagus.2 This results in a

rela-tive shortening of the esophagus that cannot be

reduced intra-abdominally at the time of repair,

thereby precluding a tension-free repair In this

chapter we will review the incidence,

preopera-tive and intra-operapreopera-tive evaluation of esophageal

shortening, and the role of lengthening

gastro-39 Lengthening Gastroplasty for Managing Giant Paraesophageal Hernia 319

sensitivity of 61% for an endoscopy in predicting

Altorki and colleagues demonstrated that 77%

of their patients had the gastroesophageal

junc-tion in the mediastinum, based on a preoperative

barium swallow However, none of their patients

required a lengthening gastroplasty In contrast,

Maziak and colleagues5 noted that 91 of their 94

patients had their gastroesophageal junction in

the thorax and 75 of their patients ended up

requiring a lengthening gastroplasty The authors

used manometry to measure the length of the

esophagus between the upper and lower

sphinc-ters in 13 patients and found that the mean length

in patients with giant paraesophageal hernias

was signifi cantly lower compared to matched

normal controls

In summary, all patients with giant

paraesoph-ageal hernias should have a barium swallow and

esophagoscopy prior to hernia repair

Manome-try and acid testing are not very reliable in this

group of patients However, the most accurate

way of determining esophageal shortening is in

the operating room at the time of repair

39.2 Lengthening Gastroplasty:

Is It Necessary? What Is the

Ideal Technique?

The role of esophageal lengthening gastroplasty

remains a controversial point among clinicians

as the true incidence of shortening is unknown

While there are no prospective, randomized,

controlled trials comparing the outcomes with

or without lengthening gastroplasty in patients

with giant paraesophageal hernias, there are

several reports of retrospective single-institution

experiences

The lengthening Collis gastroplasty is seeing

an increasing application in the management of

giant paraesophageal hernias in order to decrease

the incidence of recurrent herniation While

there is consensus among most surgeons about

the importance of adequate esophageal

mobiliza-tion, there is no consensus about the role of

lengthening gastroplasty

Traditionally, the majority of the

paraesopha-geal hernia repairs were open repairs either via a

transabdominal or transthoracic approach In recent years laparoscopic repairs of these hernias have shown mixed outcomes Experienced centers have good results with this technique, while others report a high recurrence rate

Maziak and colleagues, using an open thoracic approach, added a lengthening gastro-plasty in 80% of their patients and had a very low recurrence rate of 2% over a median follow-up of

trans-72 months In another large open transthoracic

series (n = 240) from the University of Michigan, Patel and associates reported an addition of lengthening gastroplasty in the majority of their patients (96%) and reported an anatomical recur-rence in 7.9% of the patients These two retro-spective reviews set a benchmark for outcomes following repairs of paraesophageal hernia as they have a large number of patients and a good follow-up In contrast, there are two reviews where a lengthening gastroplasty was not rou-tinely used in an open repair Low and coworkers report their experience with 72 patients where a lengthening gastroplasty was not added in any patient and had a recurrence rate of 18% after a mean follow-up of 30 months Similarly, Wil-liamson and colleagues report a recurrence of 11% after a median follow-up of 61 months There

is one report by Geha and colleagues where a lengthening gastroplasty was added in only 2%

of the patients and on a routine postoperative swallow no recurrences were identifi ed However, there is no long-term follow-up available in these patients and the timing of obtaining the barium swallow is not clear Based on these results it is fair to say that addition of lengthening gastro-plasty is associated with a lower rate of anatomi-cal recurrences following paraesophageal hernia repair Table 39.1 summarizes results of open technique for the repair

These results are corroborated in the cally challenging laparoscopic approach for paraesophageal hernia repair The University of Pittsburgh experience published by Pierre and coworkers6 sets the standard for the laparoscopic technique The authors reported their experience

techni-on 200 patients with a recurrence rate of 2.5% after a median follow-up of 18 months They per-formed a lengthening gastroplasty on 56% of their patients using a laparoscopic approach Several other series reported a high rate of

