- Email: [email protected]
New endoscopic “scissors” to treat Zenker’s diverticulum (with video)
NEW METHODS: Clinical Endoscopy
New endoscopic “scissors” to treat Zenker’s diverticulum (with video) Mohan Ramchandani, MD, DM, D. Nageshwar Reddy, MD, DM, FRCP Hyderabad, India
Background: Zenker’s diverticulum (ZD) is a rare disorder but is associated with significant morbidity. Cricopharyngeal (CP) myotomy is the mainstay of treatment, and various flexible endoscopic techniques have been used for division of the septum. However, there is a constant need for improvement in accessories. Objective: To evaluate the safety and effectiveness of a new electrocautery endoscopic scissor for CP myotomy in patients with symptomatic ZD. Design: Observational human study. Setting: Tertiary-care hospital. Patients: This study involved 3 patients with symptomatic ZD. Intervention: Flexible endoscopic CP myotomy was performed by using a novel scissors-type grasping device. CP myotomy involved 4 steps: (1) opening of the forceps, (2) grasping the muscle fiber, (3) closure of the forceps with application of gentle traction, and (4) dissection of muscle fibers by using cutting current. Intraprocedural bleeding was controlled with the same instrument by grasping vessels and applying coagulation current. Main Outcome Measurements: Overall feasibility and performance, procedure time to achieve complete CP myotomy. Results: CP myotomy was successfully performed in all patients. Mean procedure time was 10.6 minutes. There were no major adverse events. Minor intraprocedure bleeding occurred in 1 patient. Limitations: Single arm, limited number of patients. Conclusion: The new instrument has potential advantages in comparison with standard instruments used for CP myotomy. The advantages of this new technique are better control of cutting and hemostatic abilities.
Zenker’s diverticulum (ZD) is a mucosal outpouching of cervical esophagus through the Killian triangle. Cricopharyngeal (CP) myotomy is a critical component of the treatment and can be achieved by conventional open surgery1 or endoscopic methods,2 by using either a flexible or rigid endoscope. Procedure-related morbidity and hospital
stay are much higher with the surgical approach as compared with those of endoscopic methods.3 The septum, or Zenker’s bridge, is between the ZD and the lumen of the esophagus and consists of mucosa, submucosa, connective tissue, and a muscle layer. Endoscopic treatment is based on cutting this septum. Incision of the septum reduces
Abbreviations: CP, cricopharyngeal; ESD, endoscopic submucosal dissection; ZD, Zenker’s diverticulum.
Copyright ª 2013 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2013.06.003
DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.
Received March 5, 2013. Accepted June 5, 2013. Current affiliations: Asian Institute of Gastroenterology, Hyderabad, India.
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. www.giejournal.org
Reprint requests: Dr D. Nageshwar Reddy, Asian Institute Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082 India.
of
If you would like to chat with an author of this article, you may contact Dr Reddy at [email protected].
Volume 78, No. 4 : 2013 GASTROINTESTINAL ENDOSCOPY 645
Zenker’s diverticulum
cricopharyngeal spasm and also removes the partition between the diverticulum and esophageal lumen so that food can pass more easily into the esophagus. CP myotomy can be achieved by various endoscopic methods including laser,4 stapler,5 or harmonic scalpel.6 Stapling devices used via rigid endoscopes are suitable for patients with good neck flexibility, favorable dentition, and large diverticula. The flexible endoscope method is much simpler and less invasive than a rigid endoscope method. Several reports of intraluminal treatment of ZD by using a flexible endoscope have been published, with the possibility of many different techniques: needle-knife,7 hook-knife,8 monopolar forceps,9 argon plasma coagulation,10 and so forth. Bleeding and perforations are known adverse events of this procedure. Freehand techniques that use needle-knives are associated with higher rates of adverse events,11,12 and these are probably due to poor control of cutting and an inferior hemostatic mechanism of the accessories used. Hence, there is a constant need for new devices and techniques to improve the safety and efficacy of flexible endoscopic therapy.
