Interventional Endoscopy Research Articles

Complication rates of trainee- versus attending-performed upper gastrointestinal endoscopy.

BackgroundAlthough esophagogastroduodenoscopy (EGD) is usually the first procedure trainees learn, it is not known whether the involvement of a trainee affects the procedure’s complication rate, a key quality and safety indicator. The purpose of this study was to determine whether the complication rate of fellow-performed upper endoscopy differs from that of attending gastroenterologists, and whether that difference varies with the level of training.MethodsEmergency room visits within 14 days of an outpatient EGD deemed to be probably or definitely related to the EGD were categorized as complications. Complication rates were calculated for attending- and trainee-performed gastrointestinal endoscopies, the latter stratified by level of training.ResultsForty-five attendings and 43 fellows performed 21,899 EGDs during the study period. There were 43 complications (1.96 per 1000 EGDs). Procedures performed by any fellow were more likely to have a complication than those performed by an attending (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.17-4.6). This difference was driven by a higher rate of complications among fellows who had completed general gastroenterology training and were in advanced training (OR 3.8, 95%CI 1.76-8.04); all of these complications involved trainees in interventional endoscopy. Fellows in any year of general gastroenterology training were not more likely to cause complications than attendings.ConclusionsThe rate of complications from EGDs performed by fellows in their general gastroenterology training does not differ from that of attending endoscopists. The complication rate of advanced trainees exceeded that of attendings, but this is likely to be attributable to the higher-risk interventions undertaken by fellows in interventional endoscopy.

The Lithiasis of Choledoque: Epidemiological Aspects, Clinics and Therapeutiques in the Surgery Department “A” at the University Hospital Point G

Considered as rare in Africa lithiasis of the main bile duct (MBD) is a potentially serious pathology, diagnosis is facilitated by imaging tests (ultra-sound, CT, MRI cholangiopancreatography). Its surgical management is improved by laparoscopy coupled with interventional endoscopy. However, laparotomy remains the only way in Mali. This was a 14-years retrospective and descriptive study (2010-2014). All patients with BPV lithiasis were included. We studied the field, antecedents, clinical, biological, radiological, therapeutic and outcome aspects. 40 cases of stones in the main bile duct were collected during the study period. The hospital frequency was 2.8 cases per year, the clinical signs dominated by the Charcot triad (pain, fever, jaundice) found in 40 cases (100%). The average age was 60 years, female represented 70% of cases. Ultrasonography was the most requested review in 40 cases (100%). The procedure performed was cholecystectomy associated with choledochotomy with calculation extraction in all patients (100% of cases). One case of biliary fistula and one case of wall abscess were observed. The mortality was 5% and the simple suited in 90% of the cases. The lithiasis of the main bile duct is an infrequent pathology in Mali and potentially serious. This diagnosis is assisted in our context by ultrasound and CT. Laparotomy remains the only route of entry in Mali.

125 μm fiber based all-optical ultrasound probes for pulse-echo imaging

All-optical ultrasound probes that contain a photoacoustically-based ultrasound generator paired with a photonic acoustic sensor provide a promising imaging modality for diagnostic and MRI-compatible applications. Here, we demonstrate the fabrication of a fiber-based all-optical ultrasound probe and its applications in pulse-echo ultrasound imaging. The ultrasound generator is fabricated on a 125 μm multimode optical fiber by forming a light-absorbing multiwalled carbon nanotube (MWCNT)-polydimethylsiloxane (PDMS) composite coating on its distal end. A peak-to-peak acoustic pressure of 0.95 MPa was achieved with laser irradiation at 2.46 μJ by chemically functionalizing the fiber surface to enable a strong adsorption. Ultrasound reception was performed by a fiber-laser ultrasound sensor that translates ultrasound pressure into differential lasing-frequency changes. By linearly scanning the probe, ex vivo two- and three-dimensional imaging of a segment of swine trachea was demonstrated by detecting the echo ultrasound signals and reconstructing the acoustic scatterers. The probe presents axial and lateral resolutions at 150 and 62 μm, respectively. The small-sized, side-looking all-fiber ultrasound probe presents a promising approach for assembling an interventional endoscopy.

