18 - World Journal of Gastroenterology

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Bonavina L et al . Surgery of Zenker diverticulum 2589 The endoscopic approach may prove difficult in patients with cervical osteoarthritis, and in those with a reduced opening capacity of the mouth. The best indication to this procedure is represented by mediumsized diverticula in which at least two staple cartridges can be applied and an adequate cricopharyngeal myotomy can be achieved. Diverticula smaller than 3 cm in depth represent a formal contraindication to the endosurgical approach because the common wall is too short to accommodate one cartridge of staples and to allow complete division of the sphincter. This would result in an incomplete myotomy causing persistent dysphagia as it occurred in our series. Although the postoperative outcome of these patients, who are often elderly and compromised, suggests a greater comfort and a quicker recovery compared to the conventional operation, it should be taken into account that the endosurgical approach requires a general anesthesia. Therefore, in patients with excessive operative risk, a conventional operation carried out under regional anesthesia still remains the procedure of choice. At present, there is no evidence from high quality randomised controlled studies to establish which procedure is superior. It is clear that both operations relieve the outflow obstruction at the pharyngoesophageal junction, indicating that cricopharyngeal myotomy has an important therapeutic role in this disease independent of the resection of the pouch and of the surgical approach. Future trials may indicate the role of a tailored approach in the management of Zenker diverticulum [18] . Based on the findings of this study, we conclude that the endosurgical approach is as safe and effective as the open surgical procedure, provided that at least the entire length of the stapler cartridge (3 cm) can be applied to the septum. A small diverticulum limits access to the stapler head and it may not be possible to perform an adequate myotomy. COMMENTS Background The aim of surgery in Zenker diverticulum is to relieve outflow obstruction at the pharyngo-esophageal junction. This requires the performance of a cricopharyngeal myotomy and/or the resection of the pouch. Research frontiers It has been shown that effective surgery can be performed either through a transoral approach or through a transcervical approach. Innovations and breakthroughs The advent of laparoscopic instruments has represented a major technological advance in surgery over the past 15 years. Using a 5 mm telescope connected to a video-camera it is possible to insert a diverticuloscope through the mouth and divide the septum between the esophagus and Zenker diverticulum with an endostapler. Applications The transoral approach is increasingly used in the treatment of Zenker diverticulum. Compared to the conventional surgical operation the advantages of endostapling include shorter operative time, less postoperative pain, quicker recovery, and shorter hospital stay. Best long-term results are expected in patients with a > 3 cm pouch. Peer review This is an interesting review of the authors’ experience.The authors report on a large series of patients with Zenker diverticulum (n = 297). In this retrospective study, the transoral endosurgical approach (n = 181) was compared with a historical group of patients undergoing open diverticulectomy (n = 116). A subgroup of patients were followed up for 5 and 10 years, respectively. REFERENCES 1 Belsey R. Functional disease of the esophagus. J Thorac Cardiovasc Surg 1966; 52: 164-188 2 Ferguson MK. Evolution of therapy for pharyngoesophageal (Zenker's) diverticulum. Ann Thorac Surg 1991; 51: 848-852 3 Collard JM, Otte JB, Kestens PJ. Endoscopic stapling technique of esophagodiverticulostomy for Zenker's diverticulum. Ann Thorac