How is endoscopic diverticulotomy performed in the treatment of Zenker diverticulum?

Updated: Jan 23, 2018
  • Author: Joel A Ernster, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Answer

Answer

In endoscopic diverticulotomy, a double-bladed rigid endoscope is placed into the pharynx, with one blade positioned in the esophagus and the other in the diverticulum. An articulating endoscopic linear stapler is introduced into the pharynx with one jaw of the stapler in the pouch and one jaw in the esophagus. The stapler is locked across the common septum of the 2 and is fired. If necessary, this is repeated until the bottom of the pouch is reached. [43]

This results in an opening of the pouch and a division of the CP muscle, with the pouch wall becoming incorporated as a wall of the esophagus. This technique should not be used for diverticula less than 3 cm in length, owing to the fact that the stapler blade is too long for the common wall. [35]

The endoscopic stapling technique consists of adhering the mucosal edges by stapling them together while cutting across the "party wall" at the same time. It has become the preferred endoscopic approach for most American and British surgeons. Few complications have been reported with this procedure. Patients with good flexibility, favorable dentition, and larger diverticula are the best candidates. A stapling diverticulotomy is demonstrated below. [44, 45]

Zenker diverticulum. Demonstration of stapling diverticulotomy using a 35 mm vascular stapler with an articulating arm.

Using traction sutures to pull the “party wall” into the stapler may improve long-term outcomes by increasing the length of the incision. However, this may also increase the likelihood of perforation of the diverticulum while engaging the stapler, so this additional technique should be used with caution. [45, 46]

(A study by Wilmsen et al reported that the use of flexible endoscopy in stapler-assisted diverticulotomy offers a safe and efficient means of treating Zenker diverticulum. The investigators found that in 11 out of 17 patients (64.7%), complete septum division was accomplished using the stapler. In the remaining patients, stapling was unsuccessful because the septum was too thick or the head was not sufficiently reclined. [47] )

Preoperative details

Proper instrumentation, including the following, is essential for the performance of this technique:

  • Three different-sized Weerda laryngoscopes, including the diverticuloscope (anatomic differences require different scopes)

  • Hopkins endoscopes (0 and 30°, 4 mm)

  • Dental protection

  • Vascular 35-mm stapler, preferably with an articulating arm

Intraoperative details

An endoscopic diverticulotomy with stapler proceeds as follows:

  • Intubate the patient with an endotracheal tube that is smaller than standard (ie, 6-mm outside-diameter tube for 70-kg patient)

  • Place dental protection on the upper and lower dentition

  • Inspect the larynx and postcricoid region with an anterior commissure laryngoscope

  • Position and suspend an appropriate-sized Weerda laryngoscope

  • Inspect the mucosa of the sac

  • Define the partition, or "party wall," between the sac and the esophagus and ascertain the size of the sac

  • Hopkins endoscopes are used to guide the stapler into place

  • Place the straight part of the stapler (containing the staples and blade) in the esophagus; place the angled part (anvil) in the sac, as depicted in the image below

    Endoscopic view of the partition between the esoph Endoscopic view of the partition between the esophagus (anteriorly) and the Zenker diverticulum (posteriorly); the stapler is in place in the lower view.
  • Engage the device, simultaneously stapling and cutting the partition; release and remove the device (see the image below)

    Endoscopic view of the stapled and cut edges of th Endoscopic view of the stapled and cut edges of the partition between the esophagus and the Zenker diverticulum.
  • Perform a second stapling if residual partition remains

Postoperative details

Postoperative care following an endoscopic diverticulotomy with stapler includes the following (which can be safely performed on an outpatient basis) [24, 48] :

  • Administer ice chips the night of the procedure and a soft diet the following day

  • Closely monitor temperature

  • Obtain a chest radiograph

Postoperative radiologic assessment of the surgical site with barium swallow videofluoroscopy must be interpreted with understanding of the surgical intent. Findings that indicate a successful result include the following:

  • Reduced height of the partition wall

  • Easy passage of barium into the esophagus

  • Reduced height of barium in the residual sac


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