Endoscopy 2018; 50(02): 183-184
DOI: 10.1055/s-0043-123936
Letter to the editor
© Georg Thieme Verlag KG Stuttgart · New York

Differences in endoscopic techniques for symptomatic Zenker’s diverticulum

Stefan K. Gölder
Department of Internal Medicine III, Klinikum Augsburg, Augsburg, Germany
,
Juliane Brückner
,
Alanna Ebigbo
,
Helmut Messmann
› Author Affiliations
Further Information

Publication History

Publication Date:
29 January 2018 (online)

We thank Dr. Ishaq and colleagues for commenting on our study. Over the past years, an increasing number of papers have reported on flexible endoscopic treatment approaches to symptomatic Zenker’s diverticulum. New procedures and devices have emerged, but there is still no common opinion as to which offers the best treatment opportunities and which is safest for our patients. In our institution, we followed over 100 patients with Zenker’s diverticulum who were treated with either the Hook Knife, SB Knife, or SB Knife Junior, with single or double incision and snare resection [1] [2] [3]. However, prospective randomized controlled trials comparing different flexible endoscopic techniques are still lacking.

As Ishaq et al. point out, there is a similarity between their technique and that reported in our study; however, some clear differences should be noted. First, despite similar names, the device we used, the SB Knife Junior, because of its smaller size, offers easier handling compared to the SB Knife or SB Knife Standard, which were used in the study reported by Ishaq et al. [4] ([Fig. 1]). Therefore, manipulation and cutting of the muscular tissue can be more elegantly and precisely achieved.

Zoom Image
Fig. 1 Photographs showing the different knives. a The SB Knife Junior with a cutting edge of 3.5 mm. b The SB Knife Standard with a 7-mm cutting edge (both Sumitomo Bakelite, Tokyo, Japan).

Furthermore, there is a major difference in the technique itself, namely the additional single-line cutting of muscular tissue after completion of the U-shaped double incision and snare resection (DISR). One major advantage of the DISR technique is good visibility. The diverticular bridge tissue removed during snare resection contains a large part of the cricopharyngeal muscle, as determined by pathology. After the resection, it becomes possible to clearly distinguish between muscular and connective fibers, thereby allowing the correct depth of incision to be determined. In order to achieve the best possible outcome, the remaining muscular fibers of the cricopharyngeal muscle are then cut again.

However, the risk to be avoided during any technique for luminal Zenker’s diverticulum treatment is perforation into the mediastinum [5]. After DISR, this “point of entrance into the free mediastinum” can be more safely evaluated and ultimately avoided, while at the same time still allowing for a deep – if not complete – incision of the cricopharyngeal muscle because of good visibility. However, taking into account the risk posed by any electrosurgical cutting towards the mediastinum, a single cutting line for the last remaining muscle fibers seems a safer choice than extending the initial U-shape achieved by the DISR technique.

Lastly, in the study of Ishaq et al., the dissection line was closed with endoscopic clips. In our routine practice, we do not perform a closure of the dissection line so as to avoid scar formation at this trigger point of treatment.

In conclusion, our version of DISR is a technique that combines the advantages of good visibility with the possibility of complete cutting of the cricopharyngeal muscle.

 
  • References

  • 1 Brueckner J, Schneider A, Messmann H. et al. Long-term symptomatic control of Zenker diverticulum by flexible endoscopic mucomyotomy with the hook knife and predisposing factors for clinical recurrence. Scand J Gastroenterol 2016; 51: 666-671
  • 2 Gölder 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
  • 3 Gölder SK, Brueckner J, Ebigbo A. et al. Double incision and snare resection in symptomatic Zenker’s diverticulum: a modification of the stag beetle knife technique. Endoscopy DOI: 10.1055/s-0043-119286.
  • 4 Battaglia G, Antonello A, Realdon S. et al. Flexible endoscopic treatment for Zenker's diverticulum with the SB Knife. Preliminary results from a single-center experience. Dig Endosc 2015; 27: 728-733
  • 5 Feussner H. Endoscopic therapy for Zenker diverticulum--the good and the bad. Endoscopy 2007; 39: 154-155