Transoral Laser-Assisted Diverticulectomy: Swallow Study Results after Complete Endoscopic Pouch Excision for Zenker’s Diverticulum

Abstract

Objective:

Transoral endoscopic laser-assisted diverticulotomy (TELD) with diverticulectomy and diverticuloplasty (TELD + DD) for the management of Zenker’s diverticulum (ZD) has been utilized by our institution since 2016 in attempts to reduce residual pouch size. This technique involves complete endoscopic pouch excision with partial advancement of mucosal flaps. Our study compares the subjective outcomes, objective outcomes, and complication rates between TELD and TELD + DD.

Methods:

A retrospective cohort study was performed on patients who underwent TELD or TELD + DD by a single surgeon at a tertiary academic center (2013-2019). Videofluoroscopic swallow studies (VFSS) with esophagram, Eating Assessment Tool (EAT-10), Reflux Symptom Index (RSI), and Functional Outcome Swallowing Scale (FOSS) were collected at preoperative and 3 month follow-up visits. A single blinded reviewer recorded height, width, and depth of pre and postoperative pouches with volumetric analysis performed assuming an ellipsoid shape. Comorbidities, complications, postoperative course, and recurrence were recorded.

Results:

Of the 75 patients that met criteria, 27 underwent TELD + DD and 48 underwent TELD. Eighteen TELD + DD and 37 TELD had both pre and post-operative VFSS. TELD + DD and TELD had a 96 ± 7% and 87 ± 16% reduction in pouch volume, respectively (t-test; P = .01). Complications (TELD + DD 7%, TELD 17%, fisher’s exact; P = .31) and final subjective outcomes after adjusting for initial were not significantly different between methods (EAT-10 with TELD + DD ∆ + 1.3, P = .18; RSI ∆ + 1.4, P = .29; FOSS ∆-0.02, P = .91). One short-term recurrence was reported with TELD.

Conclusion:

Use of TELD + DD is associated with a statistically significantly decreased residual pouch size with no significant difference in short-term subjective outcomes. Complication rates and short-term recurrence rates are comparable. Long-term recurrence rates will require further studies to characterize.

Level of Evidence:

Level 3.

Keywords

swallowing/dysphagia Zenker’s diverticulum dysphagia surgery imaging

Introduction

Zenker’s diverticulum is the most common type of hypopharyngeal diverticulum and results from the herniation of mucosa and submucosa between the cricopharyngeal muscle and inferior constrictor muscle in an area of anatomical weakness described as the Killian triangle.¹ Symptomatic diverticulum will typically present with dysphagia, globus pharyngeus, halitosis, regurgitation, cough, choking, and aspiration.² It has been shown that Zenker’s diverticulum causes significant impairment in patients’ quality of life and has the potential to lead to more severe sequalae such as aspiration pneumonia or deterioration of pulmonary function.^1,3 Because of this, surgical management is warranted in many patients with symptomatic Zenker’s diverticulum.

Surgical management can be completed with either an open transcervical or an endoscopic transoral approach. Open approach, endoscopic stapler diverticulotomy and endoscopic laser-assisted diverticulotomy have been widely adapted by otolaryngologists for treatment of Zenker’s diverticulum. Between these 3 approaches, there is significant variation in recurrence rates, postoperative complications, hospital stay, operative time and size of residual wall.^4-6 Traditionally, endoscopic laser-assisted diverticulotomy involves a transoral exposure of the cricopharyngeal bar using a diverticuloscope and division of the cricopharyngeus muscle fibers using CO2 laser. This was first described in 1981 by Dr. Van Overbeek, and was initially not readily accepted due to concerns for mediastinitis, pneumothorax and bleeding.^4,6 However, multiple studies since its adoption have demonstrated this as a safe and effective approach to Zenker’s diverticulum.^5,7

In 2010, Mortensen et al⁸ introduced the transoral resection of the remaining diverticula after performing a cricopharyngeal myotomy for small Zenker’s diverticulum (<3 cm). This is described as eversion of the residual pouch into the operating view and sharply removing the pouch with cold instrumentation. The remaining mucosa is then sutured endoscopically and fibrin sealant is placed. Since 2016, our senior author has utilized a somewhat similar technique without suturing described as transoral endoscopic laser-assisted diverticulotomy (TELD) with diverticulectomy and diverticuloplasty (TELD + DD) in attempts to reduce residual pouch with hypothesized improvement in objective swallow study results.