recurrence using the laparoscopic approach7–11

when a lengthening gastroplasty was not

rou-tinely used for esophageal shortening Table 39.2

summarizes the results following the

laparo-scopic technique of paraesophageal hernia repair

Andujar and colleagues in their experience with

the laparoscopic technique report a 5% incidence

of anatomical recurrence for the paraesophageal

hernia; however, they also report a 20% incidence

of a recurrent sliding hernia in their follow-up

swallows True paraesophageal hernias are rare

and most of them are a combination of sliding

and paraesophageal hernias Although some

authors argue about the clinical signifi cance of

asymptomatic anatomical recurrences on operative barium swallow, there is no long-term follow-up available on these asymptomatic ana-tomical recurrences There is only one report, by

open techniques with laparoscopic techniques

They performed a lengthening gastroplasty in only one of their 54 patients In their experience laparoscopic technique had a higher rate of recur-rence (42% vs 15%) compared to open technique

Thus, published data suggests that addition of

a lengthening gastroplasty is associated with a lower incidence of recurrent herniation by open

or laparoscopic technique The evidence (level of

Altorki 15 1998 47 0 (0%) 3 (6.3%) 45 months (median) 3

Abbreviation: na, not available.

T ABLE 39.2 Outcomes of paraesophageal hernia repair following laparoscopic technique.

Dahlberg 9 2001 37 1 (2.7%) 4 (13%) 15 months (median) 3

aRecurrent paraesophageal hernias.

bRecurrent sliding hernias.

39 Lengthening Gastroplasty for Managing Giant Paraesophageal Hernia 321

evidence 3) suggests that all patients with giant

paraesophageal hernia repair should have an open

repair (recommendation grade C) and a

lengthen-ing gastroplasty should be added if there is any

question of esophageal shortening

(recommenda-tion grade C) Laparoscopic repairs can be

per-formed with good results in experienced hands

3 Mittal SK, Awad ZT, Tasset M, et al The tive predictability of the short esophagus in patients with stricture or paraesophageal hernia

preopera-Surg Endosc 2000;14:464–468.

4 Awad ZT, Mittal SK, Roth TA, Anderson PI, Wilfl ey

WA Jr, Filipi CJ Esophageal shortening during

the era of laparoscopic surgery World J Surg

2001;25:558–561.

5 Maziak DE, Todd TR, Pearson FG Massive hiatus

hernia: evaluation and surgical management J

Thorac Cardiovasc Surg 1998;115:53–60;

discus-sion 61–62.

6 Pierre AF, Luketich JD, Fernando HC, et al Results

of laparoscopic repair of giant paraesophageal

hernias: 200 consecutive patients Ann Thorac

8 Jobe BA, Aye RW, Deveney CW, Domreis JS, Hill

LD Laparoscopic management of giant type III hiatal hernia and short esophagus Objective

follow-up at three years J Gastrointest Surg 2002;

outcome of 116 patients J Gastrointest Surg 2003;

7:59–66; discussion 67.

11 Wiechmann RJ, Ferguson MK, Naunheim KS, et

al Laparoscopic management of giant

paraesoph-ageal herniation Ann Thorac Surg 2001;71:1080–

1086; discussion 1086–1087.

12 Hashemi M, Peters JH, DeMeester TR, et al roscopic repair of large type III hiatal hernia:

Lapa-objective followup reveals high recurrence rate J

Am Coll Surg 2000;190:553–560; discussion 560–

561.

13 Williamson WA, Ellis FH Jr, Streitz JM Jr, Shahian

DM Paraesophageal hiatal hernia: is an antirefl ux

procedure necessary? Ann Thorac Surg 1993;56:447–

15 Altorki NK, Yankelevitz D, Skinner DB Massive

hiatal hernias: the anatomic basis of repair J

Thorac Cardiovasc Surg 1998;115:828–835.

Addition of a lengthening gastroplasty is

asso-ciated with a lower incidence of recurrent

her-niation after repair of giant paraesophageal

hernia by open or laparoscopic technique A

lengthening gastroplasty should be added if

there is any question of esophageal shortening

(level of evidence 3; recommendation grade

C)

At our institution, we evaluate all patients with

paraesophageal hernia with a barium swallow

and an endoscopy at the time of the operation

Manometry is not routinely performed on these

patients Intraoperatively we perform the repair

via a left thoracotomy and routinely perform a

Collis gastroplasty along with a Nissen

fundopli-cation on majority of our patients

In summary, the incidence of esophageal

shortening in giant paraesophageal hernia is

unknown There is no single preoperative

inves-tigation that can identify all patients with true

esophageal shortening and the most defi nitive

way of determining shortening is

intraopera-tively The data suggests that the recurrence rate

following repair is higher if a lengthening

gastro-plasty is not used routinely in cases of esophageal

shortening

References

1 Patel HJ, Tan BB, Yee J, Orringer MB, Iannettoni

MD A 25-year experience with open primary

transthoracic repair of paraesophageal hiatal

hernia J Thorac Cardiovasc Surg 2004;127:843–

849.

