xRead - Swallowing Disorders in the Adult Patient (October 2024)
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Zenker Diverticula Surgery Endoscopic or Open
Signs of leak Crepitus, Progressive dysphagia, pain out of proportion • Admission • npo • Order Esophagram
No sign of leak • Discharge, < 23 h observation • Restricted diet 1–2 weeks • No esophagram
No Leak • Discharge, 48 h • Restricted diet 1–2 weeks
Evident leak • Inpatient observation +/– Return to OR • npo, consider NGT • Antibiotics • Repeat Esophagram
Persistent Leak Without signs of mediastinitis or infection • npo with NGT • Antibiotics • Discharge, >48 h, close clinical follow up
Resolved Leak • Discharge, >48 h • Restricted diet 1–2 weeks
Fig. 2. The Prospective OUtcomes in Cricopharyngeus Hypertonicity (POUCH) Collaborative clinical consensus: Postoperative management of Zenker diverticula. NGT = nasogastric tube; npo = nil-per-os; RTOR-return to operating room.
home on restricted diets. Speci fi cally, most patients were sent home with a liquid/pureed (49.8%) or soft (37.9%) diet. Only a small proportion were permitted a full diet at discharge from the hospital. Similarly, 3.2% of patients were sent home with a nasogastric tube and npo restric tion. Not all of these had documented leak, again suggesting some variability of practice patterns in routine postoperative management of ZD. More than two-thirds of all patients in this study had restricted diet for less than 2 weeks. Surgeon preference and complications were themost in fl uential factors on postoperative diet. In 2011, Bock et al. reported that almost half of respondents routinely order contrast esophagography following ZD repair. 6 In contrast, the 2021 ABEA survey by Wang et al. demonstrated a stark increase in that num ber to as high as 70.6% of respondents. 9 In the current study, 22.1% ( n = 61) of the patients had postoperative imaging ordered. Most imaging was obtained based on sur geon preference. Forty-one received imaging either at the time of their admission or within 2 weeks of their surgical repair; 19 (19/41, 46.3%) were obtained for concern for leak. Four of these demonstrated leak. Fourteen patients demonstrated residual pouch in their postoperative imag ing (list of other fi ndings can be found in Supplement 1). Residual diverticula and pouch residue is common in post operative esophagography and has not been demonstrated to correlate with patient symptoms. 8,17 This study demon strates that when leak was suspected, the patients in our cohort got a contrast study. Until 1960 when Dohlman and Mattson fi rst described endoscopic diverticulectomy, the surgical options were limited to open diverticulectomy, diverticulopexy, or inversion techniques. Mantsopoulos et al., in 2012, described 54 patients undergoing open transcervical ZD approach with a complication rate of 20.3% and an
average LOS for diverticulopexy patients of 8.9 compared with the diverticulectomy arm at 11 days. 18 The endo scopic method wasn ’ t popularized until 1982 and has since then demonstrated consistent patterns of postoperative management as compared to the open approach. 19 In 2002, Smith, Genden, and Urken compared both endo scopic and open approaches with ZD in 16 “ randomly selected patients ” showing an increased LOS from 1.3 to 5.2 days (endoscopic vs. open); time to oral intake was also statistically signi fi cant at 0.8 and 5.1 days (endoscopic vs. open). 20 In 2019, Andr asi et al. performed another ret rospective evaluation of 29 patients demonstrated time to po (2.9 vs. 4.6 days) and LOS (7.3 vs. 9.7 days) signi fi cantly favoring the endoscopic approach. 21 Visser et al. in the Rotterdam experience also demonstrated decreased LOS for endoscopic versus open cohorts. 22 However, the differ ences are 2 versus 3 days with a disparate proportion of endoscopic versus open ( n = 75 vs. 6). 22 In this study, there was a statistical difference in LOS in patients undergoing endoscopic versus open approaches to surgery, independent of any perioperative complications. Diet restriction was not changed based on surgical approach in patients without surgical complica tion. Differences in LOS and diet on discharge were evi dent between complicated and uncomplicated cases. Thus, presence of complication may have a larger in fl u ence on postoperative course than surgical approach, though both factors seem to have an impact. The primary limitation to this study is that which is inherent to a non-randomized observational study: man agement decisions were made based solely on surgeon preference. Furthermore, in a multicenter database, the data are limited to those institutions and patients willing to consent to the study, leading to a possible selection bias. Because there are rich data in the free text fi elds,
Laryngoscope 134: June 2024
McKeon et al.: Postop Management of ZD, Contemp. Perspective
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