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Treatment of Zenker's diverticulum with the help of a plastic hood attached to the endoscope

2002; Elsevier BV; Volume: 56; Issue: 4 Linguagem: Inglês

10.1016/s0016-5107(02)70470-7

1097-6779

Guido Costamagna, Massimiliano Mutignani, Andrea Tringali, Vincenzo Perri,

Tracheal and airway disorders

Endoscopic treatment of Zenker's diverticulum involves cutting the bridge (cricopharyngeal muscle) between esophageal lumen and diverticular pouch with a rigid or flexible endoscope and one of several different sources of energy (electrosurgery, argon plasma coagulation [APC], CO2 laser, etc.) to ensure free passage of ingested liquids and solids into the esophagus.1Mulder CJ Costamagna G Sakai P. Zenker's diverticulum: treatment using a flexible endoscope.Endoscopy. 2001; 33: 991-997PubMed Google Scholar Exposure of the bridge in the endoscopic field is a major factor in the success and safety of this procedure. We read with great interest the article by Sakai et al.2Sakai P Ishioka S Maluf-Filho F Chaves D Moura EG. Endoscopic treatment of Zenker's diverticulum with an oblique-end hood attached to the endoscope.Gastrointest Endosc. 2001; 54: 760-763Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar on endoscopic treatment of Zenker's diverticulum with an oblique-ended, “homemade” plastic hood attached to the endoscope for the purpose of improving exposure of the septum. One of us (G.C.) had the opportunity of closely observing Dr. Paulo Sakai in the performance of this procedure in a patient in Buenos Aires in September 2000. Apart from the outstanding skill of the endoscopist, it was immediately obvious that the use of the plastic hood was strikingly efficacious. The hood not only provided a clearer view, but also allowed much better control of the cutting action. Most likely, this is due not only to prevention of upper esophageal sphincter closure, as stated by Sakai et al.,2Sakai P Ishioka S Maluf-Filho F Chaves D Moura EG. Endoscopic treatment of Zenker's diverticulum with an oblique-end hood attached to the endoscope.Gastrointest Endosc. 2001; 54: 760-763Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar but also to a progressive opening action on the cut edges of the spur. As a result, the transverse fibers of the cricopharyngeal muscle are progressively stretched and exposed, permitting a neatly controlled step-by-step incision of the bridge. If required, the orientation of the oblique end of the plastic hood may be modified during the treatment to obtain a different axis of action. Having been positively impressed by this technique, we adapted the use of a commercially available oblique-end plastic hood, 14.7 mm in diameter (MH589, Olympus Optical Co., Ltd., Tokyo, Japan), originally intended for endoscopic mucosectomy. To section the bridge, we used a needle-knife (KD11Q, Olympus) and a combination of cutting and coagulation current delivered by an electrosurgical generator (200 ICC, ERBE, Elektromedizin, Tübingen, Germany). The same generator can be used for APC. However, based on our experience, we no longer use APC to cut the spur, although it is used to obtain hemostasis when required. In contrast to the technique described by Sakai et al.2Sakai P Ishioka S Maluf-Filho F Chaves D Moura EG. Endoscopic treatment of Zenker's diverticulum with an oblique-end hood attached to the endoscope.Gastrointest Endosc. 2001; 54: 760-763Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar we still place a nasogastric tube (18F) in the esophageal lumen before initiating the procedure. We think that this better displays the bridge between the esophagus and the diverticular pouch, helps to protect the anterior esophageal wall, and avoids the need to manipulate the incised area immediately after treatment. Over a 5-month period, 9 patients (8 men, 1 woman, mean age 64.4 years, range 54-79 years) were treated with this technique; all required only a single treatment session. One complication was encountered; mediastinal emphysema in a patient who remained asymptomatic and treated conservatively. With regard to this type of complication, we do not agree with Hashiba et al.3Hashiba K de Paula AL da Silva JG Cappellanes CA Moribe D Castillo CF et al.Endoscopic treatment of Zenker's diverticulum.Gastrointest Endosc. 1999; 49: 93-97Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar that it could be explained by early resumption of oral feeding, because subcutaneous and/or mediastinal emphysema is always present immediately after the procedure. Emphysema is most likely due exclusively to extending the incision to the bottom of the diverticulum. All of our patients, except the one in whom emphysema developed, resumed oral intake of liquids 24 to 48 hours after the procedure. Based on our experience, we wholly agree with Sakai et al.2Sakai P Ishioka S Maluf-Filho F Chaves D Moura EG. Endoscopic treatment of Zenker's diverticulum with an oblique-end hood attached to the endoscope.Gastrointest Endosc. 2001; 54: 760-763Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar that the hood modification has made the endoscopic treatment of Zenker's diverticulum much faster and easier. This technique is currently our standard method for endoscopic treatment of Zenker's diverticulum.