Introduction Zenker’s diverticulum is a sac-like outpouching of the mucosa and submucosa through an area of muscular weakness between the thyropharyngeus and cricopharyngeus muscles. Traditional treatments have been surgical with open or intraluminal approaches to cricopharyngeal myotomy where the overall complication rate is 9.6%. An alternative approach is to use a flexible endoscope to perform a diverticulotomy. We present a video series to illustrate the principles of flexible endoscopic diverticulotomy.
Method We reviewed prospectively collected data of patients with Zenker’s diverticulum referred to our department for endotherapy between January 2014 and January 2015. All patients had Zenker’s diverticulum confirmed on barium swallow. Every procedure was carried out under general anaesthesia by a single endoscopist (PB).
A guide wire is inserted into the stomach under direct vision, over which a double-lipped overtube (ZD overtube, ZDO-22–30; Cook Endoscopy, Winston-Salem, North Carolina) is threaded. Under direct vision, the overtube is advanced until the long flap is positioned in the oesophageal lumen and the short flap is in the diverticulum. The septum is clearly visualised and stabilised between the two flaps. The septal mucosa is cut in the middle using a needle knife or diathermy scissors. The mucosal incision is extended until the cricopharyngeal muscle fibres are completely incised. Following this, the cut is extended to approximately 1 cm from the base. Prophylactic endoclips are placed to prevent perforation or bleeding. Patients resume a liquid diet 12 h post procedure.
Results A total of 5 patients underwent flexible endoscopic diverticulotomy [female 3, median age 76 years (range 69–84 years)]. 2 patients had previous failed surgical interventions. The mean size of diverticulae was 48 mm (range 30–70 mm) and the mean duration of each procedure was 33 min (range 30–40 mins). 1 patient required an overnight stay as he lived outside our catchment area. There were no procedure related complications or mortality. All patients were able to drink within 12 h and start on a soft diet within 48 h post procedure. Prior to the diverticulotomy, 80% of patients experienced dysphagia with every meal and 60% suffered with regurgitation several times a week. All patients were asymptomatic at follow up at 3. Where 12-month data is available, all patients (3/5) remain asymptomatic.
Conclusion In expert hands, flexible endoscopic diverticulotomy is a novel, and safe treatment for Zenker’s diverticulum. It obviates the need for invasive surgery and a majority of patients can be treated on a day-case basis. Initial results are encouraging with no reported complications and excellent short-term success rates.
Disclosure of interest None Declared.