Flexible endoscopic clip-assisted Zenker\'s diverticulotomy (with videos)

NEW METHODS: Clinical Endoscopy

Flexible endoscopic clip-assisted Zenker’s diverticulotomy (with videos) Shou-jiang Tang, MD, Luis F. Lara, MD Dallas, Texas, USA

Background: In treating Zenker’s diverticulum (ZD), there are potential risks associated with flexible endoscopic diverticulotomy without suturing or stapling. Rigid endoscopic stapler-assisted diverticulotomy has limitations. The septum is usually not completely dissected with either technique. Objective: Our purpose was to evaluate the feasibility of flexible endoscopic clip-assisted diverticulotomy (ECD) for complete septum dissection. Design: Case report. Setting: Academic center. Patient: An elderly male with symptomatic residual ZD. Interventions: After 1 endoclip (InScope multiclip applier, Ethicon Endo-Surgery) was placed on each side of the cricopharyngeal bar, the septum was easily and completely dissected between these 2 clips down to the bottom of the diverticulum into the esophageal mucosa with a needle-knife. Main Outcome Measurement: Symptom resolution and complications. Results: Complete esophageal symptom resolution without complications. Limitation: Case report. Conclusions: ECD is feasible, easy, safe, and effective for complete septum dissection. This is the first reported case of ECD. ECD provides another option in managing ZD with flexible endoscopy.

Zenker’s diverticulum (ZD) is the protrusion of pharyngeal mucosa through the posterior wall of the pharynx limited inferiorly by the cricopharyngeal muscle and laterally by the thyropharyngeal muscle.1-4 ZD can cause dysphagia, regurgitation of undigested food, cough, and aspiration of food particles. ZD probably results from increased intraluminal pressures as a result of cricopharyngeal spasm.1-4 The traditional surgery is transcervical diverticulectomy and cricopharyngeal myotomy. Endoscopic treatment for ZD focuses on releasing the cricopharyngeal spasm. Recently, otolaryngologists have adopted rigid endoscopic stapler-assisted diverticulotomy (ESD) and carbon dioxide laser endoscopic diverticulotomy. These 2 methods are rapidly becoming the procedure of choice.1-9 However, Abbreviations: ECD, endoscopic clip-assisted diverticulotomy; ESC, endoscopic stapler-assisted diverticulotomy; NG, nasogastric; ZD, Zenker’s diverticulum.

a small but significant patient population is unable to accommodate the rigid laryngoscope.1-4 For a small ZD less than 2 cm, the anvil of the stapler is too long to be properly accommodated inside the pouch, so the cricopharyngeal muscle fibers cannot be completely dissected.6 With a flexible endoscope, expert endoscopists approach ZD by dissecting the cricopharyngeal bar and septum with a needle-knife or argon plasma coagulation without stapling.10-13 There are significant concerns about aggressively dissecting the septum without stapler assistance, such as mediastinitis and perforation. We report the first case of flexible endoscopic clip-assisted diverticulotomy (ECD) for complete septum dissection.

CASE REPORT

Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.11.006

An 88-year-old man was referred for a 2-year history of daily solid food and pill dysphagia with the feeling that food was stuck the throat. The patient denied weight loss or odynophagia. He underwent ZD surgery 25 years

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ago. There were no postoperative complications, including infection or bleeding. His medical history includes hypertension, coronary heart disease, chronic renal insufficiency, and hypothyroidism. A barium swallow demonstrated a hypopharyngeal ZD. The size of the diverticulum was estimated to be 6 to 7 mm on barium study. During endoscopy, a residual ZD with a cricopharyngeal bar was seen (Fig. 1, Video 1, available online at www. giejournal.org). After a nasogastric (NG) feeding tube was placed, 1 endoclip (InScope multiclip applier, Ethicon Endo-Surgery, Cincinnati, Ohio) was placed on each side of the cricopharyngeal bar without difficulty (Fig. 2). With a needle-knife (HPC-3, Wilson-Cook, Winston-Salem, NC) and coagulation current (ERBE ICC 200/350, Tubingen, Germany), the cricopharyngeal bar and septum were easily and completely dissected between the 2 clips down to the bottom of the diverticulum into the esophageal mucosa (Fig. 3, Video 2, available online at www. giejournal.org). A single-channel diagnostic gastroscope was used for the initial endoscopic evaluation and needle dissection. A single-channel therapeutic gastroscope was used for clip deployment. Excluding the time for NG tube placement and sedation, the total time of clip placement and dissection was less than 5 minutes. Antibiotic prophylaxis was not given and sedation was provided by the nurse anesthetist with propofol. There was no immediate complication including endoscopic bleeding. The patient was admitted for overnight observation, and he remained asymptomatic after therapy and throughout the hospitalization. An oral diet was started the next morning and all esophageal symptoms resolved completely. A routine follow-up upper endoscopy was performed in 3 months. No visible cricopharyngeal bar and septum was noted, and the clips were not seen in the esophagus (Fig. 4).

