Splitting of the septum between the diverticulum and the esophagus is performed through a flexible endoscope either with argon-plasma coagulation (APC) or with a needle-knife in the endo-cut mode. In both techniques, the cut edges of the wound are coagulated, so that no free perforation into the mediastinum occurs as long as the cut is taken no deeper than 5 mm above the fundus of the diverticulum. This explains why only a single case of perforation with mediastinitis has been reported in the more than 400 cases that have been published in clinical series to date (1). Because a risk of perforation still exists when the cut is carried downward too deeply toward the floor of the diverticulum, the physician performing the procedure may opt to close the wound edges with endoscopically applied clips.
Subcutaneous or mediastinal emphysema occur in up to 20% of cases and can be explained by the elevated pressure associated with coughing or vigorous insufflation of air. These phenomena caused no serious problems and regressed within a few days.
Even when a stapler is used for treatment, perforations occur in up to 3% of cases, resulting in the conversion of the endoscopic procedure to open surgery. These perforations are attributable to injury either by the rigid spreading diverticuloscope or by the stapler itself (2, 3).
There has not yet been a single reported case of a hemorrhage that could not be managed endoscopically in a patient treated via flexible endoscopy. The same holds for stapler treatment. Doppler ultrasonography is not necessary as an adjunct to either of these two techniques.
The number of repeated procedures is higher after flexible endoscopy than after stapler treatment; this can be explained as the result of postoperative adherence of the wound edges to each other near the fundus. With increasing expertise, repeated procedures become rarer (on average, 2.3 treatment sessions are needed for newly arising symptoms) (1). Thus, in view of the low complication rate and the low degree of invasiveness of the procedure—no endotracheal anesthesia, no possibility of conversion to open surgery—we consider flexible endoscopy to be the method of choice for the treatment of Zenker’s diverticulum, particularly in elderly patients.
Footnotes
Conflict of interest statement
The authors state that they have no conflict of interest as defined by the guidelines of the International Committee of Medical Journal Editors.
References
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