Interventional Radiology-Operated Endoscopy: Indications, Implementation, and Innovation.

Interventional Radiology-Operated Endoscopy: Indications, Implementation, and Innovation.

103. Multi-site experiences of radiation dose index monitoring (RDMI) in interventional radiology (IR) and cardiology

Purpose The Council Directive 2013/59/EURATOM considers IR to be a special practice involving high doses and requiring strict monitoring to ensure the best quality assurance programs. This work reports the early experience of managing dose data of angiographic patients in a multicenter study. Methods The project has involved a sample of about 10000 procedures gathered from twelve Italian hospitals centers involved on voluntary basis. The survey concerned the collection of data related to different IR procedures: interventional cardiology, radiology, neuroradiology, vascular surgery, Urology, Endoscopy and Pain Therapy from mobile and fixed units. The analysis includes 24 procedure and for each exam, air-kerma, kerma-area product and fluoroscopy time were collected. In few centres data collection was made with the aid of automatic DACS systems. For others, data were collected and processed manually. Results Duration and complexity of fluoroscopic exposures for each procedure are strongly dependent on the individual clinical circumstances, the observed distribution of patient doses is very wide, even for a specified protocol. The fixed radiological machines, all with Flat Panel, are of four different brands: Philips, Siemens, Toshiba and GE; C-arm are Siemens, Philips and Eurocolumbus. The median values of the parameters were compared with the LDRs proposed at Italian level for some procedures (GISE, INAIL, ISS) or at international level. For other procedures without LDRs, this work is a first attempt to propose LDR values also in the light of the ICRP 135. Conclusions This first data collection serves to take stock of the situation on patient’s dosimetry in several sectors and is the starting point for obtaining any LDRs recalling that, these latter, are dependent on the state of practice and the available technology at a particular point in time. A certain degree of patient dose reduction can be achieved without affecting image quality adversely.

Laparoscopic and endoscopic cooperative surgery for gastric tumors: Perspective for actual practice and oncological benefits.

Laparoscopic and endoscopic cooperative surgery (LECS) is a surgical technique that combines laparoscopic partial gastrectomy and endoscopic submucosal dissection. LECS requires close collaboration between skilled laparoscopic surgeons and experienced endoscopists. For successful LECS, experience alone is not sufficient. Instead, familiarity with the characteristics of both laparoscopic surgery and endoscopic intervention is necessary to overcome various technical problems. LECS was developed mainly as a treatment for gastric submucosal tumors without epithelial lesions, including gastrointestinal stromal tumors (GISTs). Local gastric wall dissection without lymphadenectomy is adequate for the treatment of gastric GISTs. Compared with conventional simple wedge resection with a linear stapler, LECS can provide both optimal surgical margins and oncological benefit that result in functional preservation of the residual stomach. As technical characteristics, however, classic LECS involves intentional opening of the gastric wall, resulting in a risk of tumor dissemination with contamination by gastric juice. Therefore, several modified LECS techniques have been developed to avoid even subtle tumor exposure. Furthermore, LECS for early gastric cancer has been attempted according to the concept of sentinel lymph node dissection. LECS is a prospective treatment for GISTs and might become a future therapeutic option even for early gastric cancer. Interventional endoscopists and laparoscopic surgeons collaboratively explore curative resection. Simultaneous intraluminal approach with endoscopy allows surgeons to optimizes the resection area. LECS, not simple wedge resection, achieves minimally invasive treatment and allows for oncologically precise resection. We herein present detailed tips and pitfalls of LECS and discuss various technical considerations.

Injectable Hybrid Hydrogels, with Cell-Responsive Degradation, for Tumor Resection.

