There are sparse data on the outcomes of endoscopic stapling of pharyngeal pouches. The Mersey ENT Trainee Collaborative compared regional practice against published benchmarks.

A 10-year retrospective analysis of endoscopic pharyngeal pouch surgery was conducted and practice was assessed against eight standards. Comparisons were made between results from the tertiary centre and other sites.

A total of 225 procedures were performed (range of 1.2–9.2 cases per centre per year). All centres achieved 90 per cent resumption of oral intake within 2 days. All centres achieved less than 2-day hospital stays. Primary success (84 per cent (i.e. abandonment of endoscopic stapling in 16 per cent)), symptom resolution (83 per cent) and recurrence rates (13 per cent) failed to meet the standard across the non-tertiary centres.

Endoscopic pharyngeal pouch stapling is a procedure with a low mortality and brief in-patient stay. There was significant variance in outcomes across the region. This raises the question of whether this service should become centralised and the preserve of either tertiary centres or sub-specialist practitioners.

Pharyngeal pouch surgical treatments can be carried out via an endoscopic or open approach. Injection of botulinum toxin into the cricopharyngeus was first described as an alternative treatment to the more invasive surgical procedures performed for cricopharyngeal dysfunction. It has not been previously described as a treatment option for pharyngeal pouch.

To compare operative time, average stay, complication rates and symptom control between endoscopic laser diverticulotomy, botulinum toxin injection and open procedures for pharyngeal pouch patients.

The medical records for 66 pharyngeal pouch procedures, carried out on 47 patients treated between 2011 and 2017, were identified and reviewed.

The mean operative time was 21 minutes for botulinum toxin injection, 38 for endoscopic laser diverticulotomy and 104 for open surgery. The mean hospital stay was 0.6 days for botulinum toxin injection, 4.7 for endoscopic laser diverticulotomy and 4 for open surgery. The improvement in Reflux Symptom Index scores was statistically significant for both endoscopic laser diverticulotomy and botulinum toxin injection. Botulinum toxin injection had a 0 per cent complication rate.

Botulinum toxin injection is a safe and effective treatment for pharyngeal pouch.

Pharyngoesophageal diverticula have many subtypes, with Zenker's diverticulum being the most common. First described in 1983, a Killian–Jamieson diverticulum is an outpouching in the anterolateral wall at the pharyngoesophageal junction. This is located inferiorly to the cricopharyngeus muscle, unlike Zenker's diverticula which occur superiorly. Killian–Jamieson diverticula are rare and are commonly misdiagnosed as Zenker's diverticula. Less than 30 reports of Killian–Jamieson diverticula have been described in the literature.

A 69-year-old man presented with a 2-year symptomatic history, and was found to have simultaneous Zenker's diverticulum and Killian–Jamieson diverticulum. He was treated successfully with open surgical excision of both pouches.

Zenker's diverticulum and Killian–Jamieson diverticulum are diagnosed using radiological studies and endoscopy. Their differentiation is important, as surgical management differs. This paper reviews the literature on Killian–Jamieson diverticula and the management options available.

To evaluate our results in treating Zenker's diverticulum via the transcervical approach, and to compare our experiences with a recent systematic review of both open and endoscopic approaches to the pharyngeal pouch.

An audit yielded 41 consecutive cases of Zenker's diverticulum treated between 2003 and 2013.

All 41 patients underwent transcervical cricopharyngeal myotomy; 29 sacs also required ‘inversion’. The median and mean length of hospital stay was 1 night and 2.5 nights respectively. The recurrence rate was 2.4 per cent and the complication rate was 9.8 per cent.

When compared to reported endoscopic techniques, transcervical cricopharyngeal myotomy (with or without inversion) in our unit resulted in: shorter hospital stay, a comparable complication rate and fewer recurrences.

Transoral endoscopic ENT surgical procedures are a mainstay of treatment for a variety of conditions and are often preferable to open surgery where possible. Cases of micrognathia, prominent incisor teeth or trismus may create difficulties in gaining sufficient access to undertake such procedures. Extraction of the anterior maxillary teeth can help overcome these problems in appropriate cases, with subsequent prosthetic tooth replacement supported by dental implants. To date, this approach has not been reported in the literature.

This paper reports on two cases which illustrate this approach; the first case involved pharyngeal pouch management where previous open surgery had failed, and the second case involved glottic carcinoma management where oral access was compromising resection.

This technique is recommended to facilitate effective transoral surgical procedures as a low-morbidity alternative to either open surgery or non-surgical therapies.

Management of the pharyngeal pouch has evolved enormously since the first description by Ludlow in 1764 and the first case series by Zenker and Von Ziemssen in 1877. With the introduction of antibiotics, and the advancement of surgical technique with the advent of endoscopic surgery and lasers, current management is vastly different to that in the nineteenth century.

This paper traces the history of pharyngeal pouch management, and discusses the various treatment options and opinions recorded during the nineteenth and twentieth centuries, comparing these with techniques popular today.

Pharyngeal pouch surgery has been associated with significant morbidity, both because of the elderly age of patients typically affected by the condition and because of the surgery itself and potential post-operative complications encountered. The historical development of pharyngeal pouch management and the understanding of pharyngeal pouch pathophysiology are discussed.

Zenker's diverticulum is a propulsion diverticulum in the pharynx. Current practice for the management of symptomatic pharyngeal pouches includes endoscopic pharyngeal stapling, performed trans-orally, and external approaches via a cervical incision. There is no published recommendation on how to approach diverticula with extension into the mediastinum, which may not be adequately treated with the above methods.

We describe two cases in which thoracoscopic mobilisation of Zenker's diverticulum was performed using video-assisted thoracoscopic surgery together with traditional transcervical mobilisation and excision of the pouch. This allowed safe surgical access to the inferior limit of the pouch, and delivery of the sac into the neck incision following division of any inferior adhesions (to the great vessels in one case).

In the first report of this technique, we describe a thorough, safe method of dissecting large diverticula that extend into the mediastinum, which minimises the risk to mediastinal structures.

Endoscopic hypopharyngeal diverticulotomy is now largely performed using an endoscopic stapling device. A poorly applied endoscopic stapling device can result in incomplete division of the cricopharyngeal bar, necessitating the application of a second set of staples. Applying more than one set of staples is associated with an increased risk of complications and greater cost. Small pharyngeal pouches are difficult to staple because of difficulties engaging the stapling device over the cricopharyngeal bar.

Two pairs of oesophageal forceps are used in conjunction with a 0 degree Hopkins rod to optimise the endoscopic stapling of small and large pharyngeal pouches.

Applying grasping forceps to the cricopharyngeal bar improves the accuracy of the stapling procedure, thus reducing the morbidity and cost associated with multiple staple applications.