Ramchandani & Reddy
Take-home Message Endoscopic therapy for Zenker’s diverticulum is increasing, but freehand techniques that use needleknives are associated with higher rates of adverse events. The use of a novel endoscopic scissor and electrocautery allowed for controlled cutting and coagulation with a short procedure time and may reduce adverse events.
Three patients with symptomatic ZD underwent CP myotomy that used a stag beetle knife. Informed consent was obtained from the patients, and institutional review board approval was obtained. Case 1. An 87-year-old man was seen with progressive dysphagia, weight loss, and recurrent bouts of chest infections. A barium swallow study showed a pharyngoesophageal diverticulum, and an upper endoscopy confirmed a wide ostium diverticula involving the cervical esophagus. No other pathology was seen. A CP myotomy using flexible endoscopy was planned. The patient was placed in the left
decubitus position. General anesthesia was given after airway intubation. During the initial endoscopic examination, a standard nasogastric tube was placed into the esophagus over an endoscopically placed guidewire to allow better visualization of the septum by separating the esophageal lumen from the diverticulum. A standard adult upper endoscope (GIF Q 180; Olympus, Tokyo, Japan) was then passed orally alongside the nasogastric tube to the level of the ZD and the cricopharyngeal septum. A transparent cap (MH-593; Olympus) was used for better exposure of the CP septum and muscle. CP myotomy was performed with a stag beetle knife and electrocautery (ERBE electrosurgical generator ICC 200; ERBE, Marietta, Georgia, USA). The stag beetle knife (standard type) was first used to grasp the mucosa and submucosa (Fig. 2), and after an initial short burst of coagulation current (soft coagulation 40 W), mucosa and submucosa were cut by using the Endocut mode (Endocut Q, effect 1). This procedure was done repeatedly and gently to selectively catch and dissect the muscle fibers of the ZD bridge with forward traction, thus allowing precise control of the depth and direction of the incision during the whole procedure (Video 1, available online at www.giejournal.org). The procedure was completed, and a prophylactic clip was applied at the bottom of the cut. Total procedure time was 12 minutes. No immediate postprocedure adverse events were encountered. The patient resumed a normal diet after 48 hours and was symptom free. A follow-up barium swallow done at 48 hours revealed significant improvement. Case 2. A 71-year-old woman was seen with several years of progressively worsening dysphagia, first with solids and then with liquids. During the past several years she had several episodes of choking, with food getting stuck in her throat, and she had a significant amount of weight loss. She was diagnosed with a ZD on a barium swallow study, which was confirmed on esophagogastroscopy. Subsequently, she underwent flexible endoscopic CP myotomy with a stag beetle knife. She had complete resolution of symptoms, and 2 days after the procedure a cine barium swallow demonstrated normal swallowing function without evidence of esophageal leakage or obstruction. There was a minor ooze during the procedure. The oozing site was grasped with the same forceps, and hemostasis was achieved by using soft coagulation (40 W). The total procedure time was 10 minutes. No other postprocedure adverse events were noted.
646 GASTROINTESTINAL ENDOSCOPY Volume 78, No. 4 : 2013
www.giejournal.org
METHODS Device We report our experience of flexible endoscopic CP myotomy that uses a novel scissors-type grasping device called a stag beetle knife (Sumitomo Bakelite, Tokyo, Japan). This device, originally developed for endoscopic submucosal dissection13,14 (ESD), was used for the incision of the bridge between the ZD and the esophagus. This device is a rotatable electrosurgical forceps device that can be used like a pair of scissors. These forceps have a claw and curved scissors and are designed to prevent unnecessary injury to the normal adjacent structures (Fig. 1). It is a monopolar device, and all other parts of the knife except the blades are completely insulated to concentrate the electric current only on the blades and prevent injury to adjacent areas. The stag beetle knife line includes the following: standard type (7 mm knife), short type (6 mm knife), and thin type (SB knife Jr.; 3.5 mm knife).