Biocompatible soft materials have recently found applications in interventional endoscopy to facilitate resection of mucosal tumors. When neoplastic lesions are in organs that can be easily damaged by perforation, such as stomach, intestine, and esophagus, the formation of a submucosal fluid cushion (SFC) is needed to lift the tumor from the underlying muscle during the resection of neoplasias. Such procedure is called endoscopic submucosal dissection (ESD). We describe an injectable, biodegradable, hybrid hydrogel able to form a SFC and to facilitate ESD. The hydrogel, based on polyamidoamines, contains breakable silica nanocapsules covalently bound to its network and able to release biomolecules. To promote degradation, the hydrogel is composed of cleavable disulfide moieties that are reduced by the cells through secretion of glutathione. The same stimulus triggers the breaking of the silica nanocapsules; therefore, the entire hybrid material can be completely degraded and its decomposition depends entirely on the presence of cells. Interestingly, the hydrogel precursor solution showed rapid gelation when injected in vivo and afforded a long-lasting high mucosal elevation, keeping the cushion volume constant during the dissection. This novel material can provide a solution to ESD limitations and promote healing of tissues after surgery.

Clinical Vignettes/Case Reports — Interventional Endoscopy (Abstracts 2102-2169)

Clinical Vignettes/Case Reports — Interventional Endoscopy (Abstracts 2102-2169)

Learning of flexible endoscopy, particularly endoscopic vacuum therapy (EVT)

Anastomotic insufficiency and perforations in the gastrointestinal tract are severe complications associated with ahigh complication rate and mortality. Conventional treatment options (particularly re-operations) are often unsatisfactory. Endoscopic vacuum therapy (EVT) is increasingly being used as apromising alternative. The use of EVT requires a high level of competence in interventional flexible endoscopy, which is primarily not available to every surgeon. Special training programs are required here. Based on this need the long-proven Tübingen training system for flexible endoscopy was modified to meet the special requirements of surgeons and is currently being extended by aspecial training module for EVT. In addition to the theoretical principles, the training is focused on learning the manual skills for flexible endoscopy. A2-stage process was developed for this purpose: 1) to become familiar with handling of the flexible endoscope and to learn spatial orientation by means of adidactically optimized abstract phantom (Tübingen Orientophant) and 2) learning and training of EVT using anewly developed patient-analogous training model with various insufficiencies and abscess cavities in the upper and lower gastrointestinal tract. The procedure can be trained hands-on step by step exactly as with the patient, whereby the sponge can be applied using different methods, such as overtube and dragging procedures. The consequences of mistakes and complication management can also ideally be trained hands-on using the phantom. Evaluations of the first course series show that surgeons achieve endoscopic competence very quickly and learn to master the new procedure. The structure of such acourse must, however, be designed according to long-term experience in an optimal didactic manner. Decision-makers in healthcare policy should give much more support to such courses in order to improve patient care and to increase patient safety.

Endoscopic Ultrasound-Guided Liver Biopsy Compared to Percutaneous and Transjugular Liver Biopsy: A Tertiary Center Experience: Category Award (Interventional Endoscopy)

Endoscopic Ultrasound-Guided Liver Biopsy Compared to Percutaneous and Transjugular Liver Biopsy: A Tertiary Center Experience: Category Award (Interventional Endoscopy)

