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Transoral Stapling Technique for Zenker's Diverticulum

2020; Elsevier BV; Volume: 25; Issue: 3 Linguagem: Inglês

10.1053/j.optechstcvs.2020.05.002

1532-8627

Ernest G. Chan, Nicholas Baker, James D. Luketich, Ryan M. Levy,

Esophageal and GI Pathology

Zenker's diverticulum (ZD) is a rare disorder that has a reported annual incidence of about 2 cases per 100,000. It is a pulsion (false) diverticulum that develops in an area of natural anatomic weakness called Killian's triangle. This is located between the inferior pharyngeal constrictor and the cricopharyngeus muscles. The exact etiology and pathophysiology of ZD is not known. Cricopharyngeal discoordination, spasm, or hypertension have all been implicated as underlying mechanisms leading to herniation of the hypopharyngeal mucosa and submucosa and consequently the formation of a ZD. Gastroesophageal reflux has also been implicated as a potential underlying mechanism in the development of ZD. Patients typically will present with symptoms of oropharyngeal dysphagia, food regurgitation, and in severe cases aspiration pneumonia. Cricopharyngeal myotomy is the mainstay of surgical treatment of symptomatic ZD. The traditional surgical approach to ZD includes an open cervical cricopharyngeal myotomy. However, starting with Collard's initial report of endoscopic stapling in 1993, the endoscopic approach to ZD treatment has been popularized. Since then, increasing reports have described utilizing a variety of endoscopic techniques for management of ZD. Herein we present our current preferred endoscopic approach to treatment of ZD. Zenker's diverticulum (ZD) is a rare disorder that has a reported annual incidence of about 2 cases per 100,000. It is a pulsion (false) diverticulum that develops in an area of natural anatomic weakness called Killian's triangle. This is located between the inferior pharyngeal constrictor and the cricopharyngeus muscles. The exact etiology and pathophysiology of ZD is not known. Cricopharyngeal discoordination, spasm, or hypertension have all been implicated as underlying mechanisms leading to herniation of the hypopharyngeal mucosa and submucosa and consequently the formation of a ZD. Gastroesophageal reflux has also been implicated as a potential underlying mechanism in the development of ZD. Patients typically will present with symptoms of oropharyngeal dysphagia, food regurgitation, and in severe cases aspiration pneumonia. Cricopharyngeal myotomy is the mainstay of surgical treatment of symptomatic ZD. The traditional surgical approach to ZD includes an open cervical cricopharyngeal myotomy. However, starting with Collard's initial report of endoscopic stapling in 1993, the endoscopic approach to ZD treatment has been popularized. Since then, increasing reports have described utilizing a variety of endoscopic techniques for management of ZD. Herein we present our current preferred endoscopic approach to treatment of ZD. IntroductionZenker's diverticulum (ZD) is a rare disorder of the cervical esophagus that has a reported annual incidence of about 2 cases per 100,000.1Laing MR Murthy P Ah-See KW et al.Surgery for pharyngeal pouch: Audit of management with short- and long-term follow-up.J Royal Coll Surg Edinburgh. 1995; 40: 315-318PubMed Google Scholar, 2Klockars T Sihvo E Makitie A Familial zenker's diverticulum.Acta Oto-laryngol. 2008; 128: 1034-1036Crossref PubMed Scopus (17) Google Scholar, 3Bizzotto A Iacopini F Landi R et al.Zenker's diverticulum: Exploring treatment options.Acta Otorhinolaryngol Ital. 2013; 33: 219-229PubMed Google Scholar, 4Bonavina L Aiolfi A Scolari F et al.Long-term outcome and quality of life after transoral stapling for zenker diverticulum.World J Gastroenterol. 2015; 21: 1167-1172Crossref PubMed Scopus (26) Google Scholar It most commonly presents in the seventh and eight decade of life. ZD, also known as hypopharyngeal diverticulum, was first described by Abraham Ludlow in 1769.5Ludlow A.A case of obstructed deglutition, from a preternatural dilatation of, and bag formed in, the pharynx; in a letter from mr. LUDLOW, Surgeon at Bristol to Dr WILLIAM HUNTER, ReadAugust;27:1764.Google Scholar,6Morse CR Fernando HC Ferson PF et al.Preliminary experience by a thoracic service with endoscopic transoral stapling of cervical (zenker's) diverticulum.J Gastroint Surg. 2007; 11: 1091-1094Crossref PubMed Scopus (14) Google Scholar Subsequently, German pathologists Friedrich Albert von Zenker and Hugo Wilhelm von Ziemssen published a series of 23 patients in 1878 in which they described its basic clinical features and pathophysiology.7Zenker FA Ziemssen Hv. Krankheiten des oesophagus. F.C.W. Vogel, Leipzig1877Google Scholar While the complete pathophysiology of ZD is not fully understood, it is associated with uncoordinated relaxation or hypertension of the upper esophageal sphincter on swallowing. Intraluminal pressure increases against an inadequately relaxed cricopharyngeal muscle resulting in herniation of the hypopharyngeal mucosa and submucosa between the inferior constrictor and the cricopharyngeus muscles in an area of muscular weakness termed Killian's Triangle.8Costamagna G Iacopini F Bizzotto A et al.Prognostic variables for the clinical success of flexible endoscopic septotomy of zenker's diverticulum.Gastrointest Endosc. 2016; 83: 765-773Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 9Cook IJ Cricopharyngeal function and dysfunction.Dysphagia. 