Anecdotally, it has been noted by both our senior author and radiology colleagues that postoperative imaging studies have demonstrated a dramatic improvement in residual pouch size when utilizing TELD + DD in comparison to TELD (Figure 1A-D). Our main objective in this study is to confirm this finding with an objective volumetric analysis of the postoperative pouch with secondary aims to compare subjective swallow outcomes, complication rates and recurrence rates for TELD versus TELD + DD. To our knowledge, this is the first study to perform a volumetric analysis to objectively compare surgical techniques in the management of Zenker’s diverticulum.

Materials and Methods

A retrospective cohort study (IRB 18-011152) was performed of all patients who underwent TELD or TELD + DD by a single surgeon (D.C.E.) at Mayo Clinic (Rochester, MN) between the years 2013 and 2019. Inclusion criteria included patients with preoperative evaluation by our senior surgeon that demonstrated a Zenker’s diverticulum on videofluoroscopic swallow studies (VFSS) and had surgical intervention within 3 months of initial evaluation. We identified 75 patients that met criteria, including 48 TELD and 27 TELD + DD. VFSS with esophagram, Eating Assessment Tool (EAT-10),⁹ Reflux Symptom Index (RSI),¹⁰ and Functional Outcome Swallowing Scale (FOSS)¹¹ were collected at preoperative and 3 month follow-up visits. Comorbidities, complications, post-operative course, and recurrence were recorded. Return of symptoms occurring within 1 year was considered short-term recurrence and those that returned beyond 1 year was defined as a long-term recurrence.

Fifty five patients (37 TELD, 18 TELD + DD) included in our swallow study analysis had pre and post-operative (3 months) VFSS with esophagram. A single blinded reviewer recorded height, width, and depth of pre and post-operative pouch (Figure 2A and B). Due to inconsistent measurement techniques from outside swallow studies, internal standardization was performed based off of the adjacent vertebral body. This resulted in relative measurements, not absolute, with pre and post-operative analysis being performed as a % change. Volumetric analysis was performed assuming an ellipsoid shape ( $V = \frac{4}{3} π a b c$ ), in which volume (V) is calculated utilizing height (a), width (b), and depth (c) of the pouch (Figure 2A and B). Figure 2A demonstrates the width of the pouch, whereas Figure 2B demonstrates the height (short axis) and the depth (long axis) of the pouch.

TELD is performed by exposing the cricopharyngeal bar with a Dohlman diverticuloscope (Figure 3A) and dividing the cricopharyngeal muscle in an anterior/posterior direction down to the level of the buccopharyngeal fascia with line of sight CO2 laser and operating microscope (Figure 3B). The addition of a diverticulectomy and diverticuloplasty (DD) involves extending the mucosal cut along the midline posterior wall of the pouch and then lasered laterally at the top of the pouch, followed by eversion of the posterolateral pouch mucosa into the operative view and removal of this pouch mucosa down to the buccopharyngeal fascia with the CO2 laser (Figure 3C). The lateral mucosa is laid in place with partial advancement leaving a space of buccopharyngeal fascia that is covered with fibrin sealant utilizing a 30 cm endoscopic applicator. (Figure 3D). No endoscopic sutures are placed. Patients are advanced to a soft diet for 1 week after surgery and placed on a 7-day course of prophylactic antibiotics. Placement of a nasogastric tube was reserved for patient with evidence of pneumomediastinum. VFSS was obtained pre-operatively and at 3 months postoperative follow up.

