Tu1171 EXPERIENCE WITH ENDOSCOPIC ZENKER'S DIVERTICULOTOMY IN A COMMUNITY HOSPITAL SETTING

Abstract

Phargynoesophageal diverticulum (Zenker’s) is a posterior herniation of the cervical esophageal mucosa which impairs the opening of the upper esophageal sphincter leading to its classic symptoms. Over the past decade there has been a shift to using new, minimally invasive techniques which includes using new endoscopic devices to divide the septum between the esophagus and Zenker’s pouch with reported improvements in morbidity, recovery time, and efficacy. We report the experience of a single endoscopist at a community hospital by using a flexible endoscopic (FE) technique to perform diverticulotomy for treatment of Zenker’s (ZD). A total of 31 patients, 52-97 years old (mean 77.3) presented with variety of symptoms including: dysphagia, regurgitation, cough, weight loss, aspiration, or globus. Most were referred due to extensive comorbidities, poor neck extension, or advanced age. Their ZDs were treated with the same endoscopic technique, by a single endoscopist from March 2014 to October 2016. A GIF 180 or 190 Olympus gastroscope was used for the examination, fitted with a clear cap. Cricopharyngeal myotomy (CPM) was performed using an Olympus triangulated tip needle knife. The cut was extended until all muscle fibers were cut. An ERBE generator was used and the myotomy was made in dry cut mode. All patients were intubated for airway protection during the procedure and post intervention a majority of were admitted for a minimum of 1 day and given prophylactic antibiotics (Unasyn 1.5g Q6H). They were made NPO until a follow up esophagram with gastrografin demonstrated no evidence of perforation, at which time a liquid diet was started. Procedural success was described by symptomatic improvement, and if there was a need for re-intervention. Complications were grouped into major and minor. Minor included: fever, chest pain, and brief hypoxia. Major included perforation. The median size of the ZD was 3.5 (range 1-5 cm). Post procedural clinical response was 100%, with only one (3%) having symptom recurrence, requiring second procedure 1 year later. Median hospital stay was 1.58 (range 1-8 days), and the major complication rate was 3%, while minor complications were seen in 16%. All complications were managed conservatively without the need for surgery or other radiological interventions. FE Zenker’s diverticulotomy is safe and efficient. Nevertheless, there is not yet a consensus on this technique within the interventional endoscopy community. Using hemostatic clips to close the mucosal defect has allowed us to decrease the risk for complications dramatically. Continuous improvement in technique through possible collaboration with other high-volume centers and the emergence of new technology will likely allow FE to become the preferred therapy for symptomatic ZD.View Large Image Figure ViewerDownload Hi-res image Download (PPT)