INTRODUCTION
Zenker’s diverticulum (hypopharyngeal diverticulum) is an acquired pulsion diverticulum of the mucosa through the “Killian’s triangle”, an area of muscular weakness at the lateral posterior wall of the hypopharynx. It manifests as a protrusion from a triangular area in the wall of the pharynx between the two bands of the cricopharyngeus of the inferior constrictor of the pharynx.
Zenker’s diverticulum (ZD) was first reported in 1767 by Ludlow, but was named after the German pathologist Friedrich Albert von Zenker, who published a case series in 1877 [1]. ZD usually presents in the seventh and eighth decade, with prevalence ranging from 0.01% to 0.11% [2]. It is more common in males than in females.
The pathophysiology, though not completely understood, is attributed to a dysfunctional upper oesophageal sphincter, causing increased intraluminal pressure. The most common symptom is progressive post-prandial dysphagia, other symptoms are regurgitation of undigested food, coughing, choking, halitosis, globus, aspiration, pneumonia and post-prandial esophageal obstruction. Indications for intervention are still unclear, therefore treatment is typically reserved for symptomatic patients with or without associated complications.
Many options have been described for the treatment of Zenker’s diverticulum. The open surgical approach was the treatment of choice for many years. Mosher introduced rigid endoscopy treatment in 1917, to section the septum of the diverticulum [3]. Over the past few decades, endoscopic treatment has gained more popularity, mainly due to new developments and devices in the endoscopic armamentarium. Van overbeek et al first introduced the carbon dioxide laser for septum division in 1981 [4], which still is in frequently use [5], whilst in 1993, Collard at al. introduced another new method, the endostapler [6]. Perracchia and Narne report satisfactory experiences of using endostaplers in 95 and 102 patients respectively.[7,8]
The main advantages of the endoscopic approach over open surgery are shorter operative time, less surgical trauma, lower morbidity rates and more effective myotomy of the upper oesophageal sphincter, decreasing the possibility of recurrence.
CASE SUMMARY
Our patient, a 72 year old male, presented with a history of weight loss and progressive dysphagia. The diagnosis of Zenker’s diverticulum was made through endoscopic and radiologic examination (barium swallow and abdominal CT scan).
The patient was evaluated and, after thorough counseling and pre- anaesthetic evaluation, underwent a transoral endoscopic stapled esophageal diverticulotomy under general anesthesia.
The patient was placed supine, with his neck hyper-extended. An initial upper GI-scopy was completed to assess the diverticulum and oesophagus. A guide wire was passed into the stomach under supervision, and the endoscope withdrawn to a position just distal to the upper oesophageal sphincter, to visualise the Zenker’s diverticulum and oesophageal lumen with the intervening septum. A flexible endostapler (green cartridge 60mm) was passed along the side of the gastroscope and positioned such that it straddled the common wall between the diverticulum and the oesophagus. After re-confirming the position, the stapler was fired and the septum was divided. This achieved a dual purpose of myotomy of the cricopharyngeal muscle and creation of a common cavity (between Zenker’s Diverticulum and the oesophagus). The mouth of the Zenker’s Diverticulum was thus lowered from the roof to the floor of the Zenker’s Diverticulum. Haemostasis was reconfirmed after division of the septum.
Post-operatively, the patient was kept nil orally for the first 24 hours. Subsequently an oral contrast study was performed to confirm the absence of leak and then the patient was started on liquids orally and gradually progressed to a soft diet. He was discharged home 48 hrs after the procedure.
At 6 weeks follow-up, the patient showed significant improvement in his symptoms and gained 6kgs in weight. Other than occasional mild pain in the left side of the neck while swallowing solid food, he has no complaints.
DISCUSSION
Minimally invasive techniques for treating ZD have gained popularity in recent years. The endoscopic procedure evolved over the years, from a rigid endoscope to a flexible one, with different devices used for exposing and incising the septum. However, the optimal treatment approach in terms of surgery vs endoscopy remains debatable. A Romanian study directly compared the outcomes (reappearance of symptoms) of surgical versus endoscopic treatment and found a better efficacy for the endoscopic approach [11].
