Transoral flexible endoscopic therapy of Zenker's diverticulum: is it time for gastroenterologists to stick their necks out?
2013; Elsevier BV; Volume: 77; Issue: 5 Linguagem: Inglês
10.1016/j.gie.2013.01.019
ISSN1097-6779
AutoresDavid A. Katzka, Todd H. Baron,
Tópico(s)Tracheal and airway disorders
ResumoZenker's diverticulum (ZD) is an acquired disease that is formed by outpouching of hypopharyngeal mucosa between the inferior pharyngeal constrictor and the cricopharyngeus muscle in an area of junctional muscle weakness known as Killian's triangle.1Dzeletovic I. Ekbom D.C. Baron T.H. Flexible endoscopic and surgical management of Zenker's diverticulum.Expert Rev Gastroenterol Hepatol. 2012; 6 (quiz 466): 449-465Crossref PubMed Scopus (64) Google Scholar Although the need for myotomy in addition to surgical correction of the diverticulum has been well described, it is only in the past 20 years that more clear insight has emerged on the pathophysiology of ZD despite its original description in the 1700s.1Dzeletovic I. Ekbom D.C. Baron T.H. Flexible endoscopic and surgical management of Zenker's diverticulum.Expert Rev Gastroenterol Hepatol. 2012; 6 (quiz 466): 449-465Crossref PubMed Scopus (64) Google Scholar Specifically, Cook et al2Cook I.J. Gabb M. Panagopoulos V. et al.Pharyngeal (Zenker's) diverticulum is a disorder of upper esophageal sphincter opening.Gastroenterology. 1992; 103: 1229-1235PubMed Google Scholar elegantly demonstrated that in patients with ZD, the upper esophageal sphincter is fibrotic, contributing to reduced compliance, incomplete opening, and therefore increased pressure proximal to the cricopharyngeal outlet. This leads to a “blow out” of the weakest part of the pharyngeal wall and formation of the diverticulum. Other studies have been conflicting in demonstrating an increased tone within the sphincter.1Dzeletovic I. Ekbom D.C. Baron T.H. Flexible endoscopic and surgical management of Zenker's diverticulum.Expert Rev Gastroenterol Hepatol. 2012; 6 (quiz 466): 449-465Crossref PubMed Scopus (64) Google Scholar Nevertheless, these and other data have reinforced that cricopharyngeal myotomy is essential in relieving symptoms and preventing recurrent diverticula.1Dzeletovic I. Ekbom D.C. Baron T.H. Flexible endoscopic and surgical management of Zenker's diverticulum.Expert Rev Gastroenterol Hepatol. 2012; 6 (quiz 466): 449-465Crossref PubMed Scopus (64) Google Scholar The traditional approach to cricopharyngeal myotomy and to diverticulectomy or -pexy has been open through a lateral neck incision. In the past 2 decades, however, this operation has been shifting to a transoral endoscopic approach using a rigid endoscope because of equal efficacy, shorter hospital stay, faster return to oral intake, and lower morbidity because of a reduction in adverse events compared with open surgery.3Chang C.W. Burkey B.B. Netterville J.L. et al.Carbon dioxide laser endoscopic diverticulotomy versus open diverticulectomy for Zenker's diverticulum.Laryngoscope. 2004; 114: 519-527Crossref PubMed Scopus (72) Google Scholar Such adverse events may include injury to the recurrent laryngeal nerve, mediastinitis, and fistula.1Dzeletovic I. Ekbom D.C. Baron T.H. Flexible endoscopic and surgical management of Zenker's diverticulum.Expert Rev Gastroenterol Hepatol. 2012; 6 (quiz 466): 449-465Crossref PubMed Scopus (64) Google Scholar Not all patients with ZD are amenable to transoral endoscopic therapy using a rigid endoscope. Reports in the literature have explicitly discussed the limitations of rigid endoscopic therapy and the need to manage ZD by using an open approach in 15% to 68% of cases.4Zbaren P. Schar P. Tschopp L. et al.Surgical treatment of Zenker's diverticulum: transcutaneous diverticulectomy versus microendoscopic myotomy of the cricopharyngeal muscle with CO2 laser.Otolaryngol Head Neck Surg. 1999; 121: 482-487Crossref PubMed Scopus (55) Google Scholar, 5Visosky A.M. Parke R.B. Donovan D.T. Endoscopic management of Zenker's diverticulum: factors predictive of success or failure.Ann Otol Rhinol Laryngol. 2008; 117: 531-537PubMed Google Scholar For example, an open approach is chosen, either preoperatively or intraoperatively, when there is inadequate endoscopic exposure of the diverticulum because of upper teeth protrusion, inadequate jaw opening, or insufficient neck motility or if there is insufficient protection of a small diverticulum sac by the dorsal esophageal wall risking perforation.There are variations in techniques and methods to perform transoral cricopharyngeal myotomy. For example, proposed means to divide the cricopharyngeus muscle include CO2 laser, argon plasma coagulation, needle-knife and hook-knife electrocautery, monopolar and bipolar forceps, harmonic scalpels, and stapling devices.1Dzeletovic I. Ekbom D.C. Baron T.H. Flexible endoscopic and surgical management of Zenker's diverticulum.Expert Rev Gastroenterol Hepatol. 