Statistical analysis was performed by the Mayo Clinic Division of Biomedical Statistics and Informatics. Descriptive data are reported as mean ± standard deviation (SD) plus range, or as count (percent). Baseline characteristics were compared between surgical groups with 2-sample t-tests and chi-square or Fisher’s exact tests. Two-sample t-tests and Fisher’s exact tests were performed on swallow study objective measurements between TELD and TELD + DD. Paired t-tests were utilized for pre/post subjective measurement comparisons within a surgery type. Pearson correlations were calculated between the 3 post-op subjective measures and the percent pouch volume change. Multiple variable model linear regression was performed on subjective swallow surveys and objective volume change, adjusting for baseline value, for the surgical technique effect. Post-operative complications and recurrences were compared using a Fisher’s exact test. Statistical significance was accepted at the 2-sided .05 significance level. SAS v9.4 (SAS Institute Inc, Cary, NC) was used for all analyses.

Results

Between January 2013 and January 2019, 89 TELD or TELD + DD procedures were performed by our senior author. Of the 89 procedures, 75 were unique patients who consented to research authorization, and had sufficient post-operative data to be included in the study. Of the 75 patients that met criteria, 27 underwent TELD + DD and 48 underwent TELD, of whom 18 and 37 respectively had both pre and post-operative swallow studies. There was no statistically significant difference in patient demographics between the 2 groups as shown in Table 1.

Table 1.

Patient Demographics.

	TELD (n = 48)	TELD + DD (n = 27)	P values
Age
Mean (SD)	74.9 (9.7)	73.3 (9.7)	.48^†
Range	53.2-90.2	50.6-91.1
Sex
Male	24 (50%)	18 (67%)	.16^‡
Female	24 (50%)	9 (33 %)
BMI
Mean (SD)	27.0 (4.6)	28.6 (5.4)	.17^†
Range	18.1-45.1	19.9-40.6
GERD
No	25 (52%)	11 (41%)	.35^‡
Yes	23 (48%)	16 (59%)
GERD medication
No	27 (56%)	11 (41%)	.20^‡
Yes	21 (44%)	16 (59%)
Smoking history
No	26 (54%)	18 (67%)	.29^‡
Yes	22 (46%)	9 (33%)
Prior Zenker’s surgery
No	41 (85%)	24 (89%)	1.00^§
Yes	7 (15%)	3 (11%)

Note. Quantitative data presented as mean (SD) and qualitative data presented as N (%).

Abbreviations: TELD, transoral endoscopic laser-assisted diverticulotomy; TELD + DD, transoral endoscopic laser-assisted diverticulotomy with diverticulectomy and diverticuloplasty; GERD, gastric esophageal reflux disease; BMI, body mass index.

†

Two-sample t-test.

‡

Chi-square test.

Fisher’s exact test.

There was no significant difference in preoperative swallow survey scores between TELD and TELD + DD (Table 2). Both TELD and TELD + DD had statistically significant improvement in their respective pre and postoperative EAT-10, RSI, and FOSS scores as shown in Table 2. There was no difference in the postoperative improvement when comparing TELD to TELD + DD (EAT-10 with TELD + DD ∆ + 1.3, P = .18; RSI ∆ + 1.4, P = .29; FOSS ∆ − 0.02, P = .91) as demonstrated in Table 3. There was no significant correlation between postoperative subjective survey scores and reduction in pouch volume. (EAT-10, R = .25; RSI, R = .19; FOSS, R = .55).

Table 2.

Subjective Swallow Scores.

	EAT-10			RSI			FOSS
	Pre	Post	P values	Pre	Post	P values	Pre	Post	P values
TELD	18.5 (9.2)	1.5 (3.1)	<.001^†	23.8 (9.6)	4.3 (4.5)	<.001^†	2.0 (1.0)	0.3 (0.7)	<.001^†
TELD + DD	14.3 (9.0)	2.5 (3.9)	<.001^†	19.3 (10.0)	5.4 (6.3)	<.001^†	1.9 (0.7)	0.3 (0.6)	<.001^†
P	.06^†	.29^†		.07^†	.48^†		.8^†	.94^†

Note. Quantitative data presented as mean (SD) and qualitative data presented as N (%).