1993; 8: 244-251Crossref PubMed Scopus (66) Google Scholar, 10Dohlman G Mattsson O. The endoscopic operation for hypopharyngeal diverticula: A roentgencinematographic study.JAMA Otolaryngol Head Neck Surg. 1960; 71: 744-752Google Scholar It is a false diverticulum as it does not include the muscle layers of the esophageal wall. Gastroesophageal reflux has also been implicated as a potential underlying mechanism for ZD, whereby reflux initiates cricopharyngeal spasm and consequent development of the diverticulum.11Bognar L Vereczkei A Papp A et al.Gastroesophageal reflux disease might induce certain-supposedly adaptive-changes in the esophagus: A hypothesis.Digest Dis Sci. 2018; 63: 2529-2535Crossref PubMed Scopus (6) Google Scholar, 12Smiley TB Caves PK Porter DC Relationship between posterior pharyngeal pouch and hiatus hernia.Thorax. 1970; 25: 725-731Crossref PubMed Scopus (47) Google Scholar, 13Hunt PS Connell AM Smiley TB The cricopharyngeal sphincter in gastric reflux.Gut. 1970; 11: 303-306Crossref PubMed Scopus (127) Google Scholar, 14Sasaki CT Ross DA Hundal J Association between zenker diverticulum and gastroesophageal reflux disease: Development of a working hypothesis.Am J Med. 2003; 115: 169s-171sAbstract Full Text Full Text PDF PubMed Scopus (43) Google ScholarPatients typically will present with symptoms of oropharyngeal dysphagia, food regurgitation, halitosis, and in severe cases, recurrent aspiration pneumonia.15Cook IJ Gabb M Panagopoulos V et al.Pharyngeal (zenker's) diverticulum is a disorder of upper esophageal sphincter opening.Gastroenterology. 1992; 103: 1229-1235Abstract Full Text PDF PubMed Google Scholar,16Goyal RK Martin SB Shapiro J et al.The role of cricopharyngeus muscle in pharyngoesophageal disorders.Dysphagia. 1993; 8: 252-258Crossref PubMed Scopus (65) Google Scholar Radiologic evaluation includes a barium esophagram and modified barium swallow. Anatomic characteristics of the diverticulum such as size, location, and concomitant esophageal pathology are identified on esophagram. Given the association of gastroesophageal reflux with ZD, it is not uncommon to visualize hiatal hernia, reflux, esophageal dysmotility, or schatzki ring in conjunction with a Zenker's diverticulum. Modified barium swallow helps identify underlying aspiration.Surgical management of Zenker's diverticulum has evolved over time. Open transcervical diverticulectomy was first performed in 1885 and was the preferred surgical treatment for many years. However, this paradigm had shifted with the addition of the cricopharyngeal myotomy as it demonstrated improved results and minimized resection leaks.17Beard K Swanström LL. Zenker's diverticulum: Flexible versus rigid repair.J Thorac Dis. 2017; 9: S154-S162Crossref PubMed Scopus (22) Google Scholar,18DeMeester T Bremner CG. Selective cricopharyngeal myotomy for zenker's diverticulum.J Am Coll Surg. 2003; 196: 451-452Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Therefore, depending on the size, cricopharyngeal myotomy has generally become the gold standard approach for treatment of ZD with either diverticulopexy or diverticulectomy depending on diverticulum size.19Greene CL McFadden PM Oh DS et al.Long-term outcome of the treatment of zenker's diverticulum.Ann Thorac Surg. 2015; 100: 975-978Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar,20Welsh GF Payne WS. The present status of one stage pharyngo esophageal diverticulectomy.Surg Clin North Am. 1973; 53: 953-958Crossref PubMed Scopus (27) Google Scholar However, within the last few decades, the endoscopic approach to ZD treatment has been popularized.21Collard JM Otte JB Kestens PJ Endoscopic stapling technique of esophagodiverticulostomy for zenker's diverticulum.Ann Thorac Surg. 1993; 56: 573-576Abstract Full Text PDF PubMed Scopus (232) Google Scholar, 22Howell RJ Giliberto JP Harmon J et al.Open versus endoscopic surgery of zenker's diverticula: A systematic review and meta-analysis.Dysphagia. 2019; 34: 930-938Crossref PubMed Scopus (15) Google Scholar, 23Repici 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 options include the use of lasers, various forms of electrocautery, and stapling devices through both flexible and rigid esophagoscopy. We present our endoscopic approach to treatment of ZD which includes utilization of a stapling device to divide the common septum between the esophagus and diverticulum.24Weksler B Cook C Luketich JD Endoscopic transoral stapling of zenker's diverticula.Multimed Man Cardiothorac Surg. 2010; 2010 (mmcts.2007.002923)PubMed Google Scholar This divides the cricopharyngeus and consequently relieves the muscular outflow obstruction initially responsible for the development of the diverticulum. Adjunct electrocautery or laser ablation is used for division of any residual septum (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10, Figure 11).25Bonavina L Rottoli M Bona D et al.Transoral stapling for zenker diverticulum: Effect of the traction suture-assisted technique on long-term outcomes.Surg Endosc. 2012; 26: 2856-2861Crossref PubMed Scopus (23) Google Scholar, 26Chang CW Burkey BB Netterville JL et al.Carbon dioxide laser endoscopic diverticulotomy versus open diverticulectomy for zenker's diverticulum.Laryngoscope. 2004; 114: 519-527Crossref PubMed Scopus (72) Google Scholar, 27Wilken R Whited C Scher RL Endoscopic staple diverticulostomy for zenker's diverticulum: Review of experience in 337 cases.Ann Otol Rhinol Laryngol. 