Treatment of Zenker’s diverticulum: different tastes all leading to the same flavor?

Zenker’s diverticulum is an acquired diverticulum at the Killian triangle. It was first described by Abraham Ludlow in 1764 and was formally named by the pathologist Friedrich Albert von Zenker in 1867. It has a low prevalence, ranging from 0.01 % to 0.11 %, and occurs more often in men than in women, between the seventh and eighth decade of life. With increasing size of the diverticulum, an initial globus can proceed to progressive dysphagia, chronic cough, weight loss, and aspiration of undigested food.

For a long time, surgical resection was the only treatment option in symptomatic Zenker’s diverticulum. It was followed by an otolaryngeal intraluminal technique with the dissection of the bridge that separates the diverticulum from the esophageal lumen. For this technique, a rigid endoscope combined with a carbon dioxide laser or a stapler is used with the patient under general anesthesia and in the supine position with an overextended neck. The ongoing development of flexible endoscopy led Ishioka et al. in 1995 to publish the first case series of flexible endoscopic septum dissection using a needle-knife [1]. Compared with surgical therapy and rigid endoscopy treatment options, flexible endoscopy can be performed under conscious sedation, which is the major advantage, as it leads to shorter hospital stays. Furthermore, flexible endoscopic techniques have proved to be safe and just as effective as the other treatment options [2].

However, there are a tremendous number of different approaches: guidewires, nasogastric tubes, endoscopic caps or semi-flexible overtubes for better visualization of the diverticular septum [3]; multiple cutting devices, such as different needle-knives [4] or endoscopic submucosal dissection knives [5], argon plasma coagulation [6], stag beetle knife [7]; a fully rotatable surgical 5-mm stapler in combination with an ultrathin flexible endoscope [8]; and even a submucosal tunneling technique [9]. This great number of different techniques reflects the lack of a gold standard technique for endoscopic treatment, which has overall success rates ranging from 56 % to 100 %, and a recurrence rate of at least 10 % [2] [10]. In general, recurrence of symptoms after flexible endoscopic treatment are related to incomplete dissection of the diverticular bridge because of fear of mediastinitis, which can be caused by a septum incision that is too deep, which in turn carries the risk of perforation and cervical emphysema.

“Gölder et al. suppose that the ‘U-shapeʼ allows a better overview, prevents an incision that is too deep, and reduces the risk of perforation.”

In this issue of Endoscopy, Gölder et al. present a novel technology using a modified stag beetle knife technique with two parallel incisions of the diverticular bridge, in combination with a snare resection of the remaining septum between the two incisions [11]. The procedure creates a wider “U-shape” opening, with better visualization of the transverse fibers of the cricopharyngeal muscle. This technique was first described by Battaglia et al. in 2015 [12]. The “U-shape” opening is in contrast to a smaller “V-shape” opening, which might be responsible for early treatment failures and symptomatic relapse. Furthermore, resecting the tissue in between the two incisions and achieving a complete dissection of the cricopharyngeal muscle will reduce the contact of the opposing sides of the remnant diverticular bridge, thus hopefully preventing re-formation of the fibrotic bridge tissue and producing a longer lasting recurrence-free opening between the diverticular sac and the esophageal lumen. Gölder et al. suppose that the “U-shape” allows a better overview, prevents an incision that is too deep, and reduces the risk of perforation.

The presented data from 16 patients indicate that this new technique seems to be safe, with only one patient suffering from mild recurrence of symptoms. However, the published median follow-up of only 3 months is too short to form conclusions about this innovative endoscopic treatment. In comparison with other studies of flexible endoscopic treatments in symptomatic Zenker’s diverticulum, the present preliminary data show similar results concerning technical success, clinical success, and re-intervention rates.

In the initial paper from Battaglia et al., 31 patients were treated successfully by this modified stag beetle knife and snaring technique. The median procedure time was 14 minutes, and significant symptom improvement was achieved, as demonstrated by median scores before vs. after treatment (dysphagia: < 3 vs. > 0, P < 0.001; regurgitation: < 2 vs. > 0, P < 0.001; respiratory symptoms: < 2 vs. > 0, P = 0.009). Two patients had mild relapsing symptoms after 4 and 9 months, respectively, following the procedure, but they refused further treatment [12].

In summary, flexible endoscopic treatment of Zenker’s diverticulum with low recurrence rates and long-lasting patient satisfaction remains challenging despite the new treatment options. As in other fields in gastrointestinal endoscopy, randomized controlled studies, even in relatively rare diseases, are preferred in order to identify the modality that is truly best. Furthermore, all randomized studies should ideally be compared with surgical treatment. In the meantime, there remains a “colorful bouquet” of different flexible endoscopic treatment options, the best of which is unknown, leaving the endoscopist free to select their personal and favorite technique. Finally, the choice of flexible endoscopic treatment may be a matter of taste but they all lead to the same flavor.

• References

• 1 Ishioka S, Sakai P, Maluf FilhoF. et al. Endoscopic incision of Zenker’s diverticula. Endoscopy 1995; 27: 433-437
• 2 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
• 3 Costamagna G, Iacopini F, Tringali A. et al. Flexible endoscopic Zenker’s diverticulotomy: cap-assisted technique vs. diverticuloscopeassisted technique. Endoscopy 2007; 39: 146-152
• 4 Repici A, Pagano N, Romeo F. et al. Endoscopic flexible treatment of Zenker’s diverticulum: a modification of the needle-knife technique. Endoscopy 2010; 42: 532-535
• 5 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
• 6 Rabenstein T, May A, Michel J. et al. Argon plasma coagulation for flexible endoscopic Zenker’s diverticulotomy. Endoscopy 2007; 39: 141-145
• 7 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
• 8 Wilmsen J, Baumbach R, Stüker D. et al. New flexible endoscopic controlled stapler technique for the treatment of Zenker's diverticulum: a case series. World J Gastroenterol 2017; 23: 3084-3091
• 9 Li QL, Chen WF, Zhang XC. et al. Submucosal tunneling endoscopic septum division: a novel technique for treating Zenker’s diverticulum. Gastroenterology 2016; 151: 1071-1074
• 10 Huberty V, El BachaS, Blero D. et al. Endoscopic treatment for Zenker’s diverticulum: long-term results (with video). Gastrointest Endosc 2013; 77: 701-707
• 11 Gölder SK, Brückner J, Ebigbo A. et al. Double incision and snare resection in symptomatic Zenker’s diverticulum: a modification of the stag beetle knife technique. Endoscopy 2018; 50: 137-141
• 12 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: 729-734