Study participants and procedure
Ramchandani & Reddy
Zenker’s diverticulum
Figure 1. A, Stag beetle knife seen in open position. The outer surface of the knife is completely insulated (arrow). B, Stag beetle knife in closed position. C, Inner surface of the stag beetle knife with cutting knife (arrow).
Figure 2. A, Zenker’s bridge or septum nicely exposed with esophageal lumen on top with nasogastric tube in situ, diverticular lumen is seen in the bottom. B, Stag beetle knife in open position. C, Septal tissues grasped with the stag beetle knife before cutting. D, Septum completely divided.
Case 3. An 80-year-old man presented with a history of dysphagia predominantly for solid foods; he also complained of postprandial regurgitation. He had no episodes of choking or documented lower respiratory chest infections. The diagnosis of ZD was made after barium swallow and esophagogastroscopy. He also underwent flexible endoscopy CP myotomy with a stag beetle knife. In this procedure, a soft diverticuloscope (ZD overtube, ZDO22-30; Wilson-Cook, Winston-Salem, NC, USA) was used
for the exposure of the septum. The total procedure time was 10 minutes, with no intraprocedure or postprocedure adverse events.
www.giejournal.org
Volume 78, No. 4 : 2013 GASTROINTESTINAL ENDOSCOPY 647
RESULTS By using this novel stag beetle knife, we found that all patients underwent successful CP myotomy. There was
Zenker’s diverticulum
significant symptomatic improvement in all patients. One mild oozing bleeding episode occurred during the procedure. Bleeding was successfully terminated by grasping the vessel and applying coagulation current. No additional instruments were used other than the stag beetle knife. The total time of CP myotomy in 3 patients was 12 minutes, 10 minutes, and 10 minutes, respectively. Mean procedure time was 10.6 minutes.
DISCUSSION CP myotomy is the mainstay of treatment in patients with ZD. The incision of the septum should extend along its entire vertical length, starting from the mucosal side to the bottom of the sac where the diverticulum wall meets the esophageal wall. Precision is important because a longer incision can lead to perforation, whereas a shorter incision can lead to an incomplete CP. The advantage of using a stag beetle knife is that it facilitates the procedure of “grasp and cut,” instead of just cut, as with other knives. Incision or dissection can be accomplished easily by holding the tissue with the knife and pulling it toward the operator. Although CP myotomy by using monopolar forceps has been reported previously,9 the forceps used were not insulated from the outer side, and there are high chances of thermal energy dissipating toward the adjoining areas. In our case series, we demonstrated the safety and ease of using a stag beetle knife in doing CP myotomy. The procedure time in the first case was 12 minutes, whereas the latter 2 cases took 10 minutes each. The first advantage of the stag beetle knife is safety: the cutting is limited to the inner blades, and the operator can more readily see the muscle before cutting or dissecting. Also, because the muscle fibers can be better viewed, cutting can be stopped should the cutting point be incorrect or adverse events arise. This is important, especially when the last part of the septum is to be dissected, because more precise movements at the target site, with careful selection of tissue to be cut, is required to prevent perforation. In Europe, authors have described the use of a soft diverticuloscope during the flexible endoscopic CP myotomy.12,15 This technique involves the use of a soft diverticuloscope that straddles the CP bridge, providing both stability and sufficient exposure of the Zenker’s bridge. In case 3, a soft diverticuloscope was used for exposing the bridge. However, this endoscope is not available in all countries. We believe the stability of the device makes the diverticuloscope less useful. In some centers, the perforation rate by using the needle-knife is relatively high.11,12 Prevention of perforation would offset the cost of this device. Although larger amounts of tissue can be grasped, the controllability and visibility of the distal tip and stepwise approach when using the stag beetle knife prevents cutting through the diverticulum. Another advantage of this forceps is that it can clip a vessel and coagulate blood; it also serves as hemostatic 648 GASTROINTESTINAL ENDOSCOPY Volume 78, No. 4 : 2013
Ramchandani & Reddy
forceps, and thus the need for a separate hemostatic device is avoided. We encountered mild bleeding in case 2, which was managed by using the stag beetle knife itself. A flexible bipolar hemostasis forceps is desirable in this situation because it would facilitate precise endoscopic diverticulotomy and simultaneously enable sealing of divided tissue edges. However, currently available bipolar forceps are bulky and cannot be passed through regular flexible endoscopes. In summary, we report a case series of ZD successfully treated by flexible endoscopic CP myotomy by using a stag beetle knife. The advantage of this new technique is better control of cutting and hemostatic abilities. Randomized trials are needed to show superiority of the stag beetle knife compared with a needle-knife, with and without the use of a soft diverticuloscope.