2 Mattioli S, D’Ovidio F, Di Simone MP, et al

Clini-cal and surgiClini-cal relevance of the progressive

phases of intrathoracic migration of the

gastro-esophageal junction in gastrogastro-esophageal refl ux

disease J Thorac Cardiovasc Surg 1998;116:267–

275.

experience in 100 patients with giant

paraesopha-geal hernia: the case for abdominal approach and

selective antirefl ux repair Surgery 2000;128:623–630.

17 Low DE, Unger T Open repair of paraesophageal

hernia: reassessment of subjective and objective

outcomes Ann Thorac Surg 2005;80:287–294.

tions of laparoscopic paraesophageal hernia

repair J Gastrointest Surg 1997;1:221–228.

19 Andujar JJ, Papasavas PK, Birdas T, et al scopic repair of large paraesophageal hernia is associated with a low incidence of recurrence and

Laparo-reoperation Surg Endosc 2004;18:444–447.

40

Management of Zenker’s Diverticulum:

Open Versus Transoral Approaches

Douglas E Paull and Alex G Little

but symptoms that suggest such a possibility include hemoptysis/hematemesis, complete esophageal obstruction, and a sudden increase in

Zenker’s diverticulum is Boyce’s sign, the gling sensation and noise generated beneath the examiner’s fi ngertips as the neck mass is compressed.5

gur-Zenker’s diverticulum is easily identifi ed on barium swallow and video fl uoroscopy Unless signs or symptoms suggest the rare malignancy, most authors do not recommend preoperative endoscopy given the hazard of perforation Although the diverticulum originates posteri-orly, it usually projects to the patient’s left neck and inferiorly, towards the mediastinum The diverticulum can be staged according to size using either the Brombart or Lahey classifi ca-tions.10,11 Diverticular size is defi ned as small (<2cm), medium (2–4cm), or large (>4cm) Diver-ticular size plays an important role in the selec-tion of therapy

There is no viable medical treatment option for Zenker’s diverticulum, although esophageal dila-tion and Botox injection have been utilized with poor results The surgical treatment options are

of two types: open and transoral endoscopic cedures Open procedures include (1) myotomy alone for small diverticula; (2) myotomy and diverticulectomy; and (3) myotomy and divertic-ulopexy Endoscopic procedures include (1) the Dohlman procedure utilizing diathermy or laser and (2) endoscopic stapling The purpose of this chapter is to compare and contrast the tech-niques, complications, and results of open versus

