, Volume 34, Issue 6, pp 930–938 | Cite as

Open Versus Endoscopic Surgery of Zenker’s Diverticula: A Systematic Review and Meta-analysis

  • Rebecca J. HowellEmail author
  • John Paul Giliberto
  • Jeffrey Harmon
  • Jessica Masch
  • Sid Khosla
  • Gregory N. Postma
  • Jareen Meinzen-Derr
Original Article


Most Zenker’s diverticula (ZD) cohort studies are single-institution retrospective observational studies of recurrence rates. There is a gap in the literature regarding patient-reported outcomes after ZD surgery. This study was conducted to compare if open transcervical diverticulectomy (OD) is better than endoscopic laser diverticulectomy (ELD) or endoscopic stapler-assisted diverticulectomy (ESD). The study design is of systematic review and meta-analysis. The following databases were searched: SCOPUS, EMBASE, PubMed, and Word of Science through December 2017. The quality of the studies was evaluated using 22-item STROBE checklist with 3 independent physician reviewers. The Inter-rater reliability was calculated both as a percent and utilizing Cohen’s Kappa. For the meta-analysis, Cohen’s d for an effect size was calculated for all studies comparing dysphagia results before and after surgery. A total of 865 patients were treated across 11 selected publications, of which 106 patients were treated OD, 310 ELD, and 449 with an ESD approach. Patient-reported dysphagia outcomes were reported as Cohen’s d (confidence interval): OD, ELD, and ESD were 1.31 (0.88, 1.74), 1.91 (1.62, 2.20), and 2.45 (2.04, 2.86), respectively. The pooled effect of all studies for dysphagia was 2.22 (1.85, 2.59) and regurgitation 2.20 (1.80, 2.59). We did not prove that OD has superior outcomes compared to ESD and ELD. Any method of surgical intervention yields a large effect (i.e., improvement in dysphagia and regurgitation) comparing patient-reported symptoms before and after surgery. Future research, currently underway, includes a prospective, multi-institutional study comparing standardized outcomes between treatments of ZD including symptom resolution, complications, and recurrences using validated measures to define long-term outcomes.

Level of Evidence 3


Zenker diverticulum Esophageal diverticulectomy Surgical dysphagia Dysphagia outcomes Deglutition Degluitition disorders 



We would like to thank our librarian Mr. Don Jason for his expertise during our literature search. We would also like to thank Dr. Luigi Bonavina for providing additional details to meet our inclusion criteria.

Compliance with Ethical Standards

Conflict of interest

All authors declare no conflict of interest.

Ethical Approval

This article does not contain any studies with human participants performed by any of the authors.