REFERENCES 1. Keck T, Rozsasi A, Grün PM. Surgical treatment of hypopharyngeal diverticulum (Zenker’s diverticulum). Eur Arch Otorhinolaryngol 2010;267:587-92. 2. Mulder CJJ, den Hartog G, Robijn RJ, et al. Flexible endoscopic treatment of Zenker’s diverticulum: a new approach. Endoscopy 1995;27: 438-42. 3. Herrero Egea A, Pérez Delgado L, Tejero-Garcés Galve G, et al. Treatment of Zenker’s diverticulum: comparison of different techniques. Acta Otorhinolaryngol Esp 2013;64:1-5. 4. Peretti G, Piazza C, Del Bon F, et al. Endoscopic treatment of Zenker’s diverticulum by carbon dioxide laser. Acta Otorhinolaryngol Ital 2010;30:1-4. 5. Philippsen LP, Weisberger EC, Whiteman TS, et al. Endoscopic stapled diverticulotomy: treatment of choice for Zenker’s diverticulum. Laryngoscope 2000;110:1283-6. 6. Hondo FY, Maluf-Filho F, Giordano-Nappi JH, et al. Endoscopic treatment of Zenker’s diverticulum by harmonic scalpel. Gastrointest Endosc 2011;74:666-71. 7. Vogelsang A, Preiss C, Neuhaus H, et al. Endotherapy of Zenker’s diverticulum using the needle-knife technique: long-term follow-up. Endoscopy 2007;39:131-6. 8. Repici A, Pagano N, Romeo F, et al. Endoscopic flexible treatment of Zenker’s diverticulum: a modification of the needle-knife technique. Endoscopy 2010;42:532-5. 9. Christiaens P, De Roock W, Van Olmen A, et al. Treatment of Zenker’s diverticulum through a flexible endoscope with a transparent obliqueend hood attached to the tip and a monopolar forceps. Endoscopy 2007;39:137-40. 10. Rabenstein T, May A, Michel J, et al. Argon plasma coagulation for flexible endoscopic Zenker’s diverticulotomy. Endoscopy 2007;39:141-5. 11. Case DJ, Baron TH. Flexible endoscopic management of Zenker diverticulum: the Mayo Clinic experience. Mayo Clin Proc 2010;85:719-22. 12. Costamagna G, Iacopini F, Tringali A, et al. Flexible endoscopic Zenker’s diverticulotomy: cap-assisted technique vs. diverticuloscope-assisted technique. Endoscopy 2007;39:146-52. 13. Honma K, Kobayashi M, Watanabe H, et al. Endoscopic submucosal dissection for colorectal neoplasia. Dig Endosc 2010;22:307-11. 14. Oka S, Tanaka S, Takata S, et al. Usefulness and safety of SB knife Jr in endoscopic submucosal dissection for colorectal tumors. Dig Endosc 2012;24(suppl 1):90-5. 15. Huberty V, El Bacha S, Blero D, et al. Endoscopic treatment for Zenker’s diverticulum: long-term results (with video). Gastrointest Endosc 2013;77:701-7.