pro-Pharyngoesophageal (Zenker’s) diverticulum is a

false diverticulum of the cervical esophagus

This pulsion diverticulum is composed of mucosa,

covered by thin areolar tissue, herniating at

Killian’s triangle between the obliquely

posi-tioned inferior constrictor muscle and the

transversely oriented cricopharyngeus muscle

Pharyngoesophageal diverticulum was fi rst

formed in pharynx.” Friedrich Albert Zenker in

1867 described the clinicopathological

character-istics of 23 previous cases and 5 of his own cases

patho-physiology of Zenker’s diverticulum has been

attributed to functional abnormalities of the

upper esophageal sphincter zone created by the

cricopharyngeus muscle Cricopharyngeal spasm

and achalasia, cricopharyngeal incoordination,

impaired upper esophageal sphincter opening,

and structural changes of the cricopharyngeal

muscle have all been implicated in the etiology of

Zenker’s diverticulum.3,4

The incidence of Zenker’s diverticulum is 2 per

100,000/year and it is more common in men than

and eighth decades of life The disease is rare in

patients before the age of 40.6,7 Patients may have

symptoms for years prior to the diagnosis Typical

symptoms include dysphagia and regurgitation

Patients may also complain of halitosis, choking,

cough, weight loss, and/or hoarseness

Aspira-tion of food may lead to pneumonia and lung

abscess Massive bleeding from ulcers in the

diverticulum is unusual, but may require urgent

intervention.8 Cancer in the diverticulum is rare,

grade of recommendation for the procedures are

provided in the concluding summary

40.1 Open Approaches

40.1.1 Open Techniques

Although myotomy alone has been accomplished

under local anesthesia, the majority of patients

undergoing an open procedure will benefi t from

general anesthesia for comfort and to prevent

aspiration.12 A left lateral cervical incision along

the anterior border of the sternocleidomastoid

muscle is the most common approach The

carotid sheath is gently retracted laterally, the

larynx retracted medially, and the omohyoid

muscle either divided or retracted inferiorly The

middle thyroid vein and inferior thyroid artery

are divided The diverticulum is carefully

dis-sected free from its attachments to surrounding

tissues Placement of a 28F to 50F bougie in the

esophagus facilitates the dissection and prevents

compromise of the esophageal lumen at

divertic-ulectomy Most authors believe myotomy is the

indispensable component of an operation for

Zenker’s diverticulum Cricopharyngeal myotomy

is performed posterolaterally, avoiding any injury

to the recurrent laryngeal nerve (See Figure

40.1)

Following the myotomy, in all but patients with

small diverticula, either diverticulectomy or

diverticulopexy is performed Recent experiences

utilizing endoscopic staplers for

diverticulec-tomy, especially with 3.5-mm staples, report a

low leak rate and early resumption of oral diet

compared to results after excision and suturing.13

Publications on patients undergoing myotomy

and stapled diverticulectomy have reported

resumption of liquid diet on postoperative day 1

Proponents of diverticulopexy claim a lower

rate of fi stula, mediastinitis, and stricture; a

quicker resumption of diet; and shorter hospital

stay when compared to diverticulectomy After

the sac is dissected, it is oriented superiorly, and

sewn to the prevertebral fascia The sac then

empties by gravity into the esophagus Bremner

recommends using diverticulum size to select

patients and employs diverticulectomy for sacs

to be the preferred treatment of debilitated patients with concurrent illness to avoid the risk

of a suture/staple line leak

40.1.2 Results of Open Operation

By far the largest reported series of open ticulectomy, which included patients with and without myotomy, for Zenker’s diverticulum is by Payne at the Mayo Clinic in 1983.16 In this land-mark study of 888 patients, 93% of patients were improved at a follow-up of 14 years Operative mortality was 1.2%, and recurrence occurred in 3.6% of patients Allen, reporting in 1995 on a subset of the same patients, noted a fi stula rate of

Barth-len (1990) reviewed 43 patients with Zenker’s diverticulum undergoing open procedures, of whom 32 were treated by myotomy and diverticu-lectomy.6 There was no mortality, no recurrence, and 82% of postoperative patients were com-pletely asymptomatic Crescenzo (1998) studied

75 patients treated with an open procedure, 57

There were no deaths, a 5.3% fi stula rate was

incision The thyroid and larynx are gently retracted medially, the carotid sheath laterally Diverticulum has been completely dissected from surrounding tissues Cricopharyngeal myotomy is shown being performed posterolaterally, avoiding the recurrent laryngeal nerve The diverticulum is subsequently either resected

or suspended as described in the text.