2012; 6 (quiz 466): 449-465Crossref PubMed Scopus (64) Google Scholar, 6Rieder E. Martinec D.V. Dunst C.M. et al.Flexible endoscopic Zenkers diverticulotomy with a novel bipolar forceps: a pilot study and comparison with needleknife dissection.Surg Endosc. 2011; 25: 3273-3278Crossref PubMed Scopus (19) Google Scholar, 7Adam S.I. Paskhover B. Sasaki C.T. Laser versus stapler: outcomes in endoscopic repair of Zenker diverticulum.Laryngoscope. 2012; 122: 1961-1966Crossref PubMed Scopus (34) Google Scholar, 8Heinrich H. Bauerfeind P. Endoscopic treatment of Zenker's diverticulum using a hook knife.Endoscopy. 2009; 41: E311-E312Crossref PubMed Scopus (7) Google Scholar However, the most striking variation in the transoral approach is whether the procedure is performed by using standard flexible GI endoscopes or rigid diverticuloscopes. As a general rule, this also determines which type of specialist performs the procedure and where it is performed. Flexible endoscopic procedures are usually performed by gastroenterologists or surgical endoscopists in the endoscopy suite, whereas rigid endoscopic procedures are performed by surgeons in the operating room. The advantages of a flexible endoscopic approach rest in a wider visual field and flexibility and smaller endoscope diameter, which are especially useful for patients with poor neck extension and/or limited jaw retraction. It can also be performed without the use of general anesthesia.A transoral flexible endoscopic approach to ZD was first described nearly 20 years ago,9Mulder C.J. den Hartog G. Robijn R.J. et al.Flexible endoscopic treatment of Zenker's diverticulum: a new approach.Endoscopy. 1995; 27: 438-442Crossref PubMed Scopus (145) Google Scholar, 10Ishioka S. Sakai P. Maluf-Filho F. et al.Endoscopic incision of Zenker's diverticula.Endoscopy. 1995; 27: 433-437Crossref PubMed Scopus (141) Google Scholar successfully reduces cricopharyngeal sphincter pressure,11Ishioka S. Felix V.N. Sakai P. et al.Manometric study of the upper esophageal sphincter before and after endoscopic management of Zenker's diverticulum.Hepatogastroenterology. 1995; 42: 628-632PubMed Google Scholar and has been shown to be comparable to the use of a rigid transoral diverticuloscope in efficacy and safety.12Repici A. Pagano N. Fumagalli U. et al.Transoral treatment of Zenker diverticulum: flexible endoscopy versus endoscopic stapling A retrospective comparison of outcomes.Dis Esophagus. 2011; 24: 235-239Crossref PubMed Scopus (47) Google Scholar Nonetheless, transoral cricopharyngeal myotomy is still uncommonly performed by gastroenterologists in the United States and has remained, for the most part, in the purview of otorhinolaryngologists. Issues pertinent to reluctance of gastroenterologists to perform ZD therapy might include referral patterns, procedural risks, and the complex nature of the procedure. However, the techniques used are standard for many other therapeutic endoscopic procedures including use of a transparent cap on the tip of the endoscope, needle-knife electroincision, and endoclip placement.13Tang S.J. Lara L.F. Flexible endoscopic clip-assisted Zenker's diverticulotomy (with videos).Gastrointest Endosc. 2008; 67: 704-708Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar In this issue of Gastrointestinal Endoscopy, Huberty et al,14Huberty V. El Bacha S. Blero D. et al.Endoscopic treatment for Zenker's diverticulum: long-term results (with video).Gastrointest Endosc. 2013; 77: 701-707Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar as part of one of the leading centers in complex endoscopy, promote confidence in performing flexible endoscopic cricopharyngeal myotomy in a relatively large series of patients with symptomatic ZD. This retrospective long-term follow-up study describes 150 patients who underwent the same endoscopic procedure for ZD between 2002 and 2011. A hybrid technique was used as previously described15Evrard S. Le Moine O. Hassid S. et al.Zenker's diverticulum: a new endoscopic treatment with a soft diverticuloscope.Gastrointest Endosc. 