Like Clockwork: Efficiency Metrics in an Interventional Endoscopy Suite

Like Clockwork: Efficiency Metrics in an Interventional Endoscopy Suite

When the Sound Surmounts the Magnet: Pancreatic Cancer Imaging

Outcomes in the treatment of pancreatic cancer heavily depends on early detection. CT and MRI scans are common modalities employed in the initial diagnosis of pancreatic tumors. EUS has emerged as a valuable tool to aid in the early diagnosis of pancreatic malignancy and to detail their resectability. We present three patients with MRI and MRCP negative but EUS positive pancreatic cancer. All three patients presented with biliary dilatation where MRI/MRCP failed to detect any discrete pancreatic lesions. Subsequent EUS with core needle biopsy revealed pancreatic adenocarcinoma. The largest lesion was 3.4 cm in size. Two of these lesions resided in the head of pancreas and one in the uncinate process. EUS was performed using a linear array echo endoscope. All cases were performed by a single operator, who is a board certified gastroenterologist and fellowship trained in advanced interventional endoscopy. The mass/lesions were evaluated for its size, echogenicity, lymph node involvement, loco regional extension, ductal size, and major vessel abutment. Tissue samples from these pancreatic masses were harvested via a 22g Shark Core Fine Needle Biopsy (CNB). MRI/MRCP was performed using Philips Ingenia 1.5T MR system. Two of the three cases were presented at tumor board and images were reviewed at tumor board by a second radiologist. The primary impact of endosonography on the management of pancreatic cancer is in detection and cytologic diagnosis. The accuracy of EUS for T staging of pancreatic cancer is reported to be 80-85%, which is similar to that of MRI. The degree of certainty is dependent on the experience of the endoscopist. Most of the T1 lesions are < 2 cm and difficult to image by cross sectional methods. Unfortunately these are the patients who can have a favorable treatment outcome if instituted early in the course of the disease. EUS offer the advantage of detecting pancreatic masses earlier than cross sectional imaging in patients with early features of biliary obstruction. The ampulla and pancreatic portion of the CBD is very well visualized by EUS. More over EUS can provide an overall accuracy of 93% for vascular invasion thus defining resectability. We suggest a low threshold for EUS evaluation of patients with appropriate clinical symptoms in the setting of a negative cross sectional imaging for pancreatic cancer, than the practice of surveillance imaging which may widen the lag time and lead to an unfavorable outcome.1311_A.tif Figure 1: Patient and Imaging characteristics1311_B.tif Figure 2: tumor characteristics

Pancreatico-Pleural Fistula Presenting as Recurrent Bilateral Pleural Effusion: A Rare Complication of Chronic Pancreatitis

Pancreatico-Pleural Fistula (PPF) is a rare complication of chronic pancreatitis associated with significant morbidity and mortality. Diagnosis requires a high level of suspicion and management can be very challenging. We present an unusual presentation of recurrent bilateral pleural effusion secondary to PPF. 62 year old female presented to the hospital with worsening shortness of breath. History of multiple admissions in the last 6 months for recurrent left sided pleural effusions. Thoracentesis done at each visit revealed exudative nature of fluid but failed to identify the underlying etiology. Past history significant for an episode of pancreatitis in 2014 secondary to gall stones for which she underwent cholecystectomy. Chest X-ray revealed bilateral pleural effusions and patient eventually underwent bilateral chest tube placement. CT scan of the chest and abdomen revealed massive bilateral pleural effusion along with calcification of the pancreatic head and dilated pancreatic duct. Also noted were a 4 cm pseudocyst in the body and 7 cm pseudocyst in the tail of the pancreas with connection to the pleural space (Image 1,2). Pleural fluid amylase was elevated at 6915 U/L & lipase >3000 U/L. Patient subsequently underwent ERCP and a pancreatogram revealed a high grade stricture in the neck of the pancreas with extravasation of dye at the tail consistent with an internal pancreatic fistula. A 10 cm 7 fr plastic stent was successfully placed and patient was started on octreotide. Patient was subsequently discharged with bilateral pleurex catheters and daily octreotide injections. Day 60 follow up noted the pleural fluids secretions to be minimal with continued use of octreotide. Pancreatico-Pleural Fistula presenting as recurrent bilateral pleural effusions is an extremely rare complication of chronic pancreatitis. Pleural effusion due to PPF accounts for less than 1% of cases, while pleural effusion can be seen in 3—7% of patients with pancreatitis .Diagnosis requires a high degree of suspicion with supporting laboratory and radiological studies. Conservative treatment with pancreatic duct stenting and/or octreotide has been successful in 31—45% of cases, while surgery is curative in 80—90% of cases but with a high rate of mortality upto 10%. Combination of medical management and interventional endoscopy successfully reduced the pleural drainage in our patient.1400_A.tif Figure 1: CT scan of the chest and abdomen showing massive bilateral pleural effusion along with calcification of the pancreatic head with dilated pancreatic duct.1400_B.tif Figure 2: CT scan chest and abdomen showing a 4 cm pseudocyst in the body and 7 cm pseudocyst in the tail of the pancreas with connection to the pleural space

Excellence in non-small cell lung cancer staging by endobronchial-TBNA: Comparison with PET-CT and surgery