40 Management of Zenker’s Diverticulum: Open Versus Transoral Approaches 325

reported, the hospital stay averaged 5 days, and

94% of patients were signifi cantly improved The

most common cause of late death was coronary

artery disease

Alternative open procedures have excellent

results as well Laccoudeye (1994), Fraczek (1998),

and Konowitz (1989) all demonstrated fewer leaks

and shorter hospital stay for their

diverticulo-pexy patients compared to their diverticulectomy

patients.19–21 Schmit (1992) reported on 48 patients

with small diverticula undergoing myotomy

2.1%, hospital stay was 2.7 days, and 70% of

patients had good to excellent results

Manometric abnormalities generally improve

following myotomy and diverticulectomy

Preop-erative versus postopPreop-erative fi ndings include

pharyngoesophageal dyscoordination in 45%

versus 8%, late relaxation of the upper

esopha-geal sphincter in 50% versus 8%, and incomplete

manomet-ric fi ndings are present in only 40% of

preopera-tive patients and this increases to 92% of patients

postoperatively Postoperative barium swallow

studies may show a residual diverticulum,

However, multiple studies have demonstrated no

correlation between these postoperative

radio-graphic abnormalities and the presence or

absence of recurrent symptoms

As shown in Table 40.1, open myotomy and diverticulectomy is a time-tested operation for Zenker’s diverticulum Meticulous surgical tech-nique results in low mortality in an elderly patient population with multiple comorbidities Success rates are outstanding and enduring The primary disadvantages of open procedures include sig-nifi cant complication rates and relatively long hospital stays; the more serious complications of

fi stula and vocal cord paralysis are relatively infrequent Open diverticulopexy, compared to diverticulectomy, appears to have similar out-comes with a low risk of complications, earlier resumption of diet, and shorter hospital stays One advantage of open diverticulectomy over endoscopic stapling or open diverticulopexy is the removal of the sac Carcinoma has been reported in 0.4% to 3.7% of Zenker’s diverticula.23

For this reason, even some proponents of endoscopic stapling suggest a role for open diverticulectomy and myotomy in younger patients.24

In summary, the results of open procedures for Zenker’s diverticulum can be characterized as demonstrating: (1) a high degree of success; (2) low mortality; (3) a low recurrence rate; and (4) durable results upon long-term follow-up This is accomplished with a complication rate of approx-imately 10%, although most complications are of

40.2 Endoscopic Approaches

40.2.1 Background

Transoral endoscopic surgery, dividing the

crico-pharyngeal bar between the sac and the

Dohlman, in 1935, introduced a specialized

diverticuloscope and cautery into the endoscopic

armamentarium and reported on a series of 100

refi ned the endoscopic approach with the use of

a 400-mm-lens operating microscope, allowing

1993, Collard introduced the use of the linear

stapler to divide the tissue bridge to obtain a

secure closure, reducing the risk of mediastinitis

and bleeding.29

40.2.2 Endoscopic Techniques

General anesthesia is employed and the patient is

placed in the supine position with the neck

extended A dental guard helps prevent tooth

injuries from the rigid diverticuloscope A

Weerda diverticuloscope is inserted transorally

with the long tip placed in the esophagus and the

shorter tip in the sac The instrument is gently

spread, exposing the bar of tissue separating the

posterior sac lumen from the anterior esophageal

lumen The scope is held in place with the aid of

a chest support A telescope with an attached

camera and monitor provide excellent exposure

The pouch is inspected, debris is removed, and

cancer is excluded An endoscopic linear cutting

stapler is used to divide the exposed bridge of

tissue A V-shaped opening between the sac and

esophagus is created, forming a common cavity

Endoscopic sutures may be placed for traction

prior to application of the stapler Depending on

the size/length of the pouch, a second, and rarely

a third, stapling application may be required A

small residual spur often results, but it is safer to

under divide than risk perforation and

mediasti-nitis (See Figure 40.2)

When perforation does occur, it is usually

detected intraoperatively and can be treated with

endoscopic suture, conversion to an open

proce-dure, or conservative treatment with antibiotics

of the uneventful endoscopic stapling usually

dis-charge by postoperative day 1 or 2 While a chest

X ray is often routinely performed to exclude vical/subcutaneous/mediastinal emphysema; a postoperative barium swallow study is not usually obtained

cer-There are other endoscopic techniques besides stapling The Dohlman procedure is similar to the stapling approach but either a carbon dioxide (CO2) laser or electrocautery are utilized to divide the tissue between the diverticulum and the esophagus to create a common cavity In an effort

to avoid general anesthesia altogether, a number

of authors have reported the use of a soft ticuloscope and fl exible endoscopy, with division

diver-of the tissue bar utilizing a needle knife

40.2.3 Results of Endoscopic Techniques

A review of over 29 papers involving patients undergoing endoscopic stapling by Sen revealed that: general anesthesia was applied in all cases; 80% of the cases were performed in Europe; endoscopic stapling was abandoned in 0% to 30%

of patients because of limited neck extension, prominent incisors, a small diverticulum, or a

postoperatively; and the hospital length of stay

diverticuloscope, not shown, the endoscopic stapler is inserted, with the stapler cartridge in the esophageal lumen and the cutting platform blade in the diverticulum Firing the stapler creates a V-shaped opening between the sac and esophagus, forming a common cavity Depending on the size of the pouch, more than one stapling application may be required.