Surg 1993; 56: 573-576 4 Narne S, Bonavina L, Guido E, Peracchia A: Treatment of Zenker’s diverticulum by endoscopic stapling. Endosurgery 1993; 1: 118-120 5 Cook IJ, Gabb M, Panagopoulos V, Jamieson GG, Dodds WJ, Dent J, Shearman DJ. Pharyngeal (Zenker's) diverticulum is a disorder of upper esophageal sphincter opening. Gastroenterology 1992; 103: 1229-1235 6 Shaw DW, Cook IJ, Jamieson GG, Gabb M, Simula ME, Dent J. Influence of surgery on deglutitive upper oesophageal sphincter mechanics in Zenker's diverticulum. Gut 1996; 38: 806-811 7 Venturi M, Bonavina L, Colombo L, Antoniazzi L, Bruno A, Mussini E, Peracchia A. Biochemical markers of upper esophageal sphincter compliance in patients with Zenker's diverticulum. J Surg Res 1997; 70: 46-48 8 Ellis FH Jr, Crozier RE. Cervical esophageal dysphagia: indications for and results of cricopharyngeal myotomy. Ann Surg 1981; 194: 279-289 9 Duranceau A, Rheault MJ, Jamieson GG. Physiologic response to cricopharyngeal myotomy and diverticulum suspension. Surgery 1983; 94: 655-662 10 Bonavina L, Khan NA, DeMeester TR. Pharyngoesophageal dysfunctions. The role of cricopharyngeal myotomy. Arch Surg 1985; 120: 541-549 11 Lerut T, van Raemdonck D, Guelinckx P, Dom R, Geboes K. Zenker's diverticulum: is a myotomy of the cricopharyngeus useful? How long should it be? Hepatogastroenterology 1992; 39: 127-131 12 Bonavina L, Bettineschi F, Fontebasso V, Ruol A, Nosadini A, Peracchia A. Cricopharyngeal myotomy and stapling: treatment of choice for Zenker’s diverticulum. In: Nabeya K, Hanaoka T, Nogami H, eds. Recent advances in diseases of the esophagus, Tokyo: Springer Verlag, 1993: 207-211 13 Mason RJ, Bremner CG, DeMeester TR, Crookes PF, Peters JH, Hagen JA, DeMeester SR. Pharyngeal swallowing disorders: selection for and outcome after myotomy. Ann Surg 1998; 228: 598-608 14 Hannan SA, Alusi G. Images in clinical medicine. Zenker's diverticulum. N Engl J Med 2006; 354: e24 15 Huang BS, Unni KK, Payne WS. Long-term survival following diverticulectomy for cancer in pharyngoesophageal (Zenker's) diverticulum. Ann Thorac Surg 1984; 38: 207-210 16 Peracchia A, Bonavina L, Narne S, Segalin A, Antoniazzi L, Marotta G. Minimally invasive surgery for Zenker diverticulum: analysis of results in 95 consecutive patients. Arch Surg 1998; 133: 695-700 17 Narne S, Bonavina L, Antoniazzi L, Cutrone C, Peracchia A. Safety and effectiveness of transoral stapling for recurrent Zenker diverticulum. In: Pinotti HW, Cecconello I, Felix VN, deOliveira MA, editors. Recent advances in Diseases of the Esophagus. Bologna: Monduzzi, 2001: 701-704 18 Sen P, Lowe DA, Farnan T. Surgical interventions for pharyngeal pouch. Cochrane Database Syst Rev 2005: CD004459 S- Editor Wang J L- Editor Wang XL E- Editor Liu Y www.wjgnet.com
PO Box 2345, Beijing 100023, China World J Gastroenterol 2007 May 14; 13(18): 2590-2595 www.wjgnet.com World Journal of Gastroenterology ISSN 1007-9327 wjg@wjgnet.com © 2007 The WJG Press. All rights reserved. RAPID COMMUNICATION Long-term results of subtotal colectomy with cecorectal anastomosis for isolated colonic inertia Antonio Iannelli, Thierry Piche, Raffaella Dainese, Pascal Fabiani, Albert Tran, Jean Mouiel, Jean Gugenheim Antonio Iannelli, Pascal Fabiani, Jean Mouiel, Jean Gugenheim, Service de Chirurgie Digestive - Université de Nice- Sophia-Antipolis, Faculté de Médecine, Nice, F-06107, France & Centre Hospitalier Universitaire de Nice, Pôle Digestif, Nice, F-06107, France Thierry Piche, Raffaella Dainese, Albert Tran, Service de Gastroentérologie - Université de Nice-Sophia-Antipolis, Faculté de Médecine, Nice, F-06107, France & Centre Hospitalier Universitaire de Nice, Pôle Digestif, Nice, F-06107, France Thierry Piche, Inserm U526, Nice, F-06107, France Correspondence to: Dr. Thierry Piche, Service d’Hépatogastroentérologie - Hôpital de l’Archet 2, 151 Route Saint- Antoine de Ginestière BP 3079, 06202-Nice-Cedex 