2015; 124: 21-29Crossref PubMed Scopus (23) Google ScholarFigure 2Weerda laryngoscope. A rigid esophagoscopy utilizing the Weerda laryngoscope (Karl Storz, Tuttlingen, Germany) is performed (A). Continued (B) This scope is made up of two jaws that are expandable and can be locked in place. The jaws provide a large working channel at varying heights for instrumentation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Weerda laryngoscope insertion (Video timestamp 00:40-01:26). Once mouth guards are placed to protect the patient's mouth, the Weerda laryngoscope is introduced into the oral cavity in the closed position and advanced. The esophagus is intubated with the tip of the scope. One jaw is placed in the esophagus and the second is placed in the diverticulum. The jaws are then expanded which allows clear visualization of the Zenker's diverticulum, common septum, and true lumen which is identified by the guidewire placed previously through flexible endoscopy. The Weerda laryngoscope is secured in place on a mayo stand that is positioned floating above the patient's chest. An additional 5-mm laparoscope can be introduced through the Weerda laryngoscope for additional visualization of the surgical field.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Weerda laryngoscope insertion (Video timestamp 00:40-01:26). Once mouth guards are placed to protect the patient's mouth, the Weerda laryngoscope is introduced into the oral cavity in the closed position and advanced. The esophagus is intubated with the tip of the scope. One jaw is placed in the esophagus and the second is placed in the diverticulum. The jaws are then expanded which allows clear visualization of the Zenker's diverticulum, common septum, and true lumen which is identified by the guidewire placed previously through flexible endoscopy. The Weerda laryngoscope is secured in place on a mayo stand that is positioned floating above the patient's chest. An additional 5-mm laparoscope can be introduced through the Weerda laryngoscope for additional visualization of the surgical field.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Proper orientation and view (Video timestamp 01:26-01:58). It is important to keep the proper orientation with the true lumen of the esophagus at 12 o'clock and the diverticulum at 6 o'clock. This positioning is crucial for the stapling of the common septum. The septum is identified utilizing an endoscopic dissector. The guidewire that was previously placed is helpful in this view to ensure proper identification of the true esophageal lumen.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Placement of stay suture in common septum (Video timestamp 01:58-02:42). A stay suture is placed in the common septum utilizing the Endo Stitch Suturing Device (Medtronic, Minneapolis, MN) which is introduced through the working channel of the Weerda laryngoscope. We recommend utilizing a full length 0-Surgidac suture as it is pulled out of the esophagus and oropharynx. This will provide traction on the common septum into a stapler device.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Stapling of the common septum (Video timestamp 02:42-03:40). An Endo-GIA 30-mm stapler with a modified anvil is introduced through the Weerda laryngoscope working channel and into the esophagus. (Figure 7 describes in detail the process and design of the modified anvil.) Utilizing the traction stitch, the common septum is fed into jaws of the stapler with the modified anvil in the diverticulum and the disposable staple cartridge within the esophageal lumen. The traction of the common septum will allow for complete transection of the cricopharyngeaus which is critical to a successful operation and to minimizing the rate of recurrence. Further firings of the stapler as needed are performed to ensure the common septum is divided to the base of the diverticulum. Placement of a second traction suture is sometimes needed for a larger diverticulum.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 7Modified Anvil (Video timestamp 02:42-03:40). As illustrated, the knife of the unmodified anvil tip does not reach where the staples are fired as the track ends prematurely. Therefore, to align the firing of the distal end staples and the cutting edge of the blade of the stapler, the tip of the reusable anvil is ground down by a mechanical grinder. The removal of this tip allows the stapler to both cut and staple to the end of the now shortened tip. This enables deeper placement of the anvil into the diverticulum. In our experience, the modified anvil facilitates more complete division of the common septum. However, its use is not mandatory and a standard 30 mm staple load could be utilized.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 8Inspection of the myotomy and divided common septum (Video timestamp 03:40-04:11). This figure depicts the endoscopic or direct view of the final product. After completion of the myotomy, the Weerda laryngoscope is removed. (A) A flexible endoscope is inserted into the esophagus to inspect the stapled edge of the septum for hemostasis and to ensure there is no residual diverticulum remaining. Continued (B) Division of the entire common septum will help achieve com plete myotomy of the cricopharyngeus muscle.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 8Inspection of the myotomy and divided common septum (Video timestamp 03:40-04:11). This figure depicts the endoscopic or direct view of the final product. After completion of the myotomy, the Weerda laryngoscope is removed. (A) A flexible endoscope is inserted into the esophagus to inspect the stapled edge of the septum for hemostasis and to ensure there is no residual diverticulum remaining. Continued (B) Division of the entire common septum will help achieve com plete myotomy of the cricopharyngeus muscle.