40 Management of Zenker’s Diverticulum: Open Versus Transoral Approaches 327

to 17% of patients, and mortality was 0.43% In

short-term follow-up, 53% to 100% of patients

had complete resolution of symptoms Postma, in

a review of fi ve series totaling 230 patients

under-going endoscopic stapling, reported a

complica-tion rate of only 0% to 3%.33

Complications such as vocal cord paralysis, an

occasional complication of open procedures, are

exceedingly rare after endoscopic stapling.34 As

shown in Table 40.2, advantages of endoscopic

stapling include (1) shortened

operating/anesthe-sia time; (2) early resumption of oral intake; (3)

short hospital stay; (4) few complications and low

mortality; (5) ease of application in open failures;

and (6) excellent symptom relief.25,35–49

Manomet-ric studies following endoscopic stapling have

consistently demonstrated a reduction of

intra-bolus pressure and upper esophageal sphincter

pressures.35,40

Possible disadvantages of endoscopic stapling

include: (1) diffi culty in managing small (<2cm)

diverticula; (2) stapling diffi culty due to

expo-sure problems secondary to cervical arthritis or

craniofacial abnormalities; (3) relatively high

symptom recurrence rates; (4) residual pouch; (5) persistence of sac and possibilities of future cancer; and (6) lack of information on long-term outcomes because of relatively short follow-up

Proponents of endoscopic stapling point out that recurrent symptoms are rather easily handled

by a second, or in some cases, a third stapling Small sacs can be treated utilizing traction sutures or converted to endoscopic laser treat-ment Studies document a residual pouch in nearly 100% of patients undergoing endoscopic stapling.50 This is in contrast to the much lower incidence in postoperative open procedure patients However, the presence of a small pouch distal to the cricopharyngeus appears to have no correlation to symptoms

Von Doersten reviewed 40 cases of the Dohlman procedure in which electrocautery was utilized

to divide the tissue bridge.51 Operative time was

were no postoperative deaths num occurred in 4 (10%) of patients, but all responded to conservative treatment without re-operation Thirty-seven (92%) of the 40 patients

Pneumomediasti-T ABLE 40.2 Endoscopic stapling for Zenker’s diverticulum.

Study (year) patients to opena

were asymptomatic at an average follow-up of 42

months

The results of treatment of Zenker’s

diverticu-lum using the endoscopic CO2 laser to divide the

tissue bridge are also favorable In one study of

119 patients treated with CO2 laser, there were no

cases of postoperative mediastinitis, and 90% of

patients were asymptomatic at 1-to 3-year

follow-up.52 Nyrop reported on 61 patients

endoscopi-cally treated with the CO2 laser.53 Eight percent

had postoperative emphysema in the neck and

3% of patients developed evidence of

mediastini-tis; all of the latter were successfully treated with

antibiotics and nasogastric feeding Ninety-two

percent of patients were satisfi ed with the result,

and 70% were asymptomatic at a median

follow-up of 37 months

40.2.4 Open Verus Endoscopic Approaches:

Retrospective Studies

Seventy-fi ve percent of surgeons perform fewer

than three operations for Zenker’s diverticulum

per year The choice of open procedure or

endo-scopic stapling varies Endoendo-scopic stapling is the

procedure of choice among 83% of British

sur-geons but is less commonly performed in the

United States.54 Otolaryngologists are more likely

to favor endoscopic stapling

Unfortunately, there is no randomized,

con-trolled trial of open procedures versus endoscopic

stapling for Zenker’s diverticulum There have

been a number of retrospective studies directly

comparing the results of the two techniques Several literature reviews from 1990–2002 have been conducted specifi cally comparing open to endoscopic procedures for Zenker’s diverticulum,

as seen in Table 40.3.55–61 Endoscopic stapling has

a shorter operative duration, lower complication rate, lower mortality rate, shorter hospital stay, and shorter time to oral intake than open proce-dures Both endoscopic stapling and open proce-dure patients provide good relief of symptoms However, long-term follow-up is lacking for endoscopic stapling, whereas open procedures have known, durable results Furthermore, recent studies of open procedures using endoscopic sta-plers have demonstrated hospital stays of 2 days, rivaling that for endoscopic stapling.14

