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Flexible Endoscopic Clip-Assisted Zenker's Diverticulotomy: The First Case Series (With Videos)

Authors

  • Shou-jiang Tang MD,

    1. From the Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, U.S.A.
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  • Saad F. Jazrawi MD,

    1. From the Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, U.S.A.
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  • Edward Chen MD,

    1. From the the Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, U.S.A.
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  • Linda Tang MD,

    Corresponding author
    1. From the Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, U.S.A.
    • Send correspondence to Shou-jiang Tang, MD, Director of Endoscopy, Parkland Memorial Hospital, Assistant Professor of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-9151
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  • Larry L. Myers MD

    1. From the the Department of Otolaryngology–Head and Neck Surgery, UT Southwestern Medical Center, Dallas, Texas, U.S.A.
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  • Editor's Note: This Manuscript was accepted for publication February 15, 2008.

Abstract

Background: In treating Zenker's diverticulum (ZD), there are potential risks associated with performing flexible endoscopic diverticulotomy without suturing or stapling. We recently introduced flexible endoscopic clip-assisted diverticulotomy (ECD) in treating ZD by securing the septum prior to dissection.

Objective: To evaluate the feasibility and safety of ECD for complete septum dissection.

Study Design: Case series at an academic center. Seven consecutive patients (mean age 71 y; range 48–91 y) with symptomatic ZD of various craniocaudal sizes based on radiographic measurements (mean 2.6 cm; range 0.8 cm–4.5 cm) were included. The mean depth of the septum was 1.73 cm (range 0.3 cm–3.1 cm). The mean duration of symptoms was 4.8 years (range 0.5–10 y).

Methods: After endoclips were placed on either side of the cricopharyngeal bar, the septum was dissected between these two clips down to the inferior end of the diverticulum with a needle-knife. Procedures including “one-step ECD” (n = 1), “stepwise ECD” (n = 3), and “bottom ECD” (n = 2) were performed based on the septum depth of the ZD during endoscopy. ECD was not performed on one patient due to severe mucosal fragility of the esophageal inlet. Iatrogenic blunt dissection of the septum by the endoscopic hood occurred secondary to patient retching during the procedure. Main outcome measurements were symptom resolution and complications.

Results: All patients (n = 6) who underwent ECD had complete resolution of esophageal symptoms at a minimum 6-month follow-up. There were no procedural complications. The patient who did not undergo ECD developed an esophageal perforation. She was managed conservatively without surgical intervention. On follow-up, her dysphagia was completely resolved.

Conclusions: ECD is feasible, safe, and effective for complete septum dissection. ECD and endoscopic stapler-assisted diverticulotomy are complimentary rather than competing strategies in approaching ZD. Study limitations include the case series design and limited follow-up period.

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