880 Endoscopic Treatment of Zenker's Diverticulum by Harmonic Scalpel: Experimental and Human Results

Abstract

Zenker's diverticulum, also known as cricopharyngeal or pharyngoesophageal diverticulum, is the most common type of diverticulum in the upper GI tract. Open diverticulectomy and cricopharyngeal myotomy is usually indicated with good results. Considering that this condition affects mostly the elderly population, less invasive treatment might be useful. Diathermic monopolar current, argon plasma coagulation and laser have already been employed to incise the muscular septum with satisfactory results. Complications are still the main limitation of endoscopic treatment, Perforation and hemorrhage have been reported in up to 23% and 10% of the patients respectively.The harmonic scalpel or ultracision has been used in laparoscopic surgeries providing adequate and accurate hemostasis. The aim of this study was to present the technique for endoscopic diverticulotomy with harmonic scalpel in suine model and patients with Zenker's diverticulum and the short-term clinical results obtained with this technique. First of all, endoscopic diverticulotomy was performed in 20 pigs, comparing standard technique (Group M - needle knife and monopolar current) to harmonic scalpel technique (Group U). After, in a human model, 20 patients were submitted to endoscopic diverticulotomy by harmonic scalpel technique5 patients. Endoscopic technique: A videogastroscope was used to evaluate the pharyngoesophageal diverticulum and the esophagus. With the endoscope in the esophagus, a soft diverticuloscope was positioned. A shear-type harmonic scalpel was introduced through the soft diverticuloscope along with a thin endoscope. The septum was divided between the diverticulum and the esophagus up to approximately 5mm above the bottom of the diverticular pouch. In experimental model (Table 1), the time of incision and total time were less in group U (p<0,0001). The size of border were 1,92 ±0,38 cm in group M and 2,38 ±0,25 cm in group U (p=0,00047). Regarding about microscopic parameters, only the extension of damage caused by the devices had difference (p<0,0001), in group M was 3,20 ± 0,9 mm and group U was 0,69 ± 0,25 mm. In group M, had more cases of hemorrhage (six suines - p=0,0108). In human trial, 20 cases were done, average age 73,4 ±9,75, range from 52 to 86 years. Complete resection in one session were possible in 19 (95%) patients. The average time of procedure was 14,8 ± 3,58 minutes. Any case of bleeding, one (5%) case of perforation, treated by clinical management. Improvement of dysphagia were possible in all cases after one months. Despite swallowing improvement, four (20%) patients still complain of dysphagia to solid food (Table 2).Table 1Comparative results of experimental modelPARAMETERSGROUP MGROUP Up-ValueDiverticulum Size (cm)2,6 ± 0,5163 ± 0,4710,0897Overtube time (s)31,6 ± 8,1830,4 ± 7,650,7387Procedure time (s)352 ± 71,7783 ± 18,89<0,0001Total Time (s)383,9 ± 72,28113,4 ± 23,74<0,0001Border Length (cm)1,92 ± 0,382,38 ± 0,250,0047Extension of Damage (mm)3,2 ± 0,90,69 ± 0,25<0,0001 Open table in a new tab Table 2Patient's Dysphagia ScoresPATIENTBEFORE PROCEDUREAFTER 30 DAYS OF PROCEDURE1III02I03IIII4II05I06I07I08IIII9I010III011III012II013II014IIII15I016II017III018I019IIII20II0Grade 0 = no dysphagia; Grade I = dysphagia to solid; Grade II = dysphagia to semi-solid; Grade III = dysphagia to liquid; Grade IV = no saliva swallowing. Open table in a new tab Grade 0 = no dysphagia; Grade I = dysphagia to solid; Grade II = dysphagia to semi-solid; Grade III = dysphagia to liquid; Grade IV = no saliva swallowing. Endoscopic treatment of Zenker's Diverticulum by harmonic scalpel demonstrated to be secure and reliable technique with good control of hemorrhage.