www.giejournal.org
New endoscopic “scissors” to treat Zenker’s diverticulum (with video) Mohan Ramchandani, MD, DM, D. Nageshwar Reddy, MD, DM, FRCP Hyderabad, India
Background: Zenker’s diverticulum (ZD) is a rare disorder but is associated with significant morbidity. Cricopharyngeal (CP) myotomy is the mainstay of treatment, and various flexible endoscopic techniques have been used for division of the septum. However, there is a constant need for improvement in accessories. Objective: To evaluate the safety and effectiveness of a new electrocautery endoscopic scissor for CP myotomy in patients with symptomatic ZD. Design: Observational human study. Setting: Tertiary-care hospital. Patients: This study involved 3 patients with symptomatic ZD. Intervention: Flexible endoscopic CP myotomy was performed by using a novel scissors-type grasping device. CP myotomy involved 4 steps: (1) opening of the forceps, (2) grasping the muscle fiber, (3) closure of the forceps with application of gentle traction, and (4) dissection of muscle fibers by using cutting current. Intraprocedural bleeding was controlled with the same instrument by grasping vessels and applying coagulation current. Main Outcome Measurements: Overall feasibility and performance, procedure time to achieve complete CP myotomy. Results: CP myotomy was successfully performed in all patients. Mean procedure time was 10.6 minutes. There were no major adverse events. Minor intraprocedure bleeding occurred in 1 patient. Limitations: Single arm, limited number of patients. Conclusion: The new instrument has potential advantages in comparison with standard instruments used for CP myotomy. The advantages of this new technique are better control of cutting and hemostatic abilities.
Zenker’s diverticulum (ZD) is a mucosal outpouching of cervical esophagus through the Killian triangle. Cricopharyngeal (CP) myotomy is a critical component of the treatment and can be achieved by conventional open surgery1 or endoscopic methods,2 by using either a flexible or rigid endoscope. Procedure-related morbidity and hospital
stay are much higher with the surgical approach as compared with those of endoscopic methods.3 The septum, or Zenker’s bridge, is between the ZD and the lumen of the esophagus and consists of mucosa, submucosa, connective tissue, and a muscle layer. Endoscopic treatment is based on cutting this septum. Incision of the septum reduces
Abbreviations: CP, cricopharyngeal; ESD, endoscopic submucosal dissection; ZD, Zenker’s diverticulum.
Copyright ª 2013 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2013.06.003
DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.
Received March 5, 2013. Accepted June 5, 2013. Current affiliations: Asian Institute of Gastroenterology, Hyderabad, India.
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. www.giejournal.org
Reprint requests: Dr D. Nageshwar Reddy, Asian Institute Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082 India.
of
If you would like to chat with an author of this article, you may contact Dr Reddy at [email protected].
Volume 78, No. 4 : 2013 GASTROINTESTINAL ENDOSCOPY 645
Zenker’s diverticulum
cricopharyngeal spasm and also removes the partition between the diverticulum and esophageal lumen so that food can pass more easily into the esophagus. CP myotomy can be achieved by various endoscopic methods including laser,4 stapler,5 or harmonic scalpel.6 Stapling devices used via rigid endoscopes are suitable for patients with good neck flexibility, favorable dentition, and large diverticula. The flexible endoscope method is much simpler and less invasive than a rigid endoscope method. Several reports of intraluminal treatment of ZD by using a flexible endoscope have been published, with the possibility of many different techniques: needle-knife,7 hook-knife,8 monopolar forceps,9 argon plasma coagulation,10 and so forth. Bleeding and perforations are known adverse events of this procedure. Freehand techniques that use needle-knives are associated with higher rates of adverse events,11,12 and these are probably due to poor control of cutting and an inferior hemostatic mechanism of the accessories used. Hence, there is a constant need for new devices and techniques to improve the safety and efficacy of flexible endoscopic therapy.
