title: Zenker's diverticula: feasibility of a tailored approach based on diverticulum size.
abstract: BACKGROUND
  Zenker's diverticula (ZD) can be treated by transoral diverticulostomy or open surgery (upper esophageal sphincter myotomy and diverticulectomy or diverticulopexy). The aim of this study was to compare the effectiveness of a minimally invasive (group A) versus a traditional open surgical approach (group B) in the treatment of ZD.
  
  
  METHODS
  Between 1993 and September 2007, 128 ZD patients underwent transoral diverticulostomy (n = 51) or cricopharyngeal myotomy and diverticulectomy or diverticulopexy (n = 77). All patients were evaluated for symptoms using a detailed questionnaire. Manometry recorded upper esophageal sphincter (UES) pressure, relaxations, and intrabolus pharyngeal pressure. The size of the pouch was measured on the barium swallow. The choice of treatment was based on the size of the diverticulum and the patients' preference. Long-term follow-up data were available for 121/128 (94.5%) patients with a median follow-up of 40 months (interquartile range, 17-83).
  
  
  RESULTS
  Mortality was nil. Three patients in group A (5.8%) and ten in group B (13%) had postoperative complications (p = n.s.). Hospital stays were markedly shorter for patients after diverticulostomy (p < 0.01). Postoperative manometry showed a reduction in UES pressure, improved UES relaxation, and lower intrabolus pressure in both groups (p < 0.05). Four patients in the open surgery group (5.2%) complained of severe dysphagia after surgery (three of them required endoscopic dilations). In the transoral diverticulostomy group, 11 patients (21.5%) required additional septal reduction (n = 8) or a surgical myotomy (n = 3) for persistent symptoms (p < 0.01); nine of these 11 patients had a ZD < or = 3 cm in size. After primary and complementary treatments, symptoms disappeared or improved significantly at long-term follow-up in 93.5% of patients in group A and 96% of those in group B.
  
  
  CONCLUSIONS
  Diverticulostomy is safe, quick, and effective for most patients with medium-sized ZD, but open surgery offers better long-term results as a primary treatment and should be recommended for younger, healthy patients, especially those with small diverticula. Small ZD may represent a formal contraindication to the transoral approach because an excessively short septum prevents a complete division of the sphincter fibers.
authors.affiliation: Istituto Oncologico Veneto IOV-IRCCS, Padua, Italy.
authors.forename: Christian
authors.initials: C
authors.lastname: Rizzetto
authors.forename: Giovanni
authors.initials: G
authors.lastname: Zaninotto
authors.forename: Mario
authors.initials: M
authors.lastname: Costantini
authors.forename: Raffaele
authors.initials: R
authors.lastname: Bottin
authors.forename: Elena
authors.initials: E
authors.lastname: Finotti
authors.forename: Lisa
authors.initials: L
authors.lastname: Zanatta
authors.forename: Emanuela
authors.initials: E
authors.lastname: Guirroli
authors.forename: Martina
authors.initials: M
authors.lastname: Ceolin
authors.forename: Loredana
authors.initials: L
authors.lastname: Nicoletti
authors.forename: Alberto
authors.initials: A
authors.lastname: Ruol
authors.forename: Ermanno
authors.initials: E
authors.lastname: Ancona
mesh_terms: D000368:Aged; D016009:Chi-Square Distribution; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008297:Male; D008365:Manometry; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D011183:Postoperative Complications; D018709:Statistics, Nonparametric; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D016672:Zenker Diverticulum / Q000175:diagnosis / Q000473:pathology / Q000601:surgery*