Abbreviations: TELD, Transoral endoscopic laser-assisted diverticulotomy; TELD + DD, transoral endoscopic laser-assisted diverticulotomy with diverticulectomy and diverticuloplasty; EAT-10, eating assessment tool; RSI, reflux symptom index; FOSS, functional outcome swallowing scale.

†

Two-sample t-test.

Table 3.

Postoperative Subjective Swallow Score Changes.

	TELD	TELD + DD	P values
ΔEAT-10	17.5 (8.5)	14.3 (8.6)	.18^†
ΔRSI	19.5 (9.4)	16.5 (8.0)	.29^†
ΔFOSS	1.7 (1.1)	1.8 (0.6)	.91^†

Note. Quantitative data presented as mean (SD).

Abbreviations: TELD, transoral endoscopic laser-assisted diverticulotomy; TELD + DD, transoral endoscopic laser-assisted diverticulotomy with diverticulectomy and diverticuloplasty; EAT-10, eating assessment tool; RSI, reflux symptom index; FOSS, functional outcome swallowing scale.

†

Multiple variable linear regression.

TELD + DD and TELD had a 96 ± 7% and 87 ± 16% reduction in pouch volume, respectively (t-test, P = .006) as shown in Table 4. All of the individual dimensions (height, depth, width) individually were also statistically different. Fourteen (78%) of the 18 TELD + DD had complete (≥98% reduction) pouch excision in comparison to 17 (46%) of 37 TELD patients showing no residual pouch (Fisher’s exact, P = .04). As shown in Table 5, multiple variable analysis demonstrated that surgical technique and prior surgery had an effect on postoperative volumetric change (multiple variable linear regression, P < .05). When controlling for prior surgery, there was no change on the effect size or statistical significance between utilization of the new technique with volume size.

Table 4.

Volumetric Swallow Study Analysis.

	TELD (n = 37)	TELD + DD (n = 18)	P values
Mean volume reduction (%)	87.4 (15.9)	96.4 (7.2)	.01^†
Range	39.7-100	74.6-100
Mean height reduction (%)	67.9 (34.4)	83.4 (25.6)	.04^†
Range	−13.5 to 100	24.9-100
Mean depth reduction (%)	63.1 (35.0)	85.1 (20.1)	.02^†
Range	−1.5 to 100	43.2-100
Mean width reduction (%)	54.9 (41.9)	83.1 (31.5)	.02^†
Range	−10.3 to 100	3.5-100
Complete pouch excision/residual pouch			.04‡
Yes	17 (46%)	14 (78%)
No	20 (54%)	4 (22%)

Note. Quantitative data presented as mean (SD) and qualitative data presented as N (%).

Abbreviations: TELD, transoral endoscopic laser-assisted diverticulotomy; TELD + DD, transoral endoscopic laser-assisted diverticulotomy with diverticulectomy and diverticuloplasty.

†

Two-sample t-test.

‡

Fisher’s exact test.

Table 5.

Volumetric Multivariable Model.

	Volume reduction (%)	P values
Prior surgery	10.0 (2.2)	.01^†
Surgical technique	3.7 (1.7)	.03^†
GERD	1.4 (1.6)	.37^†
BMI	0.2 (3)	.44^†

Note. Volume reduction presented as β (SD).

Abbreviations: GERD, gastric reflux disease; BMI, body mass index.

†

Multiple variable linear regression.