The rigid endoscopic diverticulotomy requires general anesthesia and a supine position with hyper-extension of the neck. The exposure of diverticulum may be compromised by some anatomic situations (short neck, shorter hyo-mental distance and higher BMI) or a small diverticulum, circumstances which may require conversion to open surgery. The endoscopic flexible diverticulotomy, first reported in 1995, is usually performed under conscious sedation and without neck extension. Multiple methods for exposing the septum are described: guidewires, endoscopic caps, semi-flexible overtubes or nasogastric tubes.
Multiple cutting devices have been used: needle-knives, endoscopic submucosal dissection knives, argon plasma coagulation, stag beetle knife and a fully rotatable surgical 5-mm stapler in combination with an ultrathin flexible endoscope. The first cutting device was the needle knife papillotome, which applied diathermy to dissect the septum. Its advantages were its low cost and availability, while its disadvantages included difficulty in precise control, with an increase risk of perforation and mediastinitis.
The Ultrasonics hear was used with a diverticuloscope. Its blades operate ultrasonically and have the ability to cut and coagulate tissue at the same time. The Hook knife[9]enables cricopharyn geal muscle fibers to be grasped, pulled upwards, and then cut, leading to a complete myotomy with a minimum perforation risk. The Stag Beetle knife is a scissor shaped cutting tool and is often used with a diverticuloscope or a cap. It allows the incision to be made from the apex to the base of the septum, but with a scissor-like movement, which pulls the muscle fibers towards the endoscope while cutting. In addition, the 360 degrees rotational ability increases therapeutic precision and prevents perforation. The Clutch Cutter knife [9], with a rotatable serrated cutting edge, has an insulated outer coating. Its rigid blades allow selective grasping and cutting, shortening the duration of the procedure and reducing the complications.
Laquiere et al. [10] reported that endoscopic diverticuloscope-assisted diverticulotomy with submucosal dissection knives was safe and efficient for symptomatic ZD between 2 to 10 cm long. The advantage of using a dual-knife was the precision of tissue cutting, without increasing the risk of perforation.
Costamagna et al. [11] compared the cap-assisted technique to the diver- ticuloscope-assisted technique and reported that the procedure time was significantly longer; The complication and recurrence rates were higher (32% vs. 0%) in the cap group. Sakai et al. [12], showed that with an oblique-end hood attached to the tip of the endoscope, incision of ZD was simplified, without recurrence during a follow-up period of 12 months.
In this case, we used a flexible endostapler (60mm green cartridge) to divide the septum. Our patient had relief of symptoms immediately after the procedure and had no signs of perforation or mediastinitis. Our rigid stapling technique achieved a similar outcome to the flexible needle knife technique. Other new endoscopic techniques have been described, using double incision and snare resection or submucosal tunneling and endoscopic septum division (Z-POEM) in a large ZD [13].
The average length of hospital stay reported in the literature for patients following endoscopic diverticulotomy is two days, shorter than has been reported for surgical counterparts [14]. The overall morbidity rate for the endoscopic approach was 8.7%, whereas it was 10.5% for open surgery [10]. Bleeding, perforation, aspiration, and emphysema are possible intra or post-procedural complications for both approaches. We have chosen to actively monitor our patients for a 12 months period after the procedure. As endoscopic approach is a fairly complicated procedure due to the diverticulum location, the operator experience was paramount and most probably had a high impact on procedural outcome and complication rate.
CONCLUSIONS
Transoral endoscopic stapled oesophageal diverticulotomy for Zenkers Diverticulum was efficient and safe in our experience. The patients had a shorter length of stay than surgical counterparts and an immediate relief of symptoms. Various stapling devices are presently available, among them the Flexible Endostapler, which is routinely available and a useful device for dividing the septum. More studies are required to establish the best treatment option and follow-up protocol.
References
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