2003; 58: 116-120Crossref PubMed Scopus (60) Google Scholar, 16Costamagna G. Lacopini F. Tringali A. et al.Flexible endoscopic Zenker's diverticulotomy cap-assisted technique vs. diverticuloscope-assisted technique.Endoscopy. 2007; 39: 146-152Crossref PubMed Scopus (96) Google Scholar in which a “soft diverticuloscope” (a specially designed overtube) to facilitate the myotomy by separating and exposing the septum containing the cricopharyngeal muscle and providing endoscope stability without the risk of trauma associated with the use of a rigid diverticuloscope. The septum was divided with a standard needle-knife followed by placement of 1 to 3 endoclips on the flayed muscle to prevent perforation and bleeding. All patients underwent a contrast radiographic swallowing study postprocedurally to exclude perforation.The success of the procedure in these authors' hands was outstanding. It is stated that endotherapy was successfully performed in all 150 patients. This needs to be tempered, as the authors had performed follow-up of only 103 patients (two thirds of treated patients) at 1 month. With eventual follow-up, however, success remained evident with a decrease in mean dysphagia score from 1.86 ± 0.62 to 0.34 ± 0.72 (P < .01). Furthermore, a broad range of diverticulum sizes were successfully treated (1-8 cm). Although there was a recurrence of symptoms in 31 of 134 patients (23%) after a median time of 7 months (range 1-82 months), most patients were successfully re-treated with the same endoscopic approach. Adverse events were also minimal and resolved with conservative management.Another minor criticism is the lack of precise selection criteria. Although all patients with ZD were included, one must assume that there were patients with ZD not referred to the GI unit who were treated during this time. Whether the patients not referred had different characteristics or contraindications to flexible endoscopic therapy is unclear.It is unknown how a transoral flexible endoscopic approach will compare with surgical therapy for relief of symptoms over decades. Although ZD classically occurs in the elderly, it can occur in patients as young as 50 years of age and with the population living longer than ever, good long-term results are essential. In 1 recent study in which transoral rigid endoscopic therapy was initiated in 94% of patients, in approximately 40% of the cases (including recurrences), only traditional surgery provided reliable treatment.17Koch M. Mantsopoulos K. Velegrakis S. et al.Endoscopic laser-assisted diverticulotomy versus open surgical approach in the treatment of Zenker's diverticulum.Laryngoscope. 2011; 121: 2090-2094Crossref PubMed Scopus (35) Google Scholar However, one would imagine that a complete myotomy can be achieved by using a flexible transoral approach.There is still no consensus on the technical details of how to perform ZD therapy by using a flexible endoscope, and it is worth noting that the flexible diverticuloscope used in this study is not commercially available in the United States. However, the use of a soft diverticuloscope is not a major limitation to performing flexible endoscopic therapy. Most often a guidewire-placed nasogastric tube, used to improve exposure of the septum and help protect the contralateral esophageal wall, and endoclips are often not placed. A transparent cap attached to the tip of the endoscope also improves exposure of the septum (Fig. 1). Whether a combination of techniques improves outcomes remains to be seen.The question then is whether transoral flexible endoscopic therapy for ZD should become part of the service of gastroenterologists. We would say yes, but with caveats. One cannot underestimate the technical requirements involved in this treatment. In the report of the study by Huberty et al,14Huberty V. El Bacha S. Blero D. et al.Endoscopic treatment for Zenker's diverticulum: long-term results (with video).Gastrointest Endosc. 2013; 77: 701-707Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar it is emphasized that only “expert endoscopists” performed this procedure. Although this is not mentioned in this report, some authors have noted that an average of 60 minutes is required to perform flexible cricopharyngeal myotomy.12Repici A. Pagano N. Fumagalli U. et al.Transoral treatment of Zenker diverticulum: flexible endoscopy versus endoscopic stapling A retrospective comparison of outcomes.Dis Esophagus. 