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Endoscopic Stapling Technique for the Treatment of Zenker Diverticulum vs Standard Open-Neck Technique
A Direct Comparison and Charge Analysis
Shane R. Smith, MD;
Eric M. Genden, MD;
Mark L. Urken, MD
Arch Otolaryngol Head Neck Surg. 2002;128:141-144.
ABSTRACT
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Background Presently, the 2 most widely used methods for the treatment of Zenker
diverticulum are endoscopic stapling of the common party wall between the
diverticulum sac and the esophagus and the standard open-neck technique involving
diverticulectomy and cricopharyngeal myotomy.
Objective To perform an analysis of the hospital charges to determine the economic
efficiency of each technique based on our experience at the Mt Sinai Medical
Center, New York, NY.
Methods A retrospective analysis of 16 patients diagnosed as having Zenker diverticulum
was conducted. Eight randomly chosen patients underwent endoscopic stapling
with an EndoGIA 35-mm endoscopic stapler (Ethicon Inc, Somerville, NJ), and
8 randomly chosen patients underwent a standard open approach with diverticulectomy.
Medical records were reviewed to determine operative time, length of hospital
stay, time to oral intake, and postoperative complications. A charge analysis
of the operative and postoperative fees was also performed. Statistical analysis
between the 2 groups was conducted using analysis of variance and the paired
t test.
Results The mean ± SD operative time for the endoscopic stapling technique
was 25.5 ± 15.78 minutes, which was significantly less (P<.001) than that for the open procedure, 87.6 ± 35.10 minutes.
The mean operative charges were roughly equivalent at $5178 for the endoscopic
procedure and $5113 for the open procedure. The endoscopic procedure, while
shorter in operative time, had the added expense of specialized equipment,
specifically the EndoGIA endoscopic stapler. The mean ± SD length of
hospital stay for the endoscopic procedure was significantly shorter (P<.001) at 1.3 ± 0.59 days vs 5.2 ± 1.03
days for the open procedure. The inpatient hospital charges for the endoscopic
group was also significantly less (P<.001) at
a mean of $3589 per stay vs $11 439 for the open group. The mean ±
SD time to oral intake was significantly shorter (<.001) at a mean of $3589
per stay vs $11 439 for the open group. The mean ± SD time to
oral intake was significantly shorter (P<.001)
in the endoscopic group at 0.8 ± 0.26 days vs 5.1 ± 1.25 days
for the open group. There were no major complications in either group, and
all patients experienced resolution of preoperative symptoms.
Conclusions Compared with the standard open technique, the endoscopic stapling technique
for the treatment of Zenker diverticulum results in a statistically significant
shorter operative time, hospital stay, and time to resume oral feedings. While
the charges of the operative procedures were roughly equivalent, the total
hospital charges were significantly less for the patients treated endoscopically.
INTRODUCTION
ZENKER DIVERTICULUM (ZD) is a specific type of esophageal diverticulum
that results in herniation of esophageal mucosa from an area of muscular weakness,
also known as Killian dehiscence, located between the inferior aspect of the
inferior constrictor muscle and the cricopharyngeus (CP) muscle and is a common
problem facing the head and neck surgeon. Despite some attempts at medical
treatment, in particular, injection of botulinum toxin (Botox; Allergan Inc,
Irvine, Calif) into the CP muscle, the standard treatment today is still surgical.
The surgical approach considered the gold standard is the open diverticulectomy
combined with the CP myotomy. This approach allows for the definitive identification
of the diverticulum and its removal, but is associated with a lengthy hospital
stay and enteral nutrition via a nasogastric tube to allow for healing of
the pharyngotomy wound that is created. In recent years, efforts have been
made to effectively treat ZD with less invasive approaches, including diverticulopexy,
diverticulum imbrication, and endoscopic diverticulum division.
The endoscopic approach was first described by Mosher1
in 1917 and includes division of the septum between the cervical esophagus
and the pouch. This method was eventually abandoned by Mosher because of increased
incidence of complications, particularly, mediastinitis.2
Dohlman and Mattson3 reintroduced the endoscopic
technique in 1960, and since then several reports have been published using
this technique with either electrocoagulation or lasers.4-8
However, continued concerns for potential complications such as bleeding,
perforation, and mediastinitis have limited its use. In 1993, Collard et al9 introduced the endoscopic stapling technique using
an endosurgical stapler that simultaneously divides the wall between the esophagus
and the pouch and staples the wound edges closed. Multiple reports2, 10-13
since then (Table 1) have shown
its efficacy and safety.
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Table 1. Literature Review of Endoscopic Stapling Technique for Repair
of Zenker Diverticulum
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The endoscopic staple-assisted approach has the distinct advantage of
offering a shorter operative time, hospital stay, and time to resume oral
feedings than the traditional open-neck procedure, but no study has conducted
a direct, cost-based analysis of the 2 procedures. The objective of this study
was to (1) directly compare the endoscopic stapling technique and the standard
open technique in terms of operative time, postoperative hospital stay, and
time to oral intake and (2) perform a charge analysis for the 2 procedures.
