What is the management of a leak following transcervical Zenker's (esophageal) diverticulectomy?

From the Guidelines

Management of a leak following transcervical Zenker diverticulectomy requires prompt intervention with endoscopic internal drainage (EID) using double pigtail stents, as it has a high success rate and lower complications compared to other methods. Initial management should include NPO (nothing by mouth) status, broad-spectrum antibiotics (such as piperacillin-tazobactam 4.5g IV every 8 hours or a combination of ceftriaxone 2g daily and metronidazole 500mg IV every 8 hours), and nutritional support via nasogastric feeding tube or parenteral nutrition. Small leaks may be managed conservatively with these measures, while larger leaks often require endoscopic intervention. EID using double pigtail stents has been shown to be effective in managing leaks, with success rates ranging from 78 to 86% 1. This technique involves deploying one or more plastic double pigtail stents through the leak orifice to internally drain any extra-luminal fluid collection and promote secondary healing.

Some key points to consider in the management of leaks following transcervical Zenker diverticulectomy include:

• The use of EID with double pigtail stents as a first-line treatment for leaks, due to its high success rate and lower complications compared to other methods 1
• The importance of close monitoring for signs of mediastinitis, sepsis, or abscess formation, as these complications can be life-threatening
• The need for imaging studies such as a contrast swallow study or CT scan with oral contrast to assess the size and location of the leak
• The use of broad-spectrum antibiotics and nutritional support via nasogastric feeding tube or parenteral nutrition to prevent contamination of surrounding tissues and promote healing of the surgical site
• The potential need for repeated endoscopic procedures to manage the leak and prevent complications, as the sponge needs to be changed every 3 to 5 days and leak closure might be more difficult to achieve with intra-luminal EVT alone 1

In terms of specific techniques, EID using double pigtail stents has been shown to be effective in managing leaks, and endoscopic septotomy is a novel approach that can be used to facilitate internal drainage of refractory leaks and fistulae 1. However, direct leak closure with endoscopic suturing system is still a relatively new approach and requires further studies to confirm its long-term efficacy 1. Overall, the management of leaks following transcervical Zenker diverticulectomy requires a multidisciplinary approach and close monitoring to prevent complications and promote healing.

From the Research

Management of Leak Following Transcervical Zenker Diverticulectomy

• The management of leak following transcervical Zenker diverticulectomy is a critical aspect of the procedure, as it can lead to significant complications, including infection, abscess formation, and mediastinitis 2.
• A study published in 2018 found that two major complications (4.5%) requiring surgical intervention occurred, including leak and hematoma, in patients who underwent open diverticulectomy for Zenker diverticulum 2.
• Another study published in 2023 found that patients who had previous endoscopic or surgical therapy for Zenker's diverticulum had a higher number of complications, including stapler line leakage, wound infections, and operative revision rate, compared to those who underwent primary open surgery 3.
• The study also found that pretreatment remained a significant independent predictor of complications in multivariate analysis, suggesting that previous therapy may increase the risk of complications in subsequent surgical procedures 3.

Surgical Techniques and Outcomes

• A systematic review and network meta-analysis published in 2021 compared three common surgical techniques for Zenker diverticulum: endoscopic laser-assisted diverticulotomy, endoscopic stapler-assisted diverticulotomy, and transcervical diverticulectomy with cricopharyngeal myotomy 4.
• The study found that the open approach showed a statistically lower likelihood of persistent or recurrent symptoms following treatment compared to the endoscopic techniques 4.
• Another systematic review and meta-analysis published in 2019 found that any method of surgical intervention yields a large effect in improving dysphagia and regurgitation symptoms in patients with Zenker diverticulum, but did not prove that open diverticulectomy has superior outcomes compared to endoscopic techniques 5.

Complications and Risk Factors

• A study published in 2015 found that cricopharyngeal myotomy with diverticulopexy/diverticulectomy and transoral endoscopic stapling are both safe and effective treatments for Zenker's diverticulum, but that age alone should not be the main criterion for choosing the treatment option 6.
• The study also found that surgical repair is effective for all sizes of diverticula, but that its most serious complications, such as leakage or laryngeal nerve injury, should be considered, especially in elderly patients with comorbidities 6.