2011; 24: 235-239Crossref PubMed Scopus (47) Google ScholarEndoscopic cricopharyngeal myotomy shares common techniques and tools that can be borrowed from those used to perform endoscopic mucosal dissection18Repici A. Hassan C. Pagano N. et al.High efficacy of endoscopic submucosal dissection for rectal laterally spreading tumors larger than 3 cm.Gastrointest Endosc. 2013; 77: 96-101Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar (eg, hook-knife8Heinrich H. Bauerfeind P. Endoscopic treatment of Zenker's diverticulum using a hook knife.Endoscopy. 2009; 41: E311-E312Crossref PubMed Scopus (7) Google Scholar [Fig. 1B]) and peroral endoscopic myotomy.19Chiu P.W. Wu J.C. Teoh A.Y. et al.Peroral endoscopic myotomy for treatment of achalasia: from bench to bedside (with video).Gastrointest Endosc. 2013; 77: 29-38Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar With advancements and increased use of these techniques, experienced therapeutic endoscopists should be well equipped to perform transoral flexible endoscopic therapy of ZD.Overall, we believe that the work by Huberty et al14Huberty V. El Bacha S. Blero D. et al.Endoscopic treatment for Zenker's diverticulum: long-term results (with video).Gastrointest Endosc. 2013; 77: 701-707Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar provides strong support for transoral flexible endoscopic treatment of ZD and the opportunity for gastroenterologists to expand their therapeutic armamentarium. Although one might perceive this as an infringement on the turf of surgeons, it is more an opportunity for greater collaboration because some patients will clearly be best served with a traditional surgical approach as the initial treatment as well as failures and recurrences after flexible endoscopic therapy. It also may be that the ultimate endoscopic approach evolves from a combination of gastroenterological and surgical techniques. Until that point, selected expert therapeutic endoscopists may carefully consider developing this therapy for their patients but with the caveats noted previously. Ideally, properly performed comparative trials of transoral flexible endoscopic and rigid endoscopic myotomy are needed.DisclosureThe authors disclosed no financial relationships relevant to this publication. Zenker's diverticulum (ZD) is an acquired disease that is formed by outpouching of hypopharyngeal mucosa between the inferior pharyngeal constrictor and the cricopharyngeus muscle in an area of junctional muscle weakness known as Killian's triangle.1Dzeletovic I. Ekbom D.C. Baron T.H. Flexible endoscopic and surgical management of Zenker's diverticulum.Expert Rev Gastroenterol Hepatol. 2012; 6 (quiz 466): 449-465Crossref PubMed Scopus (64) Google Scholar Although the need for myotomy in addition to surgical correction of the diverticulum has been well described, it is only in the past 20 years that more clear insight has emerged on the pathophysiology of ZD despite its original description in the 1700s.1Dzeletovic I. Ekbom D.C. Baron T.H. Flexible endoscopic and surgical management of Zenker's diverticulum.Expert Rev Gastroenterol Hepatol. 2012; 6 (quiz 466): 449-465Crossref PubMed Scopus (64) Google Scholar Specifically, Cook et al2Cook I.J. Gabb M. Panagopoulos V. et al.Pharyngeal (Zenker's) diverticulum is a disorder of upper esophageal sphincter opening.Gastroenterology. 1992; 103: 1229-1235PubMed Google Scholar elegantly demonstrated that in patients with ZD, the upper esophageal sphincter is fibrotic, contributing to reduced compliance, incomplete opening, and therefore increased pressure proximal to the cricopharyngeal outlet. This leads to a “blow out” of the weakest part of the pharyngeal wall and formation of the diverticulum. Other studies have been conflicting in demonstrating an increased tone within the sphincter.1Dzeletovic I. Ekbom D.C. Baron T.H. Flexible endoscopic and surgical management of Zenker's diverticulum.Expert Rev Gastroenterol Hepatol. 2012; 6 (quiz 466): 449-465Crossref PubMed Scopus (64) Google Scholar Nevertheless, these and other data have reinforced that cricopharyngeal myotomy is essential in relieving symptoms and preventing recurrent diverticula.1Dzeletovic I. Ekbom D.C. Baron T.H. Flexible endoscopic and surgical management of Zenker's diverticulum.Expert Rev Gastroenterol Hepatol. 