Therapy of Zenker’s diverticulum: Endoscopic Diverticulotomy

Abstract

Endoscopic mucomyotomy fell into disfavor in Germany in the 1950’s as the result of three fatal hemorrhages. In the 1980’s, van Overbeek and Hoeksma (1982, 1984) and van Overbeek (1994) reported on 545 cases of mucomyotomy with a CO2 laser that was directed by mirrors through the operating microscope. Thus, after the development of the Weerda spreading diverticuloscope—not the Weerda laryngoscope, as was stated in the article—and of other new instruments, we were able to start performing endoscopic mucomyotomy in Germany once again. An intraluminal Doppler ultrasonography device was used to localize large blood vessels (1, 2). A residual septum remains in the fundus when division is performed with the Endo-GIA-30 stapler, because the foot of the stapler is 1 cm in size (2). An important complication was not mentioned: The mediastinum is always opened, and this happens to the greatest extent in the area of the fundus. This situation is depicted incorrectly in figure 3. The consequences occasionally include dramatic subcutaneous and mediastinal emphysema. These phenomena are not due to microscopic openings, as was stated in the article. In a group of patients that had not undergone surgery, we observed fever in 53.1%, as a sign of mediastinal irritation; 1.6% developed mediastinitis (2, 3). We attribute the high recurrence rates to two causes: (a) the septum is not divided all the way to the fundus, and (b) after division, the cut edges come together again and fuse, particularly in the vicinity of the fundus (2). In order to minimize these complications, we have proposed the following measures (1–3): After mucomyotomy with the CO2 laser, the mediastinum should be sealed with fibrin glue under optimal vision through the spreading diverticuloscope. Superfluous mucosa should be resected. The fundus and the cut edges should be closed microsurgically. We recommend a liquid diet postoperatively. For medicolegal reasons, we also recommend a brief period of in-hospital observation. If all of these recommendations are followed, endoscopic mucomyotomy becomes a low-risk operation, but not a risk-free one. It remains superior to open surgery.