Stapling endoscopic diverticulo-esophagostomy in the treatment of Zenker's diverticulum: Experience on 84 patients

Standard treatment of Zenker's diverticulum consists of cricopharyngeal myotomy for relief of functional obstruction and resection of the diverticulum through cervicotomy. Myotomy and elimination of the pouch may be performed endoscopically by dividing the septum interposed between the diverticulum and the esophageal lumen which includes the upper esophagcal sphincter (UES) This procedure can be performed under general anesthesia with a Weerda diverticuloscope using a modified linear stapler (EndoGIA). The result of the procedure is an esophago-diverticulostomy with section of the UES. Out of 231 patients operated on for Zenker's diverticulum in our Department since 1976. this new approach was attempted in 84 cases. Conversion to open surgery was required in two patients (2.5%) in the early experience. Two cartridges were used in 75 cases (89%), one in 4 and 3 in 3, according to the size of the diverticulum. Median duration of the procedure was 20 mm. (10-50 min.). No postoperative morbidity or mortality were recorded. Oral feeding was started following radiologic control after a median of 2 days; median hospital stay was 4 days Median follow-up is 16 mos. (1-45 mos.). Four patients operated on before the introduction of the modified stapler showed a persistent diverticular pouch. 3 underwent repeat endoscopic operation and one underwent conventional open surgery. All treated patients are asymptomatic. Manometric study performed in 42 patients showed a significant reduction of basal UES pressure (53.2±26.5 vs 33.9±16.9 mmHg; p<0.005) compared to preoperative data. Esophageal scintigraphy with Tc99 was performed in 10 patients and showed a significant reduction of the radioisotopic clearance at 75% (29.3±22.2 sec vs 1.9±0.84 sec; P<0.004). In conclusion, early results obtained with endoscopie stapled esophagodiverticulotomy indicate that the procedure is safe and effective with minimal patient's discomfort, and can be recommended in patients with a Zenker's diverticulum at least of 2.5 cm of length, in whom neck iperextension and mouth conformation allow rigid endoscopy.