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 9Performing an extended myotomy for removal of the residual common septum. (A) Flexible esophagoscopy is performed to ensure the entire common septum is divided. Continued (B) If residual septum is identified, we recommend additional division of the residual common septum to complete the myotomy of the cricopharyngeus muscle. Continued (C) We either utilize the endoscopic ERBE knife (Tübingen, Germany) or Nd-YAG laser. Typically, a capped flexible esophascope is used for better visualization and manipulation of the esophagus and diverticulum. The ERBE knife or Nd-Yag laser is introduced through the working port and provides a controlled division of the residual septum. Energy is focused on the crotch of the residual common septum where residual fibers of the cricopharyngeus may be visualized.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 9Performing an extended myotomy for removal of the residual common septum. (A) Flexible esophagoscopy is performed to ensure the entire common septum is divided. Continued (B) If residual septum is identified, we recommend additional division of the residual common septum to complete the myotomy of the cricopharyngeus muscle. Continued (C) We either utilize the endoscopic ERBE knife (Tübingen, Germany) or Nd-YAG laser. Typically, a capped flexible esophascope is used for better visualization and manipulation of the esophagus and diverticulum. The ERBE knife or Nd-Yag laser is introduced through the working port and provides a controlled division of the residual septum. Energy is focused on the crotch of the residual common septum where residual fibers of the cricopharyngeus may be visualized.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 9Performing an extended myotomy for removal of the residual common septum. (A) Flexible esophagoscopy is performed to ensure the entire common septum is divided. Continued (B) If residual septum is identified, we recommend additional division of the residual common septum to complete the myotomy of the cricopharyngeus muscle. Continued (C) We either utilize the endoscopic ERBE knife (Tübingen, Germany) or Nd-YAG laser. Typically, a capped flexible esophascope is used for better visualization and manipulation of the esophagus and diverticulum. The ERBE knife or Nd-Yag laser is introduced through the working port and provides a controlled division of the residual septum. Energy is focused on the crotch of the residual common septum where residual fibers of the cricopharyngeus may be visualized.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 10If extension of the myotomy was needed with ERBE knife, endoscopic clips are used to close the mucosotomy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 11If there is evidence of a residual common septum at the staple line that is not amendable to additional stapling we complete division of any residual septum with either the Nd:95 YAG laser or the ERBE knife.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Patient SelectionThe success of this operation is intimately related to patient selection, operative exposure, and technique. Patients are screened preoperatively for cervical spine mobility and degree of neck extension. In addition, the mouth opening is inspected to ensure there is adequate room for instrumentation with the proper patient positioning. Prominent incisors, dental implants, trismus, or jaw stiffness, and the presence of an anteriorly located larynx may preclude a patient from undergoing this procedure. A detailed and focused history and physical exam to identify a history of cervical spine procedures, mandible or jaw surgeries, and the presence of prominent cervical osteophytes can make operative exposure and oropharyngeal instrumentation difficult. Preoperative barium esophagram and intraoperative flexible endoscopy are useful to evaluate the size of the diverticulum. In general, we use 2.5 cm as the lower size limit to treating ZD with rigid endoscopic therapy.Postoperative CarePostoperative care consists of nothing by mouth (NPO) until barium esophagram on postoperative day 1. This exam is used to rule out a postoperative leak and assess residual pouch. Discharge is typical on postoperative day one if there is no leak on esophagram and the patient tolerates a clear liquid diet. Patients are advanced to a full liquid diet 48 hours postoperatively. This is then advanced to a soft diet within one week and typical postoperative follow up is at 2 weeks. We typically re-evaluate patients on a yearly basis with outpatient follow up and barium esophagram. The clinical significance of residual septum on follow up esophagram is unclear. Some authors have reported that residual septum can lead to symptomatic recurrences in up to 12% of patients when compared to no residual pouch patients, whereas other publications have reported no difference.28Richtsmeier WJ. Myotomy length determinants in endoscopic staple-assisted esophagodiverticulostomy for small zenker's diverticula.Ann Otol Rhinol Laryngol. 2005; 114: 341-346Crossref PubMed Scopus (29) Google Scholar,29Shah RN Slaughter KA Fedore LW et al.Does residual wall size or technique matter in the treatment of zenker's diverticulum?.Laryngoscope. 