December 27, 2015

Flexible Endoscopic Treatment of Zenker's Diverticulum

Having treated many patients with Zenker's Diverticulum using the endoscopic approach, I've had patients from all over the world contact me to determine whether I can help them or not... some specifically asking if I can perform the flexible endoscopic approach. However, I employ a rigid endoscopic approach rather than using a flexible endoscopic technique.

For those unfamiliar with this disorder, click here for more information. If you just want to skip to the doctors who perform the flexible approach, go to the bottom.

The basic concept of treating this rare disorder is that there is a common wall that divides the esophagus from the diverticulum pouch. This common wall is endoscopically divided such that the pouch now becomes the new back wall of the esophagus. So when the patient swallows, food/liquids can no longer get "trapped" causing symptoms.

Here is a picture demonstrating the rigid technique to exposing the Zenker's diverticulum that I employ. The pouch is denoted by the arrow.

When looking through an endoscope placed into the mouth down into the throat, there is a common wall that is between the pouch (blue arrow) and esophagus (green arrow).

Endoscopically, whether using a stapler or laser, this wall is divided down the middle. The picture shown below is when a stapler is used.

After the procedure, any food/liquid substances that are swallowed can't be trapped in the pouch. Therefore, even though nothing is surgically removed, the patient's swallowing symptoms completely disappear.

Flexible Approach

When employing a flexible rather than a rigid endoscopic approach, no rigid instruments are used. Rather, an endoscope identical to that employed by a gastroenterologist when performing an EGD (esophagogastroduodenoscopy) is utilized. The flexible technique was first introduced in 1995 in the Netherlands and Brazil. The specific advantage for the flexible over the rigid approach include being able to address Zenker's pouches that can not be visualized using the rigid technique due to anatomy.

The flexible endoscope is threaded through the mouth down to where the common wall is located and division is performed typically by cautery or laser. There are very few doctors who employ this technique, almost all of whom are actually GI and not ENT doctors. The vast majority of research being performed to figure out the best possible flexible approach is being done in Europe and Brazil... not the United States. See references below.

However, there are a few rare North-American based doctors that appear to be investigating (and performing) the flexible rather than rigid approach to treating Zenker's diverticulum, the 2 most prominent doctors being:

UNC-Chapel Hill: Dr. Todd Baron (used to be at Mayo)
Mississippi: Dr. Shou Tang
Toronto, Ontario, Canada: Dr. Chris Teshima
Miami, Florida: Dr. Donald Weed

Otherwise, you'll probably have to fly to Europe or Brazil. Why is this flexible approach so rare in the United States? It's because this approach is considered more "dangerous" with a higher risk of complications.

Non-USA References:
Endoscopic incision of Zenker's diverticula. Endoscopy. 1995 Aug;27(6):433-7. [Brazil]

Flexible endoscopic treatment of Zenker's diverticulum: a new approach. Endoscopy. 1995 Aug;27(6):438-42. [Netherlands]

Zenker's diverticulum: a new endoscopic treatment with a soft diverticuloscope. Gastrointest Endosc. 2003 Jul;58(1):116-20. [Belgium]

Flexible endoscopic Zenker's diverticulotomy: cap-assisted technique vs. diverticuloscope-assisted technique. Endoscopy. 2007 Feb;39(2):146-52. [Italy]

Zenker's diverticulum: a new endoscopic treatment with a soft diverticuloscope. Gastrointest Endosc. 2003 Jul;58(1):116-20. [Belgium]

Endoscopic treatment of Zenker's diverticulum with an oblique-end hood attached to the endoscope. Gastrointest Endosc. 2001 Dec;54(6):760-3. [Brazil]

Endoscopic flexible treatment of Zenker's diverticulum: a modification of the needle-knife technique. Endoscopy. 2010 Jul;42(7):532-5. doi: 10.1055/s-0029-1244163. Epub 2010 Jun 30. [Italy]

New flexible endoscopic controlled stapler technique for the treatment of Zenker's diverticulum. Scand J Gastroenterol. 2015;50(12):1512-5. doi: 10.3109/00365521.2015.1063154. Epub 2015 Jul 3. [Germany]

Flexible endoscopic treatment for Zenker's diverticulum with the SB Knife. Preliminary results from a single-center experience. Dig Endosc. 2015 Nov;27(7):728-33. doi: 10.1111/den.12490. Epub 2015 Jun 26. [Italy]

Endoscopic treatment for Zenker's diverticulum: long-term results (with video). Gastrointest Endosc. 2013 May;77(5):701-7. doi: 10.1016/j.gie.2012.12.008. Epub 2013 Feb 5. [Belgium]

Endoscopic treatment of Zenker's diverticulum by harmonic scalpel. Gastrointest Endosc. 2011 Sep;74(3):666-71. doi: 10.1016/j.gie.2011.05.007. [Brazil]

Flexible endoscopic septoplasty for bilobed Zenker's diverticulum. Gastrointest Endosc. 2012 May;75(5):1110-1. doi: 10.1016/j.gie.2011.05.045. Epub 2011 Aug 6. [Canada
Zenker's diverticulum: treatment using a flexible endoscope. Endoscopy. 2001 Nov;33(11):991-7. [Netherlands]

Flexible endoscopic treatment for Zenker's diverticulum: from the lumen to the third space. Ann Gastroenterol . 2021;34(2):149-154. doi: 10.20524/aog.2021.0575. Epub 2021 Jan 16. [Italy]

USA References:
Flexible endosopic management of Zenker's diverticulum: characteristics and outcomes of 52 cases at a tertiary referral center. Dis Esophagus. 2015 Feb 24. doi: 10.1111/dote.12323. [Mayo Clinic and UNC-Chapel Hill]

Flexible endoscopic Zenker's diverticulotomy: approach that involves thinking outside the box (with videos). Surg Endosc. 2014 Apr;28(4):1355-9. doi: 10.1007/s00464-013-3335-3. Epub 2014 Jan 1. [Jackson, Mississippi]

Transoral flexible endoscopic therapy of Zenker's diverticulum. Dig Surg. 2013;30(4-6):393. doi: 10.1159/000355507. Epub 2013 Oct 29. [Mayo Clinic]

Transoral flexible endoscopic therapy of Zenker's diverticulum: is it time for gastroenterologists to stick their necks out? Gastrointest Endosc. 2013 May;77(5):708-10. doi: 10.1016/j.gie.2013.01.019. [Mayo Clinic]

Flexible endoscopic Zenkers diverticulotomy with a novel bipolar forceps: a pilot study and comparison with needle knife dissection. Surg Endosc. 2011 Oct;25(10):3273-8. doi: 10.1007/s00464-011-1704-3. Epub 2011 May 2. [Portland, OR]

Flexible endoscopic management of Zenker diverticulum: the Mayo Clinic experience. Mayo Clin Proc. 2010 Aug;85(8):719-22. doi: 10.4065/mcp.2009.0663. [Mayo Clinic]

Flexible endoscopic clip-assisted Zenker's diverticulotomy: the first case series (with videos). Laryngoscope. 2008 Jul;118(7):1199-205. doi: 10.1097/MLG.0b013e31816e2eee. [Dallas, TX]

Fiberoptic endoscopic-assisted diverticulotomy: a novel technique for the management of Zenker's diverticulum. Ann Otol Rhinol Laryngol. 2005 May;114(5):347-51. [New York City]
Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

1 comment:

Unknown said...

Is there an update to this article: Flexible Endoscopic Treatment of Zenker's Diverticulum. Thanks

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