Ramchandani & Reddy
Take-home Message Endoscopic therapy for Zenker’s diverticulum is increasing, but freehand techniques that use needleknives are associated with higher rates of adverse events. The use of a novel endoscopic scissor and electrocautery allowed for controlled cutting and coagulation with a short procedure time and may reduce adverse events.
Three patients with symptomatic ZD underwent CP myotomy that used a stag beetle knife. Informed consent was obtained from the patients, and institutional review board approval was obtained. Case 1. An 87-year-old man was seen with progressive dysphagia, weight loss, and recurrent bouts of chest infections. A barium swallow study showed a pharyngoesophageal diverticulum, and an upper endoscopy confirmed a wide ostium diverticula involving the cervical esophagus. No other pathology was seen. A CP myotomy using flexible endoscopy was planned. The patient was placed in the left
decubitus position. General anesthesia was given after airway intubation. During the initial endoscopic examination, a standard nasogastric tube was placed into the esophagus over an endoscopically placed guidewire to allow better visualization of the septum by separating the esophageal lumen from the diverticulum. A standard adult upper endoscope (GIF Q 180; Olympus, Tokyo, Japan) was then passed orally alongside the nasogastric tube to the level of the ZD and the cricopharyngeal septum. A transparent cap (MH-593; Olympus) was used for better exposure of the CP septum and muscle. CP myotomy was performed with a stag beetle knife and electrocautery (ERBE electrosurgical generator ICC 200; ERBE, Marietta, Georgia, USA). The stag beetle knife (standard type) was first used to grasp the mucosa and submucosa (Fig. 2), and after an initial short burst of coagulation current (soft coagulation 40 W), mucosa and submucosa were cut by using the Endocut mode (Endocut Q, effect 1). This procedure was done repeatedly and gently to selectively catch and dissect the muscle fibers of the ZD bridge with forward traction, thus allowing precise control of the depth and direction of the incision during the whole procedure (Video 1, available online at www.giejournal.org). The procedure was completed, and a prophylactic clip was applied at the bottom of the cut. Total procedure time was 12 minutes. No immediate postprocedure adverse events were encountered. The patient resumed a normal diet after 48 hours and was symptom free. A follow-up barium swallow done at 48 hours revealed significant improvement. Case 2. A 71-year-old woman was seen with several years of progressively worsening dysphagia, first with solids and then with liquids. During the past several years she had several episodes of choking, with food getting stuck in her throat, and she had a significant amount of weight loss. She was diagnosed with a ZD on a barium swallow study, which was confirmed on esophagogastroscopy. Subsequently, she underwent flexible endoscopic CP myotomy with a stag beetle knife. She had complete resolution of symptoms, and 2 days after the procedure a cine barium swallow demonstrated normal swallowing function without evidence of esophageal leakage or obstruction. There was a minor ooze during the procedure. The oozing site was grasped with the same forceps, and hemostasis was achieved by using soft coagulation (40 W). The total procedure time was 10 minutes. No other postprocedure adverse events were noted.
646 GASTROINTESTINAL ENDOSCOPY Volume 78, No. 4 : 2013
www.giejournal.org
METHODS Device We report our experience of flexible endoscopic CP myotomy that uses a novel scissors-type grasping device called a stag beetle knife (Sumitomo Bakelite, Tokyo, Japan). This device, originally developed for endoscopic submucosal dissection13,14 (ESD), was used for the incision of the bridge between the ZD and the esophagus. This device is a rotatable electrosurgical forceps device that can be used like a pair of scissors. These forceps have a claw and curved scissors and are designed to prevent unnecessary injury to the normal adjacent structures (Fig. 1). It is a monopolar device, and all other parts of the knife except the blades are completely insulated to concentrate the electric current only on the blades and prevent injury to adjacent areas. The stag beetle knife line includes the following: standard type (7 mm knife), short type (6 mm knife), and thin type (SB knife Jr.; 3.5 mm knife).