2016; 126: 2475-2479Crossref PubMed Scopus (15) Google ScholarResultsThe endoscopic approach to Zenker's diverticulum has been found to be a safe alternative to open surgery. In a review of 2826 patients across 41 studies undergoing open transcervical surgical treatment for ZD, the overall morbidity and mortality was reported to be 10.5% and 0.6% respectively.30Yuan Y Zhao YF Hu Y et al.Surgical treatment of zenker's diverticulum.Dig Surg. 2013; 30: 207-218Crossref PubMed Scopus (91) Google Scholar Specifically, the overall risk of serious complications such as recurrent laryngeal nerve injury (3.3%), leak or perforation (3.3%), and cervical infection (1.8%) were low.30Yuan Y Zhao YF Hu Y et al.Surgical treatment of zenker's diverticulum.Dig Surg. 2013; 30: 207-218Crossref PubMed Scopus (91) Google Scholar Yuan et al reported an overall complication rate of 7.1% and an overall mortality of 0.3% for patients undergoing a rigid endoscopic procedure. The most common complications were dental injury (2%), mucosal injury (1.6%), and esophageal perforation (1.6%). A total of 5.6% of patients required conversion to the open surgical approach.30Yuan Y Zhao YF Hu Y et al.Surgical treatment of zenker's diverticulum.Dig Surg. 2013; 30: 207-218Crossref PubMed Scopus (91) Google Scholar In our experience of 151 consecutive patients, we recently reported a morbidity and mortality of 4% and 0.6%. The vast majority of postoperative morbidity in the rigid transoral approach was dental and oral trauma (tongue and lip laceration/ecchymosis, chipped teeth).31Levy RL Brynien D Mpamaugo C et al.Transoral endoscopic repair of zenker's diverticulum by a thoracic surgical service: Analysis of outcomes in over 100 patients.JTCVS. 2020; (In press)Google Scholar In addition to being an incisionless approach, the most significant advantage of an endoscopic over an open approach is the elimination of the risk of recurrent laryngeal injury. Ultimately, a randomized controlled trial will be needed to identify the superior approach to Zenker's diverticulum but that may prove to be difficult given the uncommon nature of the disease.Symptomatic relief has been associated comparable to results following open approaches to Zenker's diverticulum. Collard et al were one of the first to report the use of endoscopic stapling for the treatment of Zenker's diverticulum. In a subset of 6 patients, cervical dysphagia was reported to be relieved in 5 patients and improved in the 6th over a follow-up time of 2-16 months.21Collard JM Otte JB Kestens PJ Endoscopic stapling technique of esophagodiverticulostomy for zenker's diverticulum.Ann Thorac Surg. 1993; 56: 573-576Abstract Full Text PDF PubMed Scopus (232) Google Scholar In our experience with endoscopic transoral stapling, we found that patients reported a mean dysphagia score of 1.2 at a median follow up of 7 months (P< 0.0001). During a median follow-up of 49 months, 8 patients (5.3%) failed endoscopic transoral stapling requiring an additional procedure.30Yuan Y Zhao YF Hu Y et al.Surgical treatment of zenker's diverticulum.Dig Surg. 2013; 30: 207-218Crossref PubMed Scopus (91) Google Scholar Bonavina et al reported long term outcomes following transoral stapling (n = 181) versus open resection plus cricopharyngeal myotomy (n = 116). The overwhelming majority of patients in both groups (92% of the transoral stapling group and 94% of the open surgical group) reported symptom-free or significant improvement after a median follow-up time of 27 and 48 months, respectively. These similar results were also observed in a subgroup analysis of patients who reached 5 and 10 years of follow-up time.32Bonavina L Bona D Abraham M et al.Long-term results of endosurgical and open surgical approach for zenker diverticulum.World J Gastroenterol. 2007; 13: 2586-2589Crossref PubMed Scopus (74) Google Scholar In a recent meta-analysis, Howell et al compared the open approached to Zenker's diverticulum (OD) (n = 106) with endoscopic laser diverticulectomy (ELD) (n = 310) and endoscopic staple diverticulectomy (n = 449) across 11 publications.22Howell RJ Giliberto JP Harmon J et al.Open versus endoscopic surgery of zenker's diverticula: A systematic review and meta-analysis.Dysphagia. 2019; 34: 930-938Crossref PubMed Scopus (15) Google Scholar While all 3 approaches had similar results when comparing improvement in postoperative regurgitation scores, the open approached was associated with a higher reoperative rate when compared to both endoscopic laser diverticulectomy and endoscopic staple diverticulectomy approaches (9.4% vs 4.5% vs 6.9%). While ultimately these results will have to be definitively validated in a randomized study, these promising results support the application and adoption of the transoral stapling technique for treatment of Zenker's diverticulum.ConclusionSince its early descriptions by Collard et al, the technique of transoral surgical treatment of Zenker's diverticulum has continued to evolve.21Collard JM Otte JB Kestens PJ Endoscopic stapling technique of esophagodiverticulostomy for zenker's diverticulum.Ann Thorac Surg. 1993; 56: 573-576Abstract Full Text PDF PubMed Scopus (232) Google Scholar In our experience, the rigid transoral approach to Zenker's diverticulum has been shown to provide consistent results with low patient morbidity.22Howell RJ Giliberto JP Harmon J et al.Open versus endoscopic surgery of zenker's diverticula: A systematic review and meta-analysis.Dysphagia. 2019; 34: 930-938Crossref PubMed Scopus (15) Google Scholar Long term symptom relief is comparable to that provided by the open cervical approach.4Bonavina L Aiolfi A Scolari F et al.Long-term outcome and quality of life after transoral stapling for zenker diverticulum.World J Gastroenterol. 2015; 21: 1167-1172Crossref PubMed Scopus (26) Google Scholar We have found that the ability to offer an endoscopic approach has greatly enhanced referrals to our thoracic surgery practice.As thoracic surgeons, it is imperative that we continue to evolve and incorporate new ideas and technologies. The application of a filed down staple anvil and the use of a traction suture represent important modifications that we have found useful as we have gained experience with the procedure.33Provenzano L Salvador R Cutrone C et al.Traction on the septum during transoral septotomy for zenker diverticulum improves the final outcome.Laryngoscope. 