Eight (17%) of 48 TELD patients had postoperative crepitus compared to 2 (7%) of 27 TELD + DD (Fisher’s exact, P = .31) as shown in Table 6. In the TELD group, 6 patients had minimal crepitus just present at the anterior neck over the thyroid cartilage and 2 patients had more extensive crepitus with pneumomediastinum on imaging. Both patients in the TELD + DD group had more extensive crepitus with pneumomediastinum on imaging. There was no significant difference in discharge day or return to PO diet for patients with pneumomediastinum between TELD and TELD + DD as shown in Table 4. There were no episodes of mediastinitis, postoperative intubation, or death in either group. One patient in the TELD group required intensive care unit admission. One patient in the TELD group had hemoptysis 1 week out from surgery which did not require operative intervention. No postoperative hemorrhage was observed in either group. Mean operative times for TELD and TELD + DD were 76.8 and 78.6 minutes, respectively (t-test, P = .82).

Table 6.

Postoperative Complications.

	TELD	TELD + DD	P
Crepitus
Yes	8 (16.7%)	2 (7.4%)	.31^†
Mild Crepitus	6 (12.5%)	0
Return to PO (postop day)	1 (0)	—
Discharge (postop day)	1.4 (1)	—
Severe crepitus (pneumomediastinum)	2 (4.2%)	2 (7.4%)
Return to PO (postop day)	12.5 (1.5)	12.5 (2.5)
Discharge (postop day)	3 (2)	4 (1)
No	40 (83.3%)	25 (92.6%)
Mediastinitis	0	0
Intubation	0	0
ICU transfer	1 (2.0%)	0
Death	0	0

Note. Qualitative data presented as N (%).

TELD, transoral endoscopic laser-assisted diverticulotomy; TELD + DD, transoral endoscopic laser-assisted diverticulotomy with diverticulectomy and diverticuloplasty.

†

Fisher’s exact test.

One patient who underwent TELD had a short-term recurrence 5 months after surgery. This patient had 2 previous endoscopic stapler procedures done at an outside institution. After TELD procedure at our institution, she returned with recurrent subjective dysphagia and residual pouch on repeat swallow study. Revision TELD + DD was performed and patient has not had return of symptoms 3.5 years out from surgery. One patient who underwent TELD had a long-term recurrence 3.0 years after revision surgery. The patient had 2 previous rigid endoscopic procedures at an outside institution prior to TELD at our institution. Although repeat swallow study demonstrated residual pouch, patient’s dysphagia was mild to moderate and they elected observation. There were no short term or long term recurrences in the TELD + DD group.

Discussion

Transoral endoscopic laser-assisted diverticulotomy with diverticulectomy and diverticuloplasty (TELD + DD) has been utilized by our senior author in order to remove the residual pouch in an effort to improve subjective swallowing outcomes and decrease recurrence rates. Traditionally, the open transcervical approach to a Zenker’s diverticulum has the advantage of complete diverticulum excision (diverticulectomy) in comparison to historic transoral techniques that focus on the division of the cricopharyngeus muscle and common wall between the cervical esophagus and the diverticulum (diverticulotomy).^12,13 Transcervical approaches have been shown to have longer operative time, hospital stay, and external scar, however this approach has reduced recurrent dysphagia and revision rates in comparison to transoral endoscopic approaches.^13,14 Endoscopic excision of the diverticula after cricopharyngeal myotomy, as previously described by Mortenson and Junlapan,^8,13 combine the advantages of endoscopic approaches while attempting to decrease the residual pouch size. Both techniques combine endoscopic cricopharyngeal myotomy followed by medial retraction of the pouch and excision using either cold instrumentation (Mortenson) or CO2 laser (Junlapan). Mucosal flaps are then reapproximated and closed with endoscopic suturing technique. Our technique involves reapproximation of mucosal flaps with fibrin glue, excluding the endoscopic suturing.