Objective: To determine the correlation and/or discrepancies between positron emission tomography (PET-CT) findings, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and surgery in the staging of non-small cell lung carcinoma.Material and methods: Data were evaluated retrospectively from a prospective interventional endoscopy database. Positive results with EBUS-TBNA was the first end point and all cytology negatives were confirmed with mediastinoscopy/surgery.Results: Four hundred and eighty three patients were included and 1017 lymph nodes (LNs) were sampled in the study. One hundred and twenty eight LNs were excluded (positive with EBUS-TBNA). Four hundred and sixty five LN (52.3%) were found benign with EBUS-TBNA; however, only 15 of these were confirmed to be malignant by surgery (1.7%). The sensitivity, specificity, PPV, NPV and diagnostic accuracy of EBUS-TBNA were 96.5, 100, 100, 96.7 and 98.3%, respectively. The sensitivity, specificity, PPV, NPV and diagnostic accuracy of PET-CT for maximum standardized uptake value (SUVmax) 2.5 were 90.1, 29.2, 55.3, 75.4, 59.2%, respectively. A cut-off SUVmax of 5.2 was detected with 74.8% sensitivity, 84% specificity, 82.0% PPV, 77.5% NPV and 79.5% accuracy (area under the curve (AUC) of 0.818, 95% CI 0.791–0.843, p<.001).Conclusion: EBUS is a reliable, repeatable and safe technique with a high diagnostic accuracy and should be performed quickly to avoid superfluous time loss in the staging of lung cancer.AbbreviationsPET-CTF-18 fluorodeoxyglucose positron emission computed tomographyNSCLCNon-small cell lung cancerEBUS-TBNAEndobronchial ultrasound-guided transbronchial needle aspirationSUVmaxMaximum standardized uptake valueLNsLymph nodesTTF-1Thyroid transcription factor-1H&EHematoxylin and eosin; Med: MediastinoscopyVATSVideo associated thoracic surgeryAUCArea under curveOROdds ratioCIConfidence intervals

Three-Dimensional Printing Facilitates Creation of a Biliary Endoscopy Phantom for Interventional Radiology-Operated Endoscopy Training

To create a three-dimensional endoscopic model of the biliary tract from magnetic-resonance cholangiopancreatography imaging and to evaluate its effectiveness as a tool for training in endoscopic biliary interventions. A magnetic-resonance cholangiopancreatography study was performed on a patient with biliary obstruction secondary to a distal bile duct cholangiocarcinoma. Using Vitrea, a three-dimensional volume-rendered image was created, and exported as a standard tessellated language file. The standard tessellated language model was then edited with MeshMixer. Three cylindrical entry ports were created. The ports were aligned and overlapped with the dominant ducts in three separate areas of the model and fused to the model. A 0.2 cm shell was created around the model and the model was hollowed. The ends of the ports were cut off, allowing access to the hollowed-out model. The model was printed at 125% scale to allow easy access with a 9.5-French (≤3.23 mm) endoscope. The model was printed using a Stratasys Dimension Elite Plus printer. After printing, the model was post-processed to remove support materials. A 10-question survey was administered to all trainees before and after use of the printed phantom to practice endoscopy skills. 11 trainees participated in the three-dimensional endoscopy simulation with most of the trainees (73%) having no prior formal endoscopy training. Using a 10-point Likert scale, the mean comfort-level of the trainees to use endoscopy alone for cholecystostomy, percutaneous biliary drainage, percutaneous nephrostomy, and percutaneous gastrostomy increased by 38.9%, 32.8%, 32.8%, and 34.3%, respectively, following the training experience. The use of a three-dimensionally printed endoscopic model as a simulation tool has the potential to improve trainee comfort using endoscopy during interventional radiology procedures.

Interventional radiology-operated endoscopy using the LithoVue disposable endoscope: Approach, technical success, clinical outcomes, and complications.

