How do the outcomes of laser endoscopic repair of Zenker diverticulum compare to the outcomes of stapling procedures, and how popular is flexible endoscopic diverticulotomy with cautery?

Updated: Oct 16, 2020
  • Author: Joel A Ernster, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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A study by Adam et al examining the efficacy of CO2 laser versus stapling technique in the endoscopic repair of Zenker diverticulum found that although both procedures were effective in treating the condition, the laser technique was more effective. The retrospective review, in which 148 patient charts were examined, found lower recurrence rates in patients treated by laser, as well as better outcomes in these patients with regard to dysphagia and regurgitation. [53]

In another study of the two techniques, Parker and Misono found that the CO2 laser and stapling procedures were similar with regard to most, but not all, types of complications in Zenker diverticulum treatment. The report, a meta-analysis of 391 procedures from seven retrospective, uncontrolled studies, found no differences in the prevalence of dental complications, major complications, overall complications, or revision surgery, as well as none in the length of time that patients were nil per os. However, nondental complications were more frequent in patients who underwent the CO2 laser procedure. [54]

A retrospective study by Hering and Wiegand indicated that in the treatment of Zenker diverticula, the systemic inflammatory response in the early period after endoscopic surgery is greater subsequent to CO2 laser treatment than it is following surgery with a linear stapling device. In the first postoperative days, the investigators found leukocyte counts and C-reactive protein levels to be significantly greater in the laser-surgery patients than in the stapler group. [55]

In a study by Barton et al of 106 patients, endoscopic laser- and stapler-assisted diverticulotomies were both found to be effective in short- and long-term symptom management and to be associated with high levels of patient satisfaction. Reviewing historical data for the stapler-assisted procedure alone at the single institution where the study was carried out, the investigators found that the addition of the laser-assisted technique produced a decline in the endoscopic diverticulotomy failure rate, with no rise in serious complications. [56]

A study by Visser et al indicated that laser-assisted and stapler-assisted endoscopic CP myotomy are both effective in treating Zenker diverticulum, with 45 out of 75 patients (60%)—23 out of 42 stapler patients (55%) and 22 out of 33 laser patients (67%)—experiencing complete resolution of symptoms after their initial treatment. Complications and recurrence rates did not significantly differ between the two endoscopic techniques in the study, although the investigators suggested that patients who undergo the stapler-assisted procedure nonetheless are at greater risk of requiring reintervention and of suffering more severe complications. [57]

Flexible endoscopic diverticulotomy with cautery

Peroral endoscopic myotomy (POEM) with flexible instrumentation and cautery has gained popularity in some centers and can play a role in the management of some patients. [38]

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