Endotherapy of Zenker’s diverticulum using the needle-knife technique: long-term follow-up

Background and study aims: Endotherapy of Zenker’s diverticulum by mucomyotomy of the bridge between the diverticulum and the esophageal lumen has been introduced as a promising alternative to surgical techniques. However the data on long-term clinical outcome are limited. After poor results in four patients treated by argon plasma coagulation, we studied the efficacy and the long-term outcome of dissection using a needle-knife in a consecutive series of patients. Patients and methods: Between December 2001 and November 2004, 31 consecutively treated symptomatic patients (18 men; median age 69 years; range 52 - 92) with Zenker’s diverticulum were enrolled into this retrospective study. In all cases mucomyotomy was performed with a needle-knife with the patient under conscious sedation. The procedure was repeated in the case of incomplete relief from dysphagia or of recurrent symptoms during follow-up. All patients completed questionnaires on the frequency and severity of dysphagia, using a numeric analogue scale, ranging from 0 (never/none/excellent) to 10 (each time of swallowing/very severe/very bad). Results: Endoscopic mucomyotomy was achieved in all 31 patients, with initial symptomatic improvement. Repeat treatment was required in 10 patients after a mean of 5.3 months, due to recurrence of symptoms. During a mean follow-up period of 26 months (range 14 - 49), 26 patients (84 %) had long-term success of variable degree (65 % with no or minimal remaining symptoms); four patients (13 %) had insufficient relief and wanted a repeat treatment; and one patient (3 %) underwent surgery. The success rate in the entire group was 84 % (26/31) including those with repeat treatment, and 61 % (19/31) if only success following a single treatment session was counted. Minor complications such as subcutaneous or mediastinal emphysema were observed in 23 % and were conservatively managed. There were no major complications. Conclusions: A single needle-knife mucomyotomy procedure can achieve long-term symptomatic improvement in about two out of three cases of Zenker’s diverticulum. The success rate can be increased to above 80 % by repeated sessions. Minor complications occur frequently but they can be conservatively managed. Major complications were not observed. Further long-term studies are warranted to elucidate the role of endoscopy as a definitive single treatment, with determination of prognostic parameters for a successful long-term outcome.

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