PATIENTS, MATERIALS, AND METHODS
A retrospective analysis of 16 patients diagnosed as having ZD was conducted.
All 16 patients were operated on by the senior author (M.L.U.). Eight patients
(5 men and 3 women) had undergone the endoscopic stapling technique. Each
patient underwent the same procedure. Following the induction of general endotracheal
anesthesia, a Weerda bivalved laryngoscope (Karl Storz, Tuttlingen, Germany)
was placed into the hypopharynx. The superior blade was placed into the esophagus,
and the inferior blade was placed into the lumen of the diverticulum. Next,
an EndoGIA 35-mm endoscopic stapler (Ethicon Inc, Somerville, NJ) was then
placed through the scope, engaged, and fired, thereby dividing the common
wall between the esophagus and diverticulum. Reapplication of the stapler
was performed as needed for larger diverticula in which a residual portion
of the common party wall was identified. Postoperatively, patients underwent
a barium swallow within the first 24 hours of surgery. If no evidence of a
leak existed, the patient resumed oral feedings (typically liquids, with rapid
advancement to solids).
Eight patients (4 men and 4 women) in the review had undergone the standard
open diverticulectomy and CP myotomy procedure. In this procedure, the diverticulum
was mobilized and its base was stapled. Supplemental sutures were placed as
needed. Following the removal of the diverticulum, the fibers of the CP muscle
were identified and divided sharply. Patients were hospitalized for approximately
5 days and fed by a nasogastric tube. At the end of that period, a barium
swallow was performed prior to resumption of oral intake of nutrition.
Each patient's medical record was reviewed for operative time, length
of hospital stay, time to oral intake, and postoperative complications. Statistical
analysis between the 2 groups was conducted using the paired t test. Results are presented as mean ± SD.
RESULTS
The results of endoscopic technique are summarized in Table 2. Table 3 summarizes
the results of the open (diverticulectomy) technique.
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Table 2. Results of Endoscopic Technique
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Table 3. Results of Open (Diverticulectomy) Technique
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OPERATIVE TIME
The operative time for the endoscopic stapling technique was 25.5 ±
15.78 minutes. The operative time for the open procedure was 87.6 ±
35.10 minutes. There was a statistically significant difference between these
2 groups (P<.001).
LENGTH OF HOSPITAL STAY
The hospital stay for the endoscopic stapling group was 1.3 ±
0.59 days. The hospital stay for the open procedure group was 5.2 ±
1.03 days. Again, a statistically significant difference between the 2 groups
was noted (P<.001).
TIME TO ORAL INTAKE
The time to oral intake was defined as the time from the procedure until
the patient was allowed to begin oral intake of nutrition. No nasogastric
tube was placed in patients undergoing the endoscopic stapling procedure:
6 patients began oral intake on postoperative day 1, and 2 patients began
oral intake of nutrition within several hours following surgery. The time
to oral intake for the endoscopic group was 0.8 ± 0.26 days. All patients
in the open procedure group required postoperative feedings by nasogastric
tube. The time to oral intake for this group was 5.1 ± 1.25 days. Again,
the time to oral intake was significantly shorter (P<.001)
for the endoscopic group.
COMPLICATIONS
Among the 16 patients, 1 patient in the endoscopic group had mild postoperative
bleeding, which spontaneously resolved without evidence of further sequelae.
There were no major complications in either group, including infection, fistula,
subcutaneous emphysema, or adverse pulmonary sequelae.
CHARGE ANALYSIS
A charge analysis of these 2 surgical procedures was performed by comparing
operative charges and in-hospital stay charges. For operative costs, fees
were based primarily on length of the surgery, which was divided into 30-minute
blocks. The surgeon's fees were included as part of the analysis and were
equivalent for both procedures. As for special equipment, no special equipment
was needed for the open procedure. However, the endoscopic procedure required
the use of an EndoGIA stapler, which added significantly to the overall costs.
The mean operative costs for the endoscopic procedure was approximately $5178,
which was slightly higher than the mean operative costs for the open procedure
at $5113. There was no statistically significant difference between the two.
The cost of hospitalization for the endoscopic procedure stay was $3589 ±
$1711. The cost for the open procedure was $11 439 ± $2372. Again,
there was a statistically significant difference between the two (P<.001).