Study participants and procedure
Ramchandani & Reddy
Zenker’s diverticulum
Figure 1. A, Stag beetle knife seen in open position. The outer surface of the knife is completely insulated (arrow). B, Stag beetle knife in closed position. C, Inner surface of the stag beetle knife with cutting knife (arrow).
Figure 2. A, Zenker’s bridge or septum nicely exposed with esophageal lumen on top with nasogastric tube in situ, diverticular lumen is seen in the bottom. B, Stag beetle knife in open position. C, Septal tissues grasped with the stag beetle knife before cutting. D, Septum completely divided.
Case 3. An 80-year-old man presented with a history of dysphagia predominantly for solid foods; he also complained of postprandial regurgitation. He had no episodes of choking or documented lower respiratory chest infections. The diagnosis of ZD was made after barium swallow and esophagogastroscopy. He also underwent flexible endoscopy CP myotomy with a stag beetle knife. In this procedure, a soft diverticuloscope (ZD overtube, ZDO22-30; Wilson-Cook, Winston-Salem, NC, USA) was used
for the exposure of the septum. The total procedure time was 10 minutes, with no intraprocedure or postprocedure adverse events.
www.giejournal.org
Volume 78, No. 4 : 2013 GASTROINTESTINAL ENDOSCOPY 647
RESULTS By using this novel stag beetle knife, we found that all patients underwent successful CP myotomy. There was
Zenker’s diverticulum
significant symptomatic improvement in all patients. One mild oozing bleeding episode occurred during the procedure. Bleeding was successfully terminated by grasping the vessel and applying coagulation current. No additional instruments were used other than the stag beetle knife. The total time of CP myotomy in 3 patients was 12 minutes, 10 minutes, and 10 minutes, respectively. Mean procedure time was 10.6 minutes.
DISCUSSION CP myotomy is the mainstay of treatment in patients with ZD. The incision of the septum should extend along its entire vertical length, starting from the mucosal side to the bottom of the sac where the diverticulum wall meets the esophageal wall. Precision is important because a longer incision can lead to perforation, whereas a shorter incision can lead to an incomplete CP. The advantage of using a stag beetle knife is that it facilitates the procedure of “grasp and cut,” instead of just cut, as with other knives. Incision or dissection can be accomplished easily by holding the tissue with the knife and pulling it toward the operator. Although CP myotomy by using monopolar forceps has been reported previously,9 the forceps used were not insulated from the outer side, and there are high chances of thermal energy dissipating toward the adjoining areas. In our case series, we demonstrated the safety and ease of using a stag beetle knife in doing CP myotomy. The procedure time in the first case was 12 minutes, whereas the latter 2 cases took 10 minutes each. The first advantage of the stag beetle knife is safety: the cutting is limited to the inner blades, and the operator can more readily see the muscle before cutting or dissecting. Also, because the muscle fibers can be better viewed, cutting can be stopped should the cutting point be incorrect or adverse events arise. This is important, especially when the last part of the septum is to be dissected, because more precise movements at the target site, with careful selection of tissue to be cut, is required to prevent perforation. In Europe, authors have described the use of a soft diverticuloscope during the flexible endoscopic CP myotomy.12,15 This technique involves the use of a soft diverticuloscope that straddles the CP bridge, providing both stability and sufficient exposure of the Zenker’s bridge. In case 3, a soft diverticuloscope was used for exposing the bridge. However, this endoscope is not available in all countries. We believe the stability of the device makes the diverticuloscope less useful. In some centers, the perforation rate by using the needle-knife is relatively high.11,12 Prevention of perforation would offset the cost of this device. Although larger amounts of tissue can be grasped, the controllability and visibility of the distal tip and stepwise approach when using the stag beetle knife prevents cutting through the diverticulum. Another advantage of this forceps is that it can clip a vessel and coagulate blood; it also serves as hemostatic 648 GASTROINTESTINAL ENDOSCOPY Volume 78, No. 4 : 2013
Ramchandani & Reddy
forceps, and thus the need for a separate hemostatic device is avoided. We encountered mild bleeding in case 2, which was managed by using the stag beetle knife itself. A flexible bipolar hemostasis forceps is desirable in this situation because it would facilitate precise endoscopic diverticulotomy and simultaneously enable sealing of divided tissue edges. However, currently available bipolar forceps are bulky and cannot be passed through regular flexible endoscopes. In summary, we report a case series of ZD successfully treated by flexible endoscopic CP myotomy by using a stag beetle knife. The advantage of this new technique is better control of cutting and hemostatic abilities. Randomized trials are needed to show superiority of the stag beetle knife compared with a needle-knife, with and without the use of a soft diverticuloscope.