2012; 6 (quiz 466): 449-465Crossref PubMed Scopus (64) Google Scholar The traditional approach to cricopharyngeal myotomy and to diverticulectomy or -pexy has been open through a lateral neck incision. In the past 2 decades, however, this operation has been shifting to a transoral endoscopic approach using a rigid endoscope because of equal efficacy, shorter hospital stay, faster return to oral intake, and lower morbidity because of a reduction in adverse events compared with open surgery.3Chang C.W. Burkey B.B. Netterville J.L. et al.Carbon dioxide laser endoscopic diverticulotomy versus open diverticulectomy for Zenker's diverticulum.Laryngoscope. 2004; 114: 519-527Crossref PubMed Scopus (72) Google Scholar Such adverse events may include injury to the recurrent laryngeal nerve, mediastinitis, and fistula.1Dzeletovic I. Ekbom D.C. Baron T.H. Flexible endoscopic and surgical management of Zenker's diverticulum.Expert Rev Gastroenterol Hepatol. 2012; 6 (quiz 466): 449-465Crossref PubMed Scopus (64) Google Scholar Not all patients with ZD are amenable to transoral endoscopic therapy using a rigid endoscope. Reports in the literature have explicitly discussed the limitations of rigid endoscopic therapy and the need to manage ZD by using an open approach in 15% to 68% of cases.4Zbaren P. Schar P. Tschopp L. et al.Surgical treatment of Zenker's diverticulum: transcutaneous diverticulectomy versus microendoscopic myotomy of the cricopharyngeal muscle with CO2 laser.Otolaryngol Head Neck Surg. 1999; 121: 482-487Crossref PubMed Scopus (55) Google Scholar, 5Visosky A.M. Parke R.B. Donovan D.T. Endoscopic management of Zenker's diverticulum: factors predictive of success or failure.Ann Otol Rhinol Laryngol. 2008; 117: 531-537PubMed Google Scholar For example, an open approach is chosen, either preoperatively or intraoperatively, when there is inadequate endoscopic exposure of the diverticulum because of upper teeth protrusion, inadequate jaw opening, or insufficient neck motility or if there is insufficient protection of a small diverticulum sac by the dorsal esophageal wall risking perforation. There are variations in techniques and methods to perform transoral cricopharyngeal myotomy. For example, proposed means to divide the cricopharyngeus muscle include CO2 laser, argon plasma coagulation, needle-knife and hook-knife electrocautery, monopolar and bipolar forceps, harmonic scalpels, and stapling devices.1Dzeletovic I. Ekbom D.C. Baron T.H. Flexible endoscopic and surgical management of Zenker's diverticulum.Expert Rev Gastroenterol Hepatol. 2012; 6 (quiz 466): 449-465Crossref PubMed Scopus (64) Google Scholar, 6Rieder E. Martinec D.V. Dunst C.M. et al.Flexible endoscopic Zenkers diverticulotomy with a novel bipolar forceps: a pilot study and comparison with needleknife dissection.Surg Endosc. 2011; 25: 3273-3278Crossref PubMed Scopus (19) Google Scholar, 7Adam S.I. Paskhover B. Sasaki C.T. Laser versus stapler: outcomes in endoscopic repair of Zenker diverticulum.Laryngoscope. 2012; 122: 1961-1966Crossref PubMed Scopus (34) Google Scholar, 8Heinrich H. Bauerfeind P. Endoscopic treatment of Zenker's diverticulum using a hook knife.Endoscopy. 2009; 41: E311-E312Crossref PubMed Scopus (7) Google Scholar However, the most striking variation in the transoral approach is whether the procedure is performed by using standard flexible GI endoscopes or rigid diverticuloscopes. As a general rule, this also determines which type of specialist performs the procedure and where it is performed. Flexible endoscopic procedures are usually performed by gastroenterologists or surgical endoscopists in the endoscopy suite, whereas rigid endoscopic procedures are performed by surgeons in the operating room. The advantages of a flexible endoscopic approach rest in a wider visual field and flexibility and smaller endoscope diameter, which are especially useful for patients with poor neck extension and/or limited jaw retraction. It can also be performed without the use of general anesthesia. A transoral flexible endoscopic approach to ZD was first described nearly 20 years ago,9Mulder C.J. den Hartog G. Robijn R.J. et al.Flexible endoscopic treatment of Zenker's diverticulum: a new approach.Endoscopy. 1995; 27: 438-442Crossref PubMed Scopus (145) Google Scholar, 10Ishioka S. Sakai P. Maluf-Filho F. et al.Endoscopic incision of Zenker's diverticula.Endoscopy. 1995; 27: 433-437Crossref PubMed Scopus (141) Google Scholar successfully reduces cricopharyngeal sphincter pressure,11Ishioka S. Felix V.N. Sakai P. et al.Manometric study of the upper esophageal sphincter before and after endoscopic management of Zenker's diverticulum.Hepatogastroenterology. 