Subjective Outcomes

Swallowing surveys after both TELD and TELD + DD demonstrated substantial improvement in subjective swallowing scores. Both groups demonstrated statistically significant improvement in their postoperative EAT-10, RSI, and FOSS. Our study did not demonstrate any short term difference in the improvement of EAT-10, RSI, and FOSS scores between TELD and TELD + DD. This is consistent with the results of Junlapan et al¹³ which demonstrated improved EAT-10 and RSI postoperatively for their endoscopic pouch excision technique. Their study did not compare the change in pre and postoperative scores between endoscopic CO2 pouch excision, endoscopic stapler, or transcervical technique.¹³ In our study, there was no correlation found between pouch reduction seen on postoperative swallow study and subjective swallow questionnaires. This is similar to findings by Shah et al who demonstrated a poor correlation between EAT-10 surveys and postoperative party wall length.⁴ Our study confirms that the both the traditional TELD and our modified technique TELD + DD significantly improve patient’s subjective swallowing outcomes.

Objective Outcomes

Our study demonstrates that TELD + DD has statistically significant decreased residual pouch size in comparison to TELD with a mean postoperative reduction of 96 ± 7% and 87 ± 16%, respectively. Residual diverticular pouch on postoperative barium swallow is a common radiologic finding after traditional endoscopic approaches to Zenker’s diverticulum.¹⁵ As described by Hadley et al,¹⁵ there are distinct patterns on postoperative imaging that suggest successful endoscopic procedure in light of a residual pouch. These include smooth flow of transition of barium down esophagus, height of barium contained in residual pouch and height of the remaining party wall. In our study, 78% of patients who underwent TELD + DD had complete pouch excision with smooth flow of barium down into the esophagus, no residual barium in the pouch and no remaining party wall. This is in comparison to 46% of patients in the TELD group.

In the study by Shah et al,⁴ open approaches had a statistically significant decrease in residual party wall size after surgery in comparison to endoscopic approaches, however, this was not correlated with improved subjective outcomes. Van Overbeek¹⁶ in his original paper describing the transoral diverticulotomy argued that the postoperative swallow studies should not be overestimated and that subjective symptomatology should guide the need for revision surgery. Our study provides further evidence that short-term postoperative subjective outcomes cannot be predicted by the findings on video fluoroscopy. Anecdotally, we have not noted improvement in the reported subjective symptomatology at postoperative return visits with the utilization of our new technique. In the Shah et al⁴ study, endoscopic stapler technique had a significantly larger postoperative party wall compared to open and endoscopic laser approaches, and was the only group with recurrent symptoms requiring revision surgery. We theorize that the reduction in residual pouch size will lead to decreased long-term recurrences and delayed return of dysphagia.

On multi-variable analysis, prior surgery negatively impacted the degree of postoperative pouch reduction. However, when controlling for surgical technique, our results demonstrate that postoperative pouch size was not adversely affected by prior surgery for the TELD + DD group. Although studies have demonstrated residual pouch size does not predict functional change, it is possible the more extensive dissection associated with TELD + DD in a revision case is accompanied with a more complete cricopharyngeal myotomy which could have functional implications.¹⁶ Nonetheless, this finding supports the ability to perform TELD + DD in previously operated patients.

Recurrence

In our study we defined recurrence as return of subjective symptoms of dysphagia with confirmation of residual or recurrent pouch on swallow study. Rates of short term recurrence for TELD and TELD + DD were 2.1% and 0%, respectively and long term recurrence rates were 2.8% and 0%, respectively. A recent meta-analysis of 3079 patients demonstrated that endoscopic approaches carry an 18.4% recurrence rate in comparison to 4.2% for open approaches.⁶ Recurrence after surgical management of Zenker’s diverticulum is associated with an incomplete cricopharyngeal myotomy resulting in persistent elevation in hypopharyngeal pressures.¹⁷ The open approach lends itself to complete myotomy and diverticulectomy, however, our modified technique results in a more complete myotomy compared to TELD as the diverticulectomy improves access to the full thickness of the cricopharyngeus muscle. Recurrence rates in studies by Junlapan and Mortenson^8,13 are 5.6% and 16.6%, respectively, although it must be noted the recurrence in Mortenson study was due to esophageal dysmotility and not recurrent diverticulum. The Mortenson study also was limited by smaller sample size and limited follow up, therefore, the true recurrence rate is difficult to interpret. Long-term recurrence rates for TELD + DD will require further studies to characterize as this technique has only been utilized the past 3 years.