  1. 1.
    Mosher H. Webs and pouches of the oesophagus, thier diagnosis and treatment. Surg Gynecol Obstet. 1917;25:175–87.Google Scholar
  2. 2.
    Bock JM, Van Daele DJ, Gupta N, Blumin JH. Management of Zenker’s diverticulum in the endoscopic age: Current practice patterns. Ann Otol Rhinol Laryngol. 2011;120(12):796–806.CrossRefGoogle Scholar
  3. 3.
    Wilken R, Whited C, Scher RL. Endoscopic staple diverticulostomy for zenker’s diverticulum: review of experience in 337 cases. Ann Otol Rhinol Laryngol. 2015;124(1):21–9.CrossRefGoogle Scholar
  4. 4.
    Parker NP, Misono S. Carbon dioxide laser versus stapler-assisted endoscopic zenker’s diverticulotomy: a systematic review and meta-analysis. Otolaryngol Head Neck Surg. 2014;150(5):750–3.CrossRefGoogle Scholar
  5. 5.
    Verdonck J, Morton RP. Systematic review on treatment of Zenker’s diverticulum. Eur Arch Otorhinolaryngol. 2015;272(11):3095–107.CrossRefGoogle Scholar
  6. 6.
    Vandenbroucke JP, von Elm E, Altman DG, et al. Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration. Int J Surg. 2014;12(12):1500–24.CrossRefGoogle Scholar
  7. 7.
    Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.CrossRefGoogle Scholar
  8. 8.
    Adam SI, Paskhover B, Sasaki CT. Laser versus stapler: Outcomes in endoscopic repair of Zenker diverticulum. Laryngoscope. 2012;122(9):1961–6.CrossRefGoogle Scholar
  9. 9.
    Adam SI, Paskhover B, Sasaki CT. Revision zenker diverticulum: laser versus stapler outcomes following initial endoscopic failure. Ann Otol Rhinol Laryngol. 2013;122(4):247–53.CrossRefGoogle Scholar
  10. 10.
    Bonavina L, Aiolfi A, Scolari F, Bona D, Lovece A, Asti E. Long-term outcome and quality of life after transoral stapling for zenker diverticulum. World J Gastroenterol. 2015;21(4):1167–72.CrossRefGoogle Scholar
  11. 11.
    Colombo-Benkmann M, Unruh V, Krieglstein C, Senninger N. Cricopharyngeal myotomy in the treatment of zenker’s diverticulum. J Am Coll Surg. 2003;196(3):370–7 discussion 377; author reply 378.CrossRefGoogle Scholar
  12. 12.
    Lang RA, Spelsberg FW, Winter H, Jauch KW, Huttl TP. Transoral diverticulostomy with a modified endo-gia stapler: Results after 4 years of experience. Surg Endosc. 2007;21(4):532–6.CrossRefGoogle Scholar
  13. 13.
    Leibowitz JM, Fundakowski CE, Abouyared M, et al. Surgical techniques for Zenker’s diverticulum: a comparative analysis. Otolaryngol Head Neck Surg. 2014;151(1):52–8.CrossRefGoogle Scholar
  14. 14.
    Miller FR, Bartley J, Otto RA. The endoscopic management of zenker diverticulum: CO2 laser versus endoscopic stapling. Laryngoscope. 2006;116(9):1608–11.CrossRefGoogle Scholar
  15. 15.
    Murer K, Soyka MB, Broglie MA, Huber GF, Stoeckli SJ. Zenker’s diverticulum: outcome of endoscopic surgery is dependent on the intraoperative exposure. Eur Arch Otorhinolaryngol. 2015;272(1):167–73.CrossRefGoogle Scholar
  16. 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(7):695–700.CrossRefGoogle Scholar
  17. 17.
    Rodella L, Saladino E, Lombardo F, et al. Endoscopic diverticulostomy for Zenker’s diverticulum experience on 123 cases. G Chir. 2010;31(4):180–5.PubMedGoogle Scholar
  18. 18.
    Stoeckli SJ, Schmid S. Endoscopic stapler-assisted diverticuloesophagostomy for zenker’s diverticulum: patient satisfaction and subjective relief of symptoms. Surgery. 2002;131(2):158–62.CrossRefGoogle Scholar
  19. 19.
    von Elm E, Altman DG, Egger M, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. PLoS Med. 2007;4(10):e296.CrossRefGoogle Scholar
  20. 20.
    Vandenbroucke JP, von Elm E, Altman DG, et al. Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration. Epidemiology. 2007;18(6):805–35.CrossRefGoogle Scholar
  21. 21.
    Lipsey MWWD, editor. Practical meta-analysis. 1st ed. Thousand Oaks, CA: Sage Pulications; 2000.Google Scholar
  22. 22.
    Ludlow A. A case of obstructed deglutition from a preternatural dilation of and bag formed in the pharynx. Med Observ Inquiries. 1769;3:85–101.Google Scholar
  23. 23.
    Zenker F, von Ziemssen H. Dilatations of the esophagus. Cycl Pr Med. 1878;3:46–8.Google Scholar
  24. 24.
    Hendriksma M, Joosten MH, Peters JP, Grolman W, Stegeman I. Evaluation of the quality of reporting of observational studies in otorhinolaryngology—based on the STROBE statement. PLoS ONE. 2017;12(1):e0169316.CrossRefGoogle Scholar
  25. 25.
    Colpaert C, Vanderveken OM, Wouters K, Van de Heyning P, Van Laer C. Changes in swallowing-related quality of life after endoscopic treatment for zenker’s diverticulum using SWAL-QOL questionnaire. Dysphagia. 2017;32(3):339–44.CrossRefGoogle Scholar
  26. 26.
    Belafsky PC, Mouadeb DA, Rees CJ, et al. Validity and reliability of the eating assessment tool (EAT-10). Ann Otol Rhinol Laryngol. 2008;117(12):919–24.CrossRefGoogle Scholar
  27. 27.
    Johnson CM, Postma GN. Zenker diverticulum—which surgical approach is superior? JAMA Otolaryngol Head Neck Surg. 2016;142(4):401–3.CrossRefGoogle Scholar
  28. 28.
    Venkatesan NN, Evangelista LM, Kuhn MA, Belafsky PC. Normal fluoroscopic appearance status post-successful endoscopic zenker diverticulotomy. Laryngoscope. 2017;127(8):1762–6.CrossRefGoogle Scholar
  29. 29.
    Leonard R, Rees CJ, Belafsky P, Allen J. Fluoroscopic surrogate for pharyngeal strength: the pharyngeal constriction ratio (PCR). Dysphagia. 2011;26(1):13–7.CrossRefGoogle Scholar
  30. 30.
    Berzofsky CE, Holiday RA, Pitman MJ. Variability of postoperative esophagrams after endoscopic cricopharyngeal myotomy: technique dependence. Ann Otol Rhinol Laryngol. 2012;121(3):145–50.CrossRefGoogle Scholar
  31. 31.
    Bonavina L, Bona D, Abraham M, Saino G, Abate E. Long-term results of endosurgical and open surgical approach for zenker diverticulum. World J Gastroenterol. 2007;13(18):2586–9.CrossRefGoogle Scholar
  32. 32.
    Rosen SP, Jones CA, McCulloch TM. Pharyngeal swallowing pressures in the base-of-tongue and hypopharynx regions identified with three-dimensional manometry. Laryngoscope. 2017;127(9):1989–95.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Otolaryngology Head and Neck SurgeryUniversity of CincinnatiCincinnatiUSA
  2. 2.Department of Otolaryngology Head and Neck SurgeryMedical College of Georgia at Augusta UniversityAugustaUSA
  3. 3.Department of Pediatrics, Department of Environmental HealthUniversity of CincinnatiCincinnatiUSA
  4. 4.Department of Otolaryngology Head and Neck SurgeryUniversity of Cincinnati College of MedicineCincinnatiUSA

Personalised recommendations