3, France. tpiche@fc.horus-medical.fr Telephone: +33-4-92036168 Fax: +33-4-92036575 Received: 2007-01-29 Accepted: 2007-02-14 Abstract AIM: To evaluate the results of sub total colectomy with cecorectal anastomosis (STC-CRA) for isolated colonic inertia (CI). METHODS: Fourteen patients (mean age 57.5 ± 16.5 year) underwent surgery for isolated CI between January 1986 and December 2002. The mean frequency of bowel motions with the aid of laxatives was 1.2 ± 0.6 per week. All subjects underwent colonoscopy, anorectal manometry, cinedefaecography and colonic transit time (CTT). CI was defined as diffuse markers delay on CTT without evidence of pelvic floor dysfunction. All patients underwent STC- CRA. Long-term follow-up was obtained prospectively by clinical visits between October 2005 and February 2006 at a mean of 10.5 ± 3.6 years (range 5-16 years) during which we considered the number of stool emissions, the presence of abdominal pain or digitations, the use of pain killers, laxatives and/or fibers. Patients were also asked if they were satisfied with the surgery. RESULTS: There was no postoperative mortality. Postoperative complications occurred in 21.4% (3/14). At the end of follow-up, bowel frequency was significantly (P < 0.05) increased to a mean of 4.8 ± 7.5 per day (range 1-30). One patient reported disabling diarrhea. Two patients used laxatives less than three times per month without complaining of what they called constipation. Overall, 78.5% of patients would have chosen surgery again if necessary. CONCLUSION: STC-CRA is feasible and safe in patients www.wjgnet.com with CI achieving 79% of success at a mean followup of 10.5 years. A prospective controlled evaluation is warranted to verify the advantages of this surgical approach in patients with CI. © 2007 The WJG Press. All rights reserved. Key words: Constipation; Colonic inertia; Surgery; Subtotal colectomy; Cecorectal anastomosis Iannelli A, Piche T, Dainese R, Fabiani P, Tran A, Mouiel J, Gugenheim J. Long-term results of subtotal colectomy with cecorectal anastomosis for isolated colonic inertia. World J Gastroenterol 2007; 13(18): 2590-2595 http://www.wjgnet.com/1007-9327/13/2590.asp INTRODUCTION Constipation is a common problem, with an estimated prevalence of 2%-20% [1,2] . It is one of the more presenting complaints to both general practitioners and gastroenterologists, and carries a significant economic impact. In the vast majority of patients with constipation, restoration of bowel habits is achieved by dietary fiber supplements or the use of laxatives. Severe lifestyle-altering chronic constipation is indeed rare and the surgical treatment of slow transit constipation concerns approximately 10% of patients after the failure of an aggressive and prolonged trial of laxatives, fibers and prokinetics [3] . Before referral for surgical treatment, an eventual contribution of pelvic floor dysfunction to constipation must be carefully diagnosed [4,5] . Indeed, it was shown that patients with slow transit constipation without outlet delay are the best responders to surgical treatment [6] . The standard surgical procedure for severe constipation is subtotal colectomy with ileorectal anastomosis (STC- IA) [7-9] . However, STC-IA leads to small bowel obstruction, in 8% to 50% of cases with a relaparotomy rate ranging from 0% to 14% (for review see [3] ). Furthermore, in recent studies, STC-IA also resulted in intractable diarrhoea in 6% to 17% of patients with a disabling modification of stool consistency in approximately 30% of patients 8 years after surgery [6] . Recurrent constipation requiring laxatives has been reported to occur in 27% of cases [10] . Subtotal abdominal colectomy with cecorectal anastomosis (STC- CRA) is an alternative procedure that has, for instance, received little attention. However, STC-CRA offers the
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