Complications

In both diverticulotomy and diverticulectomy, the buccopharyngeal fascia defines the limits of dissection and must be respected in order to prevent communication with deeper neck spaces leading to crepitus and mediastinitis.¹⁶ In theory, the increased dissection involved with TELD + DD would increase risk of buccopharyngeal fascia violation. In our surgeon’s practice, minor crepitus limited to the anterior neck is typically observed without further imaging or nasogastric (NG) tube placement. Lateral crepitus extension prompted further imaging and placement of NG tube for 10 to 14 days. Our study demonstrates patients undergoing TELD + DD were not at increased risk of postoperative complications. The overall crepitus rates were slightly higher in TELD (17%) compared to TELD + DD group (7%), however, rates of extensive crepitus in the form of pneumomediastinum were comparable with TELD (4.2%) and TELD + DD (7.4%). For those patients with extensive crepitus, there was no difference in discharge date or return to PO diet between TELD and TELD + DD. In our cohort of patients, there were no patients with mediastinitis or death. This is in comparison to a meta-analysis of 1060 patients undergoing TELD demonstrating a crepitus rate of 3%, mediastinitis rate of 1.2% and mortality rate of 0.2%.¹⁷ Crepitus rates were not reported in studies by Mortenson and Junlapan, therefore, the absence of endoscopic suturing and its role on crepitus rates cannot be compared. While overall rates of crepitus in our study are elevated compared to others reported in the literature, it is important to note that the majority is limited anterior neck crepitus over the thyroid cartilage that was observed without any clinical significance or delays in discharge. It is our suspicion that this crepitus is under reported in the literature.

Limitations

One of the limitations of our study is the lack of long term follow up. The majority of the patients in the study returned to clinic 3 months postoperatively with repeat EAT-10, RSI, FOSS, and video swallow study with esophagram, however, there is little patient data beyond that 3 months visit. It is possible that patients had recurrences and sought out medical care at a different facility. Future studies could include mail-out surveys or phone interviews; however, repeating objective data would be quite difficult. Another limitation is the inability to quantify the size of the Zenker’s pouch pre and postoperatively. Our results were internally standardized and we could only report the percent decrease in pouch size compared to preoperative. This is due to the large number of outside preoperative imaging studies that lacked standardized measurements. In Mortenson et al study, they recommend utilizing their technique when the Zenker’s pouch is <3 cm. Our surgeon utilizes this technique for all transoral Zenker’s diverticulum, and due to the lack of size measurements, we are unable to comment on what size pouch this technique is most beneficial for. Finally, as an academic institution with trainees, the mean operative time is likely an inaccurate depiction of operative time. Anecdotally, the addition of diverticulectomy with diverticuloplasty adds approximately 10 minutes to a surgical case.

Conclusion

The transoral endoscopic laser-assisted diverticulotomy with diverticulectomy and diverticuloplasty combines the advantages of transoral and transcervical approaches to Zenker’s diverticulum. Our study demonstrates that this is a safe technique with improved objective swallow study outcomes. Although TELD and TELD + DD both demonstrated significant improvement in pre and postoperative subjective swallow surveys, there was no difference in the postoperative swallow surveys between the 2 groups.

Footnotes

Authors’ Note

Abstract originally accepted for poster presentation at American Broncho-Esophagological Association Annual Meeting 2020 (April 22nd-24th, 2020, Atlanta, Georgia). Due to cancellation of event, abstract presented as part of Combined Otolaryngology Spring Meeting 2020 Virtual Poster Session (May 15th-June 15th, 2020).

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ryan A. McMillan

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