2019; 130: 637-640Crossref PubMed Scopus (3) Google Scholar In the last few years, we have added use of the flexible endoscopic approach to complement the rigid transoral stapling technique (Erbe knife or Nd:YAG laser). This has allowed for complete division of any residual septum at the time of cricopharyngeal myotomy. The critical technical concept of the procedure remains complete cricopharyngeal myotomy (complete division of the common septum).Video Legend: This is an instructional video on how to perform an endoscopic trans-oral stapling of a Zenker's diverticulum. IntroductionZenker's diverticulum (ZD) is a rare disorder of the cervical esophagus that has a reported annual incidence of about 2 cases per 100,000.1Laing MR Murthy P Ah-See KW et al.Surgery for pharyngeal pouch: Audit of management with short- and long-term follow-up.J Royal Coll Surg Edinburgh. 1995; 40: 315-318PubMed Google Scholar, 2Klockars T Sihvo E Makitie A Familial zenker's diverticulum.Acta Oto-laryngol. 2008; 128: 1034-1036Crossref PubMed Scopus (17) Google Scholar, 3Bizzotto A Iacopini F Landi R et al.Zenker's diverticulum: Exploring treatment options.Acta Otorhinolaryngol Ital. 2013; 33: 219-229PubMed Google Scholar, 4Bonavina L Aiolfi A Scolari F et al.Long-term outcome and quality of life after transoral stapling for zenker diverticulum.World J Gastroenterol. 2015; 21: 1167-1172Crossref PubMed Scopus (26) Google Scholar It most commonly presents in the seventh and eight decade of life. ZD, also known as hypopharyngeal diverticulum, was first described by Abraham Ludlow in 1769.5Ludlow A.A case of obstructed deglutition, from a preternatural dilatation of, and bag formed in, the pharynx; in a letter from mr. LUDLOW, Surgeon at Bristol to Dr WILLIAM HUNTER, ReadAugust;27:1764.Google Scholar,6Morse CR Fernando HC Ferson PF et al.Preliminary experience by a thoracic service with endoscopic transoral stapling of cervical (zenker's) diverticulum.J Gastroint Surg. 2007; 11: 1091-1094Crossref PubMed Scopus (14) Google Scholar Subsequently, German pathologists Friedrich Albert von Zenker and Hugo Wilhelm von Ziemssen published a series of 23 patients in 1878 in which they described its basic clinical features and pathophysiology.7Zenker FA Ziemssen Hv. Krankheiten des oesophagus. F.C.W. Vogel, Leipzig1877Google Scholar While the complete pathophysiology of ZD is not fully understood, it is associated with uncoordinated relaxation or hypertension of the upper esophageal sphincter on swallowing. Intraluminal pressure increases against an inadequately relaxed cricopharyngeal muscle resulting in herniation of the hypopharyngeal mucosa and submucosa between the inferior constrictor and the cricopharyngeus muscles in an area of muscular weakness termed Killian's Triangle.8Costamagna G Iacopini F Bizzotto A et al.Prognostic variables for the clinical success of flexible endoscopic septotomy of zenker's diverticulum.Gastrointest Endosc. 2016; 83: 765-773Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 9Cook IJ Cricopharyngeal function and dysfunction.Dysphagia. 1993; 8: 244-251Crossref PubMed Scopus (66) Google Scholar, 10Dohlman G Mattsson O. The endoscopic operation for hypopharyngeal diverticula: A roentgencinematographic study.JAMA Otolaryngol Head Neck Surg. 1960; 71: 744-752Google Scholar It is a false diverticulum as it does not include the muscle layers of the esophageal wall. Gastroesophageal reflux has also been implicated as a potential underlying mechanism for ZD, whereby reflux initiates cricopharyngeal spasm and consequent development of the diverticulum.11Bognar L Vereczkei A Papp A et al.Gastroesophageal reflux disease might induce certain-supposedly adaptive-changes in the esophagus: A hypothesis.Digest Dis Sci. 2018; 63: 2529-2535Crossref PubMed Scopus (6) Google Scholar, 12Smiley TB Caves PK Porter DC Relationship between posterior pharyngeal pouch and hiatus hernia.Thorax. 1970; 25: 725-731Crossref PubMed Scopus (47) Google Scholar, 13Hunt PS Connell AM Smiley TB The cricopharyngeal sphincter in gastric reflux.Gut. 1970; 11: 303-306Crossref PubMed Scopus (127) Google Scholar, 14Sasaki CT Ross DA Hundal J Association between zenker diverticulum and gastroesophageal reflux disease: Development of a working hypothesis.Am J Med. 2003; 115: 169s-171sAbstract Full Text Full Text PDF PubMed Scopus (43) Google ScholarPatients typically will present with symptoms of oropharyngeal dysphagia, food regurgitation, halitosis, and in severe cases, recurrent aspiration pneumonia.15Cook IJ Gabb M Panagopoulos V et al.Pharyngeal (zenker's) diverticulum is a disorder of upper esophageal sphincter opening.Gastroenterology. 1992; 103: 1229-1235Abstract Full Text PDF PubMed Google Scholar,16Goyal RK Martin SB Shapiro J et al.The role of cricopharyngeus muscle in pharyngoesophageal disorders.Dysphagia. 1993; 8: 252-258Crossref PubMed Scopus (65) Google Scholar Radiologic evaluation includes a barium esophagram and modified barium swallow. Anatomic characteristics of the diverticulum such as size, location, and concomitant esophageal pathology are identified on esophagram. Given the association of gastroesophageal reflux with ZD, it is not uncommon to visualize hiatal hernia, reflux, esophageal dysmotility, or schatzki ring in conjunction with a Zenker's diverticulum. Modified barium swallow helps identify underlying aspiration.Surgical management of Zenker's diverticulum has evolved over time. Open transcervical diverticulectomy was first performed in 1885 and was the preferred surgical treatment for many years. However, this paradigm had shifted with the addition of the cricopharyngeal myotomy as it demonstrated improved results and minimized resection