40.3 Recurrent Zenker’s Diverticulum

Re-operative diverticulectomy and myotomy for recurrent Zenker’s diverticulum following a failed open procedure is typically successful, albeit with a higher mortality and morbidity rate Huang (1984) reported on open diverticulectomy for 31 recurrent patients.62 Six of 31 developed a postoperative fi stula, and altogether 35% patients had postoperative complications Of 28 evaluable patients, 27 had a good to excellent result Payne (1992) reported a mortality of 3% and a morbidity

of 51% in a large series of patients undergoing redo open operation.63

OR (min) LOS (days) Complications (%) Mortality (%) Successa

(%)

Study (year) Operation No Open Endoscopic Open Endoscopic Open Endoscopic Open Endoscopic Open Endoscopic

Van Eeden 55 (1999) O vs ES 37 na na 4.0 2.3 23 6 0 0 70 88 Zbaren 60 (1999) O vs D 97 na na 11.4 8 15 6.4 1.5 0 94 97 Smith 56 (2002) O vs ES 16 88 25 5.2 1.3 0 6 0 0 100 100 Mirza 57 (2002) O vs ES 43 na na 8.5 3.0 13 15 0 0 91 55 Zaninotto 58 (2003) O vs ES 58 80 20 9 5 9 0 0 0 100 87 Safdar 59 (2004) O vs ES 19 105 25 10 3.9 22 0 0 0 100 100 Chang 61 (2004) O vs D 49 107 47 5 4 14 8 0 0 100 90 Total/average 319 95 29 7.6 3.9 13.7 5.9 0.2 0 94 88

Abbreviations: D, majority of endoscopic patients having Dohlman procedure; Endo, endoscopic procedure; ES, majority of endoscopic patients having endoscopic stapling; LOS, length of hospital stay postoperatively; na, not applicable; O/open, open diveticulectomy and myotomy group; OR, operating room.

a

Success defined as good-to-excellent result with either no symptoms or improved symptoms postoperatively.

40 Management of Zenker’s Diverticulum: Open Versus Transoral Approaches 329

Scher published the outcomes of 18 patients

with recurrent Zenker’s diverticulum treated

opera-tion was an open procedure in nine cases and

endoscopic stapling in nine cases There were no

perioperative complications and all patients were

discharged by postoperative day 2 Symptom

relief occurred in 16 of 18 patients

40.4 Conclusions

Based on our review, the following observations

can be made65:

1 Both open and endoscopic approaches

provide equivalent early results in experienced

grade B)

2 Since longer follow-up is available with the

open approach, it remains the standard However,

intermediate follow-up of endoscopically treated

patients with stapling and longer term follow-up

with the Dohlman procedure suggest similar

out-comes Endoscopic approaches may eventually

prove to be preferable in the majority of patients,

especially the elderly, with medium-sized

pouches Complications are minimal, and relief

of symptoms is high Patients who have

limita-tion of neck extension, retrognathia, goiters, or

other exposure problems prohibiting stapler use

may undergo either an open procedure or

endo-scopic laser treatment depending on the surgeon’s

preference and skill (level of evidence 2++;

rec-ommendation grade B)

3 Patients with a small diverticulum, less

4 Patients who develop a mucosal tear during

endoscopic stapling may be repaired

endoscopi-cally, treated conservatively, or converted to an

open procedure depending on the particular

clinical circumstance (level of evidence 2++;

rec-ommendation grade B)

5 Patients with recurrent pouch after

previ-ous open procedure are probably best approached

by endoscopic stapling given the high

com-plication rate associated with redo open

proce-dures (level of evidence 3; recommendation

grade D)

6 Patients with suspected cancer in the pouch based on symptoms, barium studies, or endos-copy should undergo open diverticulectomy and myotomy (level of evidence 3; recommendation grade D)

Both open and endoscopic approaches provide equivalent early results in experienced hands

B)

Patients with a small diverticulum (<2cm) should undergo open myotomy (level of evi-

Patients with a recurrent pouch after ous open procedure are best approached by endoscopic stapling (level of evidence 3; rec-ommendation grade D)

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