1995; 42: 628-632PubMed Google Scholar and has been shown to be comparable to the use of a rigid transoral diverticuloscope in efficacy and safety.12Repici A. Pagano N. Fumagalli U. et al.Transoral treatment of Zenker diverticulum: flexible endoscopy versus endoscopic stapling A retrospective comparison of outcomes.Dis Esophagus. 2011; 24: 235-239Crossref PubMed Scopus (47) Google Scholar Nonetheless, transoral cricopharyngeal myotomy is still uncommonly performed by gastroenterologists in the United States and has remained, for the most part, in the purview of otorhinolaryngologists. Issues pertinent to reluctance of gastroenterologists to perform ZD therapy might include referral patterns, procedural risks, and the complex nature of the procedure. However, the techniques used are standard for many other therapeutic endoscopic procedures including use of a transparent cap on the tip of the endoscope, needle-knife electroincision, and endoclip placement.13Tang S.J. Lara L.F. Flexible endoscopic clip-assisted Zenker's diverticulotomy (with videos).Gastrointest Endosc. 2008; 67: 704-708Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar In this issue of Gastrointestinal Endoscopy, Huberty et al,14Huberty V. El Bacha S. Blero D. et al.Endoscopic treatment for Zenker's diverticulum: long-term results (with video).Gastrointest Endosc. 2013; 77: 701-707Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar as part of one of the leading centers in complex endoscopy, promote confidence in performing flexible endoscopic cricopharyngeal myotomy in a relatively large series of patients with symptomatic ZD. This retrospective long-term follow-up study describes 150 patients who underwent the same endoscopic procedure for ZD between 2002 and 2011. A hybrid technique was used as previously described15Evrard S. Le Moine O. Hassid S. et al.Zenker's diverticulum: a new endoscopic treatment with a soft diverticuloscope.Gastrointest Endosc. 2003; 58: 116-120Crossref PubMed Scopus (60) Google Scholar, 16Costamagna G. Lacopini F. Tringali A. et al.Flexible endoscopic Zenker's diverticulotomy cap-assisted technique vs. diverticuloscope-assisted technique.Endoscopy. 2007; 39: 146-152Crossref PubMed Scopus (96) Google Scholar in which a “soft diverticuloscope” (a specially designed overtube) to facilitate the myotomy by separating and exposing the septum containing the cricopharyngeal muscle and providing endoscope stability without the risk of trauma associated with the use of a rigid diverticuloscope. The septum was divided with a standard needle-knife followed by placement of 1 to 3 endoclips on the flayed muscle to prevent perforation and bleeding. All patients underwent a contrast radiographic swallowing study postprocedurally to exclude perforation. The success of the procedure in these authors' hands was outstanding. It is stated that endotherapy was successfully performed in all 150 patients. This needs to be tempered, as the authors had performed follow-up of only 103 patients (two thirds of treated patients) at 1 month. With eventual follow-up, however, success remained evident with a decrease in mean dysphagia score from 1.86 ± 0.62 to 0.34 ± 0.72 (P < .01). Furthermore, a broad range of diverticulum sizes were successfully treated (1-8 cm). Although there was a recurrence of symptoms in 31 of 134 patients (23%) after a median time of 7 months (range 1-82 months), most patients were successfully re-treated with the same endoscopic approach. Adverse events were also minimal and resolved with conservative management. Another minor criticism is the lack of precise selection criteria. Although all patients with ZD were included, one must assume that there were patients with ZD not referred to the GI unit who were treated during this time. Whether the patients not referred had different characteristics or contraindications to flexible endoscopic therapy is unclear. It is unknown how a transoral flexible endoscopic approach will compare with surgical therapy for relief of symptoms over decades. Although ZD classically occurs in the elderly, it can occur in patients as young as 50 years of age and with the population living longer than ever, good long-term results are essential. In 1 recent study in which transoral rigid endoscopic therapy was initiated in 94% of patients, in approximately 40% of the cases (including recurrences), only traditional surgery provided reliable treatment.17Koch M. Mantsopoulos K. Velegrakis S. et al.Endoscopic laser-assisted diverticulotomy versus open surgical approach in the treatment of Zenker's diverticulum.Laryngoscope. 