leaks.17Beard K Swanström LL. Zenker's diverticulum: Flexible versus rigid repair.J Thorac Dis. 2017; 9: S154-S162Crossref PubMed Scopus (22) Google Scholar,18DeMeester T Bremner CG. Selective cricopharyngeal myotomy for zenker's diverticulum.J Am Coll Surg. 2003; 196: 451-452Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Therefore, depending on the size, cricopharyngeal myotomy has generally become the gold standard approach for treatment of ZD with either diverticulopexy or diverticulectomy depending on diverticulum size.19Greene CL McFadden PM Oh DS et al.Long-term outcome of the treatment of zenker's diverticulum.Ann Thorac Surg. 2015; 100: 975-978Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar,20Welsh GF Payne WS. The present status of one stage pharyngo esophageal diverticulectomy.Surg Clin North Am. 1973; 53: 953-958Crossref PubMed Scopus (27) Google Scholar However, within the last few decades, the endoscopic approach to ZD treatment has been popularized.21Collard JM Otte JB Kestens PJ Endoscopic stapling technique of esophagodiverticulostomy for zenker's diverticulum.Ann Thorac Surg. 1993; 56: 573-576Abstract Full Text PDF PubMed Scopus (232) Google Scholar, 22Howell RJ Giliberto JP Harmon J et al.Open versus endoscopic surgery of zenker's diverticula: A systematic review and meta-analysis.Dysphagia. 2019; 34: 930-938Crossref PubMed Scopus (15) Google Scholar, 23Repici 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 options include the use of lasers, various forms of electrocautery, and stapling devices through both flexible and rigid esophagoscopy. We present our endoscopic approach to treatment of ZD which includes utilization of a stapling device to divide the common septum between the esophagus and diverticulum.24Weksler B Cook C Luketich JD Endoscopic transoral stapling of zenker's diverticula.Multimed Man Cardiothorac Surg. 2010; 2010 (mmcts.2007.002923)PubMed Google Scholar This divides the cricopharyngeus and consequently relieves the muscular outflow obstruction initially responsible for the development of the diverticulum. Adjunct electrocautery or laser ablation is used for division of any residual septum (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9, Figure 10, Figure 11).25Bonavina L Rottoli M Bona D et al.Transoral stapling for zenker diverticulum: Effect of the traction suture-assisted technique on long-term outcomes.Surg Endosc. 2012; 26: 2856-2861Crossref PubMed Scopus (23) Google Scholar, 26Chang CW Burkey BB Netterville JL et al.Carbon dioxide laser endoscopic diverticulotomy versus open diverticulectomy for zenker's diverticulum.Laryngoscope. 2004; 114: 519-527Crossref PubMed Scopus (72) Google Scholar, 27Wilken R Whited C Scher RL Endoscopic staple diverticulostomy for zenker's diverticulum: Review of experience in 337 cases.Ann Otol Rhinol Laryngol. 2015; 124: 21-29Crossref PubMed Scopus (23) Google ScholarFigure 3Weerda laryngoscope insertion (Video timestamp 00:40-01:26). Once mouth guards are placed to protect the patient's mouth, the Weerda laryngoscope is introduced into the oral cavity in the closed position and advanced. The esophagus is intubated with the tip of the scope. One jaw is placed in the esophagus and the second is placed in the diverticulum. The jaws are then expanded which allows clear visualization of the Zenker's diverticulum, common septum, and true lumen which is identified by the guidewire placed previously through flexible endoscopy. The Weerda laryngoscope is secured in place on a mayo stand that is positioned floating above the patient's chest. An additional 5-mm laparoscope can be introduced through the Weerda laryngoscope for additional visualization of the surgical field.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Weerda laryngoscope insertion (Video timestamp 00:40-01:26). Once mouth guards are placed to protect the patient's mouth, the Weerda laryngoscope is introduced into the oral cavity in the closed position and advanced. The esophagus is intubated with the tip of the scope. One jaw is placed in the esophagus and the second is placed in the diverticulum. The jaws are then expanded which allows clear visualization of the Zenker's diverticulum, common septum, and true lumen which is identified by the guidewire placed previously through flexible endoscopy. The Weerda laryngoscope is secured in place on a mayo stand that is positioned floating above the patient's chest. An additional 5-mm laparoscope can be introduced through the Weerda laryngoscope for additional visualization of the surgical field.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Proper orientation and view (Video timestamp 01:26-01:58). It is important to keep the proper orientation with the true lumen of the esophagus at 12 o'clock and the diverticulum at 6 o'clock. This positioning is crucial for the stapling of the common septum. The septum is identified utilizing an endoscopic dissector. The guidewire that was previously placed is helpful in this view to ensure proper identification of the true esophageal lumen.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Placement of stay suture in common septum (Video timestamp 01:58-02:42). A stay suture is placed in the common septum utilizing the Endo Stitch Suturing Device (Medtronic, Minneapolis, MN) which is introduced through the working channel of the Weerda laryngoscope. We recommend utilizing a full length 0-Surgidac suture as it is pulled out of the esophagus and oropharynx. This will provide traction on the common septum into a stapler device.