COMMENT
The goal of surgical treatment of ZD is 2-fold: (1) elimination of the
reservoir that traps food particles and secretions and results in the classic
array of symptoms, and (2) release of the upper esophageal sphincter via a
CP myotomy, thereby eliminating increased pressures of the upper esophageal
sphincter, which are believed to be the main causative factor in the development
of ZD. There are 4 basic surgical approaches that are used with varying frequency
for the treatment of ZD: (1) open diverticulectomy and CP myotomy, (2) diverticulopexy
and CP myotomy, (3) imbrication of the diverticulum sac and CP myotomy, and
(4) endoscopic division of the common wall between the esophagus and diverticulum.
Open diverticulectomy includes a lateral neck incision, exposure and
excision of the offending pouch, and meticulous closure of the pharyngotomy
wound site. A cricopharyngeal myotomy is also performed at this time. Postoperatively,
oral feedings are performed for approximately 5 days while the pharyngotomy
site is allowed to heal. Over the years, other less invasive techniques have
evolved in an attempt to avoid the pharyngotomy, thereby reducing postoperative
healing time and time to resume oral intake as well as reducing potential
complications associated with a pharyngotomy. Many authors during the 1960s
and 1970s reported that ZD could be treated with CP myotomy alone without
addressing the reservoir itself.14-18
However, studies by Payne and King19 in 1983
and Bonafede et al20 in 1997 showed that this
method was associated with higher rates of recurrence and persistent dysphagia.
There are a number of open surgical procedures that were designed to
eliminate the dependent diverticulum, while avoiding the creation of a pharyngotomy
that would require closure and a delay in instituting oral intake of nutrition
as well as the attendant risks of infection and fistula formation. Diverticulopexy
involves suspending the diverticulum sac superiorly to the prevertebral fascia,
thereby removing it from a dependent position. Imbrication involves dissecting
the diverticulum and inverting it into the lumen of the esophagus and closing
the mucosa over with a "purse string" suture. Both techniques have been shown
to be successful and are generally associated with a decreased hospital stay
and time to resume oral intake because the pharyngoesophageal mucosa is not
violated.21-26
However, a lateral neck incision is still required, and recurrence of symptoms
has been reported.
The endoscopic approach is the only approach in which an external excision
is avoided. This technique, originally described by Mosher1
in 1917, was abandoned early because of an increased complication rate, in
particular, mediastinitis, which in the preantibiotic era had devastating
consequences. The endoscopic stapling technique has revolutionized the treatment
of ZD. With this technique, not only is a lateral neck incision avoided, but
the patient is allowed to resume oral intake rapidly, usually within 24 hours
of surgery. A further advantage is the decreased morbidity associated with
this technique. Most patients had no complications, and the 1 minor complication
of mild postoperative bleeding resolved quickly and spontaneously with no
long-term sequelae.
In our charge analysis, we found the intraoperative charges to be slightly
higher for the endoscopic approach, although the difference between the 2
procedures did not reach statistical significance. Because the endoscopic
technique is faster, it is logical to think that this would result in lower
operative charges. However, this benefit is offset by the specialized equipment
needed, specifically the EndoGIA stapler. Our analysis did not include the
enhanced revenue that could be generated by "back filling" the operating room
following a shorter endoscopic procedure. This analysis would surely favor
the endoscopic approach. However, the major benefit from the endoscopic procedure
is derived from the greatly reduced postoperative hospital stay. By reducing
the hospital stay by a mean of 3.9 days, the total fees were decreased by
a mean of $7850. One might argue that patients should be able to go home earlier
following an open procedure and continue their tube feedings as an outpatient.
While this strategy may be entertained in a younger population, there are
often extenuating circumstances in the older population who most often present
with ZD, which make shorter hospitalizations more difficult. Finally, one
other parameter that was not analyzed in this study was the days in lost earnings
to the patients from undergoing either of the 2 procedures. Clearly, for those
individuals who are employed, the shortened procedure would provide an optimal
financial analysis that would further favor the minimally invasive approach.
It is important to state that not all patients with a diagnosis of ZD
are candidates for an endoscopic stapling approach. Exposure of the diverticulum
and the esophagus is critical to provide access to the common party wall for
application of the stapling device. Patients with limited neck extension or
limited oral apertures are not favorable candidates, and transition to an
open procedure may be required to resolve the patient's symptoms.
CONCLUSIONS
The endoscopic stapling technique for the treatment of ZD has been proven
to be as equally effective and safe as the open procedure, with a marked reduction
in the postoperative recovery time. This results in a statistically significant
shorter hospital stay and time to resume oral feedings compared with the standard
open technique. This faster recovery time translates into a markedly reduced
hospital fee for the patient and easily counterbalances the slightly increased
charges of the surgery.
AUTHOR INFORMATION
Accepted for publication August 30, 2001.
Corresponding author and reprints: Mark L. Urken, MD, Department
of Otolaryngology, Mt Sinai Medical Center, One Gustave Levy Place, Box 1189,
New York, NY 10029.
From the Department of Otolaryngology, Mt Sinai School of Medicine,
Mt Sinai Medical Center, New York, NY.
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