2011; 121: 2090-2094Crossref PubMed Scopus (35) Google Scholar However, one would imagine that a complete myotomy can be achieved by using a flexible transoral approach. There is still no consensus on the technical details of how to perform ZD therapy by using a flexible endoscope, and it is worth noting that the flexible diverticuloscope used in this study is not commercially available in the United States. However, the use of a soft diverticuloscope is not a major limitation to performing flexible endoscopic therapy. Most often a guidewire-placed nasogastric tube, used to improve exposure of the septum and help protect the contralateral esophageal wall, and endoclips are often not placed. A transparent cap attached to the tip of the endoscope also improves exposure of the septum (Fig. 1). Whether a combination of techniques improves outcomes remains to be seen. The question then is whether transoral flexible endoscopic therapy for ZD should become part of the service of gastroenterologists. We would say yes, but with caveats. One cannot underestimate the technical requirements involved in this treatment. In the report of the study by Huberty et al,14Huberty V. El Bacha S. Blero D. et al.Endoscopic treatment for Zenker's diverticulum: long-term results (with video).Gastrointest Endosc. 2013; 77: 701-707Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar it is emphasized that only “expert endoscopists” performed this procedure. Although this is not mentioned in this report, some authors have noted that an average of 60 minutes is required to perform flexible cricopharyngeal myotomy.12Repici A. Pagano N. Fumagalli U. et al.Transoral treatment of Zenker diverticulum: flexible endoscopy versus endoscopic stapling A retrospective comparison of outcomes.Dis Esophagus. 2011; 24: 235-239Crossref PubMed Scopus (47) Google Scholar Endoscopic cricopharyngeal myotomy shares common techniques and tools that can be borrowed from those used to perform endoscopic mucosal dissection18Repici A. Hassan C. Pagano N. et al.High efficacy of endoscopic submucosal dissection for rectal laterally spreading tumors larger than 3 cm.Gastrointest Endosc. 2013; 77: 96-101Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar (eg, hook-knife8Heinrich H. Bauerfeind P. Endoscopic treatment of Zenker's diverticulum using a hook knife.Endoscopy. 2009; 41: E311-E312Crossref PubMed Scopus (7) Google Scholar [Fig. 1B]) and peroral endoscopic myotomy.19Chiu P.W. Wu J.C. Teoh A.Y. et al.Peroral endoscopic myotomy for treatment of achalasia: from bench to bedside (with video).Gastrointest Endosc. 2013; 77: 29-38Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar With advancements and increased use of these techniques, experienced therapeutic endoscopists should be well equipped to perform transoral flexible endoscopic therapy of ZD. Overall, we believe that the work by Huberty et al14Huberty V. El Bacha S. Blero D. et al.Endoscopic treatment for Zenker's diverticulum: long-term results (with video).Gastrointest Endosc. 2013; 77: 701-707Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar provides strong support for transoral flexible endoscopic treatment of ZD and the opportunity for gastroenterologists to expand their therapeutic armamentarium. Although one might perceive this as an infringement on the turf of surgeons, it is more an opportunity for greater collaboration because some patients will clearly be best served with a traditional surgical approach as the initial treatment as well as failures and recurrences after flexible endoscopic therapy. It also may be that the ultimate endoscopic approach evolves from a combination of gastroenterological and surgical techniques. Until that point, selected expert therapeutic endoscopists may carefully consider developing this therapy for their patients but with the caveats noted previously. Ideally, properly performed comparative trials of transoral flexible endoscopic and rigid endoscopic myotomy are needed. DisclosureThe authors disclosed no financial relationships relevant to this publication. The authors disclosed no financial relationships relevant to this publication. Endoscopic treatment for Zenker's diverticulum: long-term results (with video)Gastrointestinal EndoscopyVol. 77Issue 5PreviewDiverticulotomy is a standard treatment for Zenker's diverticulum (ZD). This technique was adapted to flexible endoscopy. Full-Text PDF
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