Endoscopic treatment of Zenkerʼs diverticulum by complete septotomy: initial experience in 19 patients

Abstract

Background and study aims Endoscopic treatment of Zenker’s Diverticulum (ZD) using a flexible endoscope and a diverticuloscope consists of myotomy of the cricopharyngeus muscle, sparing the lower part of the diverticular septum. However, recurrence occurs in up to 54 % of patients at 4 years. We assessed the feasibility and safety of a complete septotomy in endoscopic treatment of ZD.

Patients and methods We conducted a retrospective analysis of a prospectively collected database at a single referral center. All consecutive patients treated by complete resection of the diverticular wall were included. The endoscopic technique used a distal attachment cap and division of the ZD septum using a Dual Knife or a Triangle Tip knife in endocut mode, until the esophageal muscularis propria was seen and no residual diverticulum remained. Symptoms were evaluated using the Augsburger questionnaire.

Results Nineteen patients, 10 of whom were men with mean age 79 ± 12 years, were treated by complete septotomy for a symptomatic ZD with a median size of 2.5 cm (range 1–5 cm). The clinical success rate was 100 % and the complication rate was 10 % (one pneumonia and one atrial fibrillation). Median hospital stay was 2 days (range 1–3 days). On Day 1 esophagogram, no extraesophageal contrast leakage was seen, periesophageal CO₂ was still visible in two patients, and complete ZD regression was seen in 63 % of patients. The 6-month clinical success rate was 100 %, with two patients lost to follow-up, and a median symptom score of 0 (range 0–4). After a mean ± SD follow-up of 9 ± 5 months, the clinical success rate was 94 % (16/17).

Conclusion Complete endoscopic septotomy is a feasible and safe therapeutic modality in patients with symptomatic ZD that does not require use of a diverticuloscope, and with good short-term efficacy. The complete regression of the diverticulum observed on Day 1 in 63 % of patients could be a marker of long-term clinical success.

Publication History

Received: 07 January 2020

Accepted: 25 March 2020

Article published online:
16 June 2020

• References

• 1 Van Overbeek JJ. Meditation on the pathogenesis of hypopharyngeal (Zenker’s) diverticulum and a report of endoscopic treatment in 545 patients. Ann Otol Rhinol Laryngol 1994; 103: 178-185
• 2 Law R, Katzka DA, Baron TH. Zenker’s Diverticulum. Clin Gastroenterol Hepatol 2014; 12: 1773-1882; quiz e111-e112
• 3 Verdonck J, Morton RP. Systematic review on treatment of Zenker’s diverticulum. Eur Arch Otorhinolaryngol 2015; 272: 3095-3107
• 4 Albers DV, Kondo A, Bernardo WM. et al. Endoscopic versus surgical approach in the treatment of Zenker’s diverticulum: systematic review and meta-analysis. Endosc Int Open 2016; 4: E678-E686
• 5 Mulder CJ, Costamagna G, Sakai P. Zenker’s diverticulum: treatment using a flexible endoscope. Endoscopy 2001; 33: 991-997
• 6 Evrard S, Le Moine O, Hassid S. et al. Zenker’s diverticulum: a new endoscopic treatment with a soft diverticuloscope. Gastrointest Endosc 2003; 58: 116-120
• 7 Ishaq S, Hassan C, Antonello A. et al. Flexible endoscopic treatment for Zenker’s diverticulum: a systematic review and meta-analysis. Gastrointest Endosc 2016; 83: 1076-1089.e5
• 8 Costamagna G, Iacopini F, Bizzotto A. et al. Prognostic variables for the clinical success of flexible endoscopic septotomy of Zenker’s diverticulum. Gastrointest Endosc 2016; 83: 765-773
• 9 Bresteau C, Barret M, Guillaumot M-A. et al. Do we still need a diverticuloscope for the flexible endoscopic septotomy of Zenker’s diverticulum?. J Gastroenterol Hepatol 2020; 35: 630-633
• 10 Goelder SK, Brueckner J, Messmann H. Endoscopic treatment of Zenker’s diverticulum with the stag beetle knife (sb knife) – feasibility and follow-up. Scand J Gastroenterol 2016; 51: 1155-1158
• 11 Charlson ME, Pompei P, Ales KL. et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40: 373-383
• 12 Cederholm T, Bosaeus I, Barazzoni R. et al. Diagnostic criteria for malnutrition – An ESPEN Consensus Statement. Clin Nutr 2015; 34: 335-340
• 13 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 14 Shah RN, Slaughter KA, Fedore LW. et al. Does residual wall size or technique matter in the treatment of Zenker’s diverticulum?. Laryngoscope 2016; 126: 2475-5479
• 15 Ishaq S, Battaglia G, Antonello A. Double incision and snare resection in symptomatic Zenker’s diverticulum: a modification of the stag-beetle knife technique. Endoscopy 2018; 50: 182
• 16 Laquière A, Grandval P, Arpurt JP. et al. Interest of submucosal dissection knife for endoscopic treatment of Zenkerʼs diverticulum. Surg Endosc 2015; 29: 2802-2810
• 17 Li Q-L, Chen W-F, Zhang X-C. et al. Submucosal Tunneling endoscopic septum division: a novel technique for treating Zenker’s diverticulum. Gastroenterology 2016; 151: 1071-1074
• 18 Yang J, Novak S, Ujiki M. et al. An international study on the use of peroral endoscopic myotomy in the management of Zenker’s diverticulum. Gastrointest Endosc 2020; 91: 163-168