Purpose:To report the approach, technical success, clinical outcomes, and complications of interventional radiology-operated endoscopy using the LithoVue disposable endoscope.Materials and Methods:12 patients, 6 (50%) males and 6 (50%) females, underwent interventional radiology-operated endoscopy using the LithoVue disposable endoscope between April 2016 and August 2017. Presenting complaint, reason for endoscopic evaluation, technical success, clinical success, procedure time, fluoroscopy time, hospital length of stay, and complications were recorded.Results:Interventional radiology-operated endoscopy using the LithoVue disposable endoscope was used in 8 (67%) biliary, 2 (16.5%) urologic, and 2 (16.5%) gastrointestinal procedures. Five (42%) patients required endoscopy to locate an ostium that could not be cannulated under fluoroscopy. Five (42%) patients had a biliary-enteric anastomosis with postoperative anatomy of the bowel which precluded endoscopic retrograde cholangiopancreatography and underwent endoscopy for removal of calculi. One (8%) patient underwent treatment of a stricture and one (8%) underwent biopsy. Technical success was 92% (11/12). Clinical success was 83% (10/12). Two complications, a perinephric hematoma and sepsis, occurred.Conclusion:Disposable endoscopes, including the LithoVue, may be used in a variety of procedures to improve patient care and limit fluoroscopy.

Minimally Invasive Management of Abdominal Trauma

AbstractManagement of traumatic abdominal injuries has traditionally relied upon a combination of systematic physical examination, image-guided evaluation, clinical judgment, and, when necessary, maximally invasive surgical intervention. Advances in the fields of interventional radiology, endoscopy, and laparoscopy have altered these traditional treatment algorithms. As growth of these techniques continues, an increasing number of minimally invasive strategies are available to clinicians for the management of abdominal trauma. Here reviewed is a brief overview of minimally invasive strategies for the management of non–solid organ abdominal trauma with a focus on new, minimally invasive diagnostic and treatment tools.

Using Endoscopic Submucosal Dissection as a Routine Component of the Standard Treatment Strategy for Large and Complex Colorectal Lesions in a Western Tertiary Referral Unit.

Colorectal endoscopic submucosal dissection results in high rates of en bloc resection, few recurrences, and accurate diagnosis, and it is useful in lesions with significant fibrosis. However, endoscopic submucosal dissection has not been widely adopted by Western endoscopists and the published experience from Western centers is very limited. This study aims to report the outcomes from a UK tertiary center using colorectal endoscopic submucosal dissection as part of a standard lesion specific treatment approach. This was a retrospective study. The study was conducted in a tertiary referral unit for interventional endoscopy in the United Kingdom. A total of 116 colorectal lesions were resected using endoscopic submucosal dissection or hybrid endoscopic submucosal dissection in 107 patients. Outcomes included complications, recurrence, requirement for surgery, en bloc and R0 resection. One hundred sixteen lesions (mean size 58.8mm) were resected using endoscopic submucosal dissection (n = 58) and hybrid endoscopic submucosal dissection (n = 58). Eighty-two (70.7%) had failed attempts at resection (n = 58) or extensive sampling before referral. Twelve contained invasive adenocarcinoma; endoscopic resection was curative in 6. Only 2 of 6 patients with noncurative endoscopic resection agreed to surgery, and none had lymph node metastases. Six of 7 perforations were successfully treated with endoscopic clips. Where endoscopic submucosal dissection was used alone, en bloc resection was achieved in 93% and R0 resection was achieved in 91%. Two patients experienced recurrence; both were managed with endoscopic resection. This was a retrospective study. Procedures were planned as endoscopic submucosal dissection, but some may have been converted to hybrid endoscopic submucosal dissection and not recorded. Colorectal endoscopic submucosal dissection can be used in a Western center as part of a standard lesion-specific approach to deliver effective organ-conserving treatment to patients with large challenging lesions. Lesion assessment in Western practice should be improved to reduce the incidence of prior heavy manipulation and to guide appropriate referral. See Video Abstract at http://links.lww.com/DCR/A601.

Postoperative interventional endoscopy for the remnant pancreas of patients who have undergone pancreaticoduodenectomy

Postoperative interventional endoscopy for the remnant pancreas of patients who have undergone pancreaticoduodenectomy

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

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)