Zenker’s diverticulum (ZD) is an acquired pulsion pouch that was first described by Ludlow in 1769. It develops within a natural anatomic dehiscence zone (Killian’s triangle), which is located between the cricopharyngeal and the inferior constrictor muscles, and is due to failure of the cricopharyngeus to relax with swallowing.
The principles of treatment include division of the obstructing cricopharyngeal muscle and adequate drainage of the pouch. This can be achieved successfully with an endoscopic per-oral technique using an endoscopic stapler, as described by Collard in 1993.
Adequate cervical extension and opening of the mouth are a prerequisite for the procedure, which is otherwise indicated for all patients having a symptomatic ZD larger than 2.0cm. Very small diverticula (< 1.0cm), make it difficult to achieve adequate exposure and a complete myotomy; in contrast, very large diverticula leave behind a residual pouch which may be responsible for postoperative dysphagia.
ESD provides short inpatient and operating times, along with a short anesthesia time (mean of 10 to 30 minutes duration). Also, it only causes a mild postoperative discomfort and the patient is able to resume a diet on the same day. It is therefore cost-effective. The most common encountered complications are chipped teeth, postoperative fever and aspiration pneumonia.
Overall, results of this technique in appropriately selected patients are excellent, with a success rate well above 90%.
Needed equipment for this procedure includes:
- Weerda’s diverticuloscope
- Endopath™ articulating endoscopic stapler ATB 45
- Standard cartridges 45mm/3.5mm
- Endo Stitch™ with 2/0 silk sutures
- Closed-end esophageal suction
- 4mm, 0-degree rigid endoscope, 30cm long
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