REFERENCES 1. Keck T, Rozsasi A, Grün PM. Surgical treatment of hypopharyngeal diverticulum (Zenker’s diverticulum). Eur Arch Otorhinolaryngol 2010;267:587-92. 2. Mulder CJJ, den Hartog G, Robijn RJ, et al. Flexible endoscopic treatment of Zenker’s diverticulum: a new approach. Endoscopy 1995;27: 438-42. 3. Herrero Egea A, Pérez Delgado L, Tejero-Garcés Galve G, et al. Treatment of Zenker’s diverticulum: comparison of different techniques. Acta Otorhinolaryngol Esp 2013;64:1-5. 4. Peretti G, Piazza C, Del Bon F, et al. Endoscopic treatment of Zenker’s diverticulum by carbon dioxide laser. Acta Otorhinolaryngol Ital 2010;30:1-4. 5. Philippsen LP, Weisberger EC, Whiteman TS, et al. Endoscopic stapled diverticulotomy: treatment of choice for Zenker’s diverticulum. Laryngoscope 2000;110:1283-6. 6. Hondo FY, Maluf-Filho F, Giordano-Nappi JH, et al. Endoscopic treatment of Zenker’s diverticulum by harmonic scalpel. Gastrointest Endosc 2011;74:666-71. 7. Vogelsang A, Preiss C, Neuhaus H, et al. Endotherapy of Zenker’s diverticulum using the needle-knife technique: long-term follow-up. Endoscopy 2007;39:131-6. 8. Repici A, Pagano N, Romeo F, et al. Endoscopic flexible treatment of Zenker’s diverticulum: a modification of the needle-knife technique. Endoscopy 2010;42:532-5. 9. Christiaens P, De Roock W, Van Olmen A, et al. Treatment of Zenker’s diverticulum through a flexible endoscope with a transparent obliqueend hood attached to the tip and a monopolar forceps. Endoscopy 2007;39:137-40. 10. Rabenstein T, May A, Michel J, et al. Argon plasma coagulation for flexible endoscopic Zenker’s diverticulotomy. Endoscopy 2007;39:141-5. 11. Case DJ, Baron TH. Flexible endoscopic management of Zenker diverticulum: the Mayo Clinic experience. Mayo Clin Proc 2010;85:719-22. 12. Costamagna G, Iacopini F, Tringali A, et al. Flexible endoscopic Zenker’s diverticulotomy: cap-assisted technique vs. diverticuloscope-assisted technique. Endoscopy 2007;39:146-52. 13. Honma K, Kobayashi M, Watanabe H, et al. Endoscopic submucosal dissection for colorectal neoplasia. Dig Endosc 2010;22:307-11. 14. Oka S, Tanaka S, Takata S, et al. Usefulness and safety of SB knife Jr in endoscopic submucosal dissection for colorectal tumors. Dig Endosc 2012;24(suppl 1):90-5. 15. Huberty V, El Bacha S, Blero D, et al. Endoscopic treatment for Zenker’s diverticulum: long-term results (with video). Gastrointest Endosc 2013;77:701-7.
www.giejournal.org