Endoscopic staple-assisted diverticulostomy in the treatment of Zenker’s diverticulum
Epublication WebSurg.com, Feb 2012;12(02). URL: http://websurg.com/doi/vd01en3573
Zenker’s diverticulum (ZD) is an acquired pulsion pouch that was first described by Ludlow in 1769. It develops within a natural anatomic dehiscence zone (Killian’s triangle), which is located between the cricopharyngeal and the inferior constrictor muscles, and is due to failure of the cricopharyngeus to relax with swallowing. The principles of treatment include division of the obstructing cricopharyngeal muscle and adequate drainage of the pouch. This can be achieved successfully with an endoscopic per-oral technique using an endoscopic stapler, as described by Collard in 1993. Adequate cervical extension and opening of the mouth are a prerequisite for the procedure, which is otherwise indicated for all patients having a symptomatic ZD larger than 2.0cm. Very small diverticula (< 1.0cm), make it difficult to achieve adequate exposure and a complete myotomy; in contrast, very large diverticula leave behind a residual pouch which may be responsible for postoperative dysphagia. ESD provides short inpatient and operating times, along with a short anesthesia time (mean of 10 to 30 minutes duration). Also, it only causes a mild postoperative discomfort and the patient is able to resume a diet on the same day. It is therefore cost-effective. The most common encountered complications are chipped teeth, postoperative fever and aspiration pneumonia. Overall, results of this technique in appropriately selected patients are excellent, with a success rate well above 90%. Needed equipment for this procedure includes: - Weerda’s diverticuloscope - Endopath™ articulating endoscopic stapler ATB 45 - Standard cartridges 45mm/3.5mm - Endo Stitch™ with 2/0 silk sutures - Closed-end esophageal suction - 4mm, 0-degree rigid endoscope, 30cm long References Ludlow A. A case of obstructed deglutition from a preternatural dilation of and bag formed in the pharynx. Medical Observations Inquiries 1769;3:85-101. Chang CY, Payyapilli RJ, Scher RL.Endoscopic staple diverticulostomy for Zenker's diverticulum: review of literature and experience in 159 consecutive cases. Laryngoscope. 2003 Jun;113(6):957-65. Leporrier J, Salamé E, Gignoux M, Ségol P. Zenker's diverticulum: diverticulopexy versus diverticulectomy. Ann Chir. 2001 Feb;126(1):42-5. Wasserzug O, Zikk D, Raziel A, Cavel O, Fleece D, Szold A. Endoscopically stapled diverticulostomy for Zenker's diverticulum: results of a multidisciplinary team approach. SurgEndosc. 2010 Mar;24(3):637-41. Epub 2009 Aug 18. Feeley MA, Righi PD, Weisberger EC, Hamaker RC, Spahn TJ, Radpour S, Wynne MK. Zenker's diverticulum: analysis of surgical complications from diverticulectomy and cricopharyngealmyotomy. Laryngoscope. 1999 Jun;109(6):858-61. Cook RD, Huang PC, Richstmeier WJ, Scher RL.Endoscopic staple-assisted esophagodiverticulostomy: an excellent treatment of choice for Zenker's diverticulum. Laryngoscope. 2000 Dec;110(12):2020-5. Cummings CW, Haughey BH, Thomas JR, Harker LA, Flint PW. Cummings Otolaryngology: Head and Neck Surgery. Chapter 74.