title: Evolving Management of Zenker's Diverticulum in the Endoscopic Era: A North American Experience.
abstract: BACKGROUND
  Open surgical cricopharyngeal myotomy(CM) is considered standard of care for Zenker's diverticulum(ZD). Trans-oral CM has been described using a rigid stapling device for two decades; however, this remains problematic for severely kyphotic patients. This problem can be overcome with flexible endoscopy utilizing an electrosurgical needle knife. We sought to compare clinical outcomes between these techniques to stratify patient selection.
  
  
  METHODS
  Patients undergoing ZD treatment from 1992 to 2015 were reviewed. Demographics, diverticulum size, post-operative complications, and length of stay (LOS) were compared between open cricopharyngeal myotomy (OpenCM), rigid trans-oral stapling myotomy (RigidCM), and flexible endoscopic myotomy (FlexCM). Dysphagia scores (DS, 0:best-4:worst) and pneumonia incidence were assessed pre-operatively and post-operatively.
  
  
  RESULTS
  62 patients underwent OpenCM (39/62(63 %)) or endoscopic CM (23/62(37 %) (8 RigidCM/15 FlexCM)). CM significantly reduced dysphagia for all approaches [OpenCM:2(2-3)-0(0-0); RigidCM:2(2-2)-0(0-0); FlexCM:3(3-3)-0(0-0)]. FlexCM patients had significantly worse pre-operative DS. Endoscopic CM was attempted and completed in 23/35(66 %) patients. Reasons for OpenCM conversion included inability to position the diverticular retractor due to patient body habitus (RigidCM), and the inability to position the overtube due to small ZD (FlexCM). Major post-operative complications were rare and similar in all groups. Medium-to-long-term post-myotomy pneumonia was comparable between groups. LOS (days) was reduced for FlexCM (1(1-2)) versus RigidCM (3(2-6)) and OpenCM (4(3-7)).
  
  
  CONCLUSIONS
  CM is highly effective for treating ZD. Open and endoscopic approaches offer comparable outcomes and dysphagia resolution. FlexCM is efficacious for large ZD and can be performed in most patients irrespective of body habitus. FlexCM represents an excellent approach for large ZD, while OpenCM should be reserved for small ZD for which an overtube cannot be positioned.
authors.affiliation: Division of Thoracic, McGill University, Montreal General Hospital, Room L9-112, 1650 Cedar Avenue, Montreal, QC, H3A 1G4, Canada. daniel.jones2@mail.mcgill.ca.
authors.forename: Daniel
authors.initials: D
authors.lastname: Jones
authors.affiliation: Division of Thoracic, McGill University, Montreal General Hospital, Room L9-112, 1650 Cedar Avenue, Montreal, QC, H3A 1G4, Canada.
authors.forename: Abdullah
authors.initials: A
authors.lastname: Aloraini
authors.affiliation: Division of Thoracic, McGill University, Montreal General Hospital, Room L9-112, 1650 Cedar Avenue, Montreal, QC, H3A 1G4, Canada.
authors.forename: Stephen
authors.initials: S
authors.lastname: Gowing
authors.affiliation: Division of Thoracic, McGill University, Montreal General Hospital, Room L9-112, 1650 Cedar Avenue, Montreal, QC, H3A 1G4, Canada.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Cools-Lartigue
authors.affiliation: Division of Thoracic, McGill University, Montreal General Hospital, Room L9-112, 1650 Cedar Avenue, Montreal, QC, H3A 1G4, Canada.
authors.forename: Mara
authors.initials: M
authors.lastname: Leimanis
authors.affiliation: Division of General Surgery, McGill University, Montreal General Hospital, Montreal, QC, Canada.
authors.forename: Roger
authors.initials: R
authors.lastname: Tabah
authors.affiliation: Division of Thoracic, McGill University, Montreal General Hospital, Room L9-112, 1650 Cedar Avenue, Montreal, QC, H3A 1G4, Canada.|Division of General Surgery, McGill University, Montreal General Hospital, Montreal, QC, Canada.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Ferri
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003680:Deglutition Disorders / Q000209:etiology / Q000601:surgery; D019468:Disease Management; D020776:Endoscopes, Gastrointestinal; D004945:Esophagoscopy / Q000379:methods; D005260:Female; D005773:Gastroscopy / Q000379:methods; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D010609:Pharyngeal Muscles / Q000601:surgery*; D011183:Postoperative Complications; D012189:Retrospective Studies; D012720:Severity of Illness Index; D017792:Surgical Stapling / Q000379:methods; D016896:Treatment Outcome; D016672:Zenker Diverticulum / Q000150:complications / Q000175:diagnosis / Q000601:surgery*