CO2 Laser versus Stapler‐Assisted Endoscopic Zenker's Diverticulotomy: A Systematic Review

Abstract

Objectives: To evaluate outcomes following endoscopic Zenker’s diverticulotomy using a carbon dioxide (CO2) laser or stapler-assisted technique. Methods: Systematic review and meta-analysis of retrospective studies comparing CO2 laser and stapler-assisted endoscopic Zenker’s diverticulotomy were performed. PubMed, Scopus (Embase), and United States and United Kingdom clinical trial registries were searched. References were cross-checked. Results: No randomized controlled trials were identified. Six studies were included: 2 retrospective reviews of consecutive patients, 3 retrospective reviews with unknown consecutive status, and 1 case series totaling 379 procedures (219 laser, 160 stapler). Individual study outcomes favoring the stapler technique included a shorter duration of nil per os (NPO) status and hospital stay (4 studies), as well as fewer postoperative fevers and abnormal chest x-rays (1 study). Individual study outcomes favoring the laser technique included greater improvement in postoperative dysphagia and regurgitation scores and a lower revision rate (1 study). Random effects meta-analysis of 2 appropriate studies demonstrated a greater duration of NPO status (weighted mean difference (WMD): 1.14, 95% confidence interval [0.46-1.81]) and hospital stay (WMD: 2.84 [2.10-3.58]) for the laser technique. Mantel-Haenzel fixed effects meta-analysis of all studies suggested a greater rate of non-dental complications (odds ratio (OR): 2.32 [0.87-6.20]) and revision surgery (OR: 1.27 [0.68-2.36]) for the laser technique, but differences were not statistically significant. Conclusions: The stapler-assisted technique may shorten duration of NPO status and hospital stay, while decreasing complication and revision rates compared to the laser technique for endoscopic Zenker’s diverticulotomy; however, the best available evidence is Level 4.