Zenker’s diverticulum: flexible versus rigid repair

Abstract

Zenker's diverticula (ZDs) are a relatively common cause of cervical dysphagia. Diagnosis is best by a good upper GI exam though upper endoscopy should be performed as well. Treatment is either by open, transcervical approaches or trans-oral. Over the past 20 years, transoral approach has mostly replace transcervical approaches due to less pain, no scarring and a rapid recovery. Transoral approaches are either using rigid access or flexible endoscopy. Today, the most common approach is transoral stapling using a 12 mm laparoscopic linear cutting stapler. This has the drawbacks of requiring extreme neck extension, the massive size of the stapler making visualization mostly impossible and the current staple design that does not cut/staple all the way to the end of the blades-resulting in a residual pouch. Flexible endoscopy allows a more tailored approach under direct vision, the myotomy can even be extended beyond the diverticulum and onto the esophageal wall to minimize the risk of incomplete myotomy. Experienced endoscopists report high technical success and low complication. Success rates are similar but maybe slightly higher than with ridged transoral approaches or open surgery. Today, flexible endoscopic Zenkers is our preferred initial approach-with open or ridged being reserved for special indications.

Esophageal diverticulum: New perspectives in the era of minimally invasive endoscopic treatment

“…ZD is a rare condition with a yearly incidence rate of 2 per 100000 adults. Geographical variation in the incidence has been observed with a significantly lower incidence in Asian than in Western countries[30]. It occurs predominantly in men, and is most common in the seventh and eight decades of life (Table 1)[31].…”

A multi-centre analysis of a decade of endoscopic pharyngeal pouch surgery in Cheshire and Merseyside

“…2 The estimated overall incidence of pharyngeal pouch is 1-2 per 100 000 per year. 3,4 Surgical management can be divided into open and endoscopic approaches, and is dependent largely on patient choice, patient factors and local surgical expertise. 3 Before the introduction of contemporary endoscopic techniques, an external cervical approach with diverticulectomy or diverticulopexy was the standard of care.…”

Endoscopic Transversal Incision and Longitudinal Septostomy (TILS): An Updated Technique for Treating Esophageal Diverticulum

“…An esophageal diverticulum is a protruding pouch in a weak portion of the esophageal lining. Esophageal diverticulum can affect individuals of all ages; however, it tends to manifest in elderly and debilitated patients [1]. Thus, its treatment needs to be less invasive with fewer complications.…”