Aktuelle Behandlungskonzepte des Zenker- Divertikels - Indikationen und Ergebnisse

Zusammenfassung

Zenker-Divertikel werden konventionell transzervikal per Divertikelabtragung, Divertikelinvagination, Divertikulopexie sowie Myotomie, die mit den anderen Verfahren z. T. kombiniert wird, therapiert, oder es erfolgt transoral über ein starres Ösophagoskop eine latero-laterale Divertikuloösophagostomie mittels Diathermie, Laser oder Klammernahtgerät. Neu ist die Applikation von Diathermie oder Argonplasmakoagulatoren über flexible Endoskope. Die Morbidität transzervikaler Verfahren liegt zwischen 3 (Myotomie) und 23 % (Divertikelresektion + Myotomie), der Prozentsatz symptomatisch gebesserter Patienten bei mindestens 92 %, die Rezidivrate bei 5,7 (alleinige Divertikelresektion) bzw. 21 % (Divertikelinvagination). Die Morbidität transoraler Verfahren schwankt zwischen 9 (Klammernahtgerät) und 26 % (Laser), die Quote symptomatisch gebesserter Patienten zwischen 91 (Diathermie per starrem Ösophagoskop) und 99 % (Diathermie per flexiblem Endoskop), jedoch sind Mehrfacheingriffe in bis zu 64 % notwendig. Kleine Divertikel (Brombart I/II) sind einer manuellen Divertikelabtragung (mit/ohne Myotomie) oder flexibel endoskopischer Therapie, größere Divertikel meist allen genannten Verfahren zugänglich. Patienten jünger als 60 Jahre sollten per Divertikelabtragung, ältere und multimorbide Patienten mittels transoraler Verfahren therapiert werden.

Abstract

Conventional transcervical therapy of Zenker's diverticulum comprises diverticulectomy, invagination, diverticulopexy and myotomy, which may be combined with the aforementioned methods. Transoral diverticuloesophagostomy is performed by diathermy, lasers or staplers through a rigid esophagoscope, or more recently by diathermy applied via a flexible endoscope. Morbidity of transcervical procedures ranges between 3 (myotomy) and 23 % (diverticulectomy + myotomy). The percentage of patients with at least significantly improved symptoms is 92 % or more, while recurrences occur in 5.7 (diverticulectomy alone) to 21 % (invagination). Transoral procedures have a morbidity of 9 (stapler) to 26 % (Laser), while symptoms improve in 91 (diathermy through rigid esophagoscope) to 99 % (diathermy via flexible endoscope), however in up to 64 % of patients reoperations are necessary. Small diverticula (Brombart I/II) can be treated by diverticulectomy (with/without myotomy) or flexible endoscopy, larger diverticula in general by all methods. Patients younger than 60 years should undergo diverticulectomy, elderly multimorbid patients should be treated by transoral procedures.

Schlüsselwörter

Zenker-Divertikel - chirurgische Verfahren - endoskopische Verfahren

Key Words

Zenker's diverticulum - surgical procedures - endoscopic procedures

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