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Stapling of the common septum (Video timestamp 02:42-03:40). An Endo-GIA 30-mm stapler with a modified anvil is introduced through the Weerda laryngoscope working channel and into the esophagus. (Figure 7 describes in detail the process and design of the modified anvil.) Utilizing the traction stitch, the common septum is fed into jaws of the stapler with the modified anvil in the diverticulum and the disposable staple cartridge within the esophageal lumen. The traction of the common septum will allow for complete transection of the cricopharyngeaus which is critical to a successful operation and to minimizing the rate of recurrence. Further firings of the stapler as needed are performed to ensure the common septum is divided to the base of the diverticulum. Placement of a second traction suture is sometimes needed for a larger diverticulum.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 7Modified Anvil (Video timestamp 02:42-03:40). As illustrated, the knife of the unmodified anvil tip does not reach where the staples are fired as the track ends prematurely. Therefore, to align the firing of the distal end staples and the cutting edge of the blade of the stapler, the tip of the reusable anvil is ground down by a mechanical grinder. The removal of this tip allows the stapler to both cut and staple to the end of the now shortened tip. This enables deeper placement of the anvil into the diverticulum. In our experience, the modified anvil facilitates more complete division of the common septum. However, its use is not mandatory and a standard 30 mm staple load could be utilized.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 8Inspection of the myotomy and divided common septum (Video timestamp 03:40-04:11). This figure depicts the endoscopic or direct view of the final product. After completion of the myotomy, the Weerda laryngoscope is removed. (A) A flexible endoscope is inserted into the esophagus to inspect the stapled edge of the septum for hemostasis and to ensure there is no residual diverticulum remaining. Continued (B) Division of the entire common septum will help achieve com plete myotomy of the cricopharyngeus muscle.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 8Inspection of the myotomy and divided common septum (Video timestamp 03:40-04:11). This figure depicts the endoscopic or direct view of the final product. After completion of the myotomy, the Weerda laryngoscope is removed. (A) A flexible endoscope is inserted into the esophagus to inspect the stapled edge of the septum for hemostasis and to ensure there is no residual diverticulum remaining. Continued (B) Division of the entire common septum will help achieve com plete myotomy of the cricopharyngeus muscle.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 9Performing an extended myotomy for removal of the residual common septum. (A) Flexible esophagoscopy is performed to ensure the entire common septum is divided. Continued (B) If residual septum is identified, we recommend additional division of the residual common septum to complete the myotomy of the cricopharyngeus muscle. Continued (C) We either utilize the endoscopic ERBE knife (Tübingen, Germany) or Nd-YAG laser. Typically, a capped flexible esophascope is used for better visualization and manipulation of the esophagus and diverticulum. The ERBE knife or Nd-Yag laser is introduced through the working port and provides a controlled division of the residual septum. Energy is focused on the crotch of the residual common septum where residual fibers of the cricopharyngeus may be visualized.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 9Performing an extended myotomy for removal of the residual common septum. (A) Flexible esophagoscopy is performed to ensure the entire common septum is divided. Continued (B) If residual septum is identified, we recommend additional division of the residual common septum to complete the myotomy of the cricopharyngeus muscle. Continued (C) We either utilize the endoscopic ERBE knife (Tübingen, Germany) or Nd-YAG laser. Typically, a capped flexible esophascope is used for better visualization and manipulation of the esophagus and diverticulum. The ERBE knife or Nd-Yag laser is introduced through the working port and provides a controlled division of the residual septum. Energy is focused on the crotch of the residual common septum where residual fibers of the cricopharyngeus may be visualized.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 9Performing an extended myotomy for removal of the residual common septum. (A) Flexible esophagoscopy is performed to ensure the entire common septum is divided. Continued (B) If residual septum is identified, we recommend additional division of the residual common septum to complete the myotomy of the cricopharyngeus muscle. Continued (C) We either utilize the endoscopic ERBE knife (Tübingen, Germany) or Nd-YAG laser. Typically, a capped flexible esophascope is used for better visualization and manipulation of the esophagus and diverticulum. The ERBE knife or Nd-Yag laser is introduced through the working port and provides a controlled division of the residual septum. Energy is focused on the crotch of the residual common septum where residual fibers of the cricopharyngeus may be visualized.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 10If extension of the myotomy was needed with ERBE knife, endoscopic clips are used to close the mucosotomy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 11If there is evidence of a residual common septum at the staple line that is not amendable to additional stapling we complete division of any residual septum with either the Nd:95 YAG laser or the ERBE knife.View Large Image Figure ViewerDownload Hi-res image Download (PPT)