Zenker’s diverticulotomy

Capsule Summary What is already known on this topic d

Rigid endoscopic stapler-assisted diverticulectomy is associated with short hospital stays, decreased time to resumption of oral intake, and significant decreases in patient morbidity, but some patients cannot accommodate the rigid laryngoscope.

What this study adds to our knowledge d

In a single patient with symptomatic residual Zenker’s diverticulum, flexible endoscopic clip-assisted diverticulectomy resulted in complete septum dissection with no complications.

Endoscopic dissection of septum/wall between the diverticulum and the esophagus with electrocautery or laser without tissue suturing or stapling has long been performed by otolaryngologists and experienced endoscopists; however, these sutureless techniques gained limited popularity because of the risk of severe complications such as mediastinitis.1-6 Collard et al5 proposed simultaneously dividing and stapling the septum with a laparoscopic stapler introduced through a rigid diverticuloscope. ESD is minimally invasive, effective, and associated with shorter hospital stays, decreased time to resumption of oral intake, significant decreases in patient morbidity, and overall cost.1-4,7 However, there are limitations to ESD. A small but significant patient population is unable to accommodate the rigid laryngoscope.1-4 Because of the size of the stapler’s anvil, ESD is best suited for medium-sized ZDs of 3 to 6 cm.6 For a small ZD less than 2 cm, the anvil of the stapler is too long to be

properly accommodated inside the pouch, so the cricopharyngeal muscle fibers cannot be completely dissected.1-4,6,9,13 The incompletely dissected septum is likely to result in a residual diverticulum and uncut cricopharyngeal muscle fiber and may lead to residual symptoms and symptomatic recurrence. Therefore, open surgery or carbon dioxide laser endoscopic diverticulotomy is sometimes recommended for a small ZD.2,6 Besides placing a traction suture at the apex for deeper dissection, modification of the stapler without damaging the mechanism has been proposed and performed experimentally.9 Current staplers used for ESD leave a residual pouch of 1.5 cm when unmodified. The modified anvil staplers still give a small 4 to 5 mm pouch.9 Although there are no reported significant complications with flexible endoscopic diverticulotomy performed in expert centers,10-13 the main criticism by otolaryngologists and surgeons toward this technique is the lack of simultaneous tissue stapling to seal the cut edges of the mucosal and muscular edges.1-4 Many surgeons consider the sutureless techniques to have an unacceptably high risk of mediastinitis.2,3 Because of the same concerns, the septum is not dissected completely to the bottom during flexible endoscopic diverticulotomy to minimize the risk of complications.10-13 In a recent article, Costamagna et al12 routinely applied a single endoclip (Quickclip, Olympus, Tokyo, Japan) at the apex of dissected septum to prevent microscopic perforation after septum dissection. The 2 sides of the divided septum were left unclipped. We list the differences between this ‘‘postdissection one clipping method’’ and ECD (Table 1). During ECD, complete septum dissection can be performed even into the esophageal mucosa because the apex of the septum is free. ECD incorporates the rationale used in rigid ESD: securing the 2 sides of the septum first and then dissecting the septum. Some investigators use the cap-fitted method or diverticuloscope for better visualization and stabilization of the septum during dissection.10,12,14 However, the diverticuloscope is inappropriate for therapeutic

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DISCUSSION

Zenker’s diverticulotomy

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Figure 1. Endoscopic view of a residual ZD with a cricopharyngeal bar in the center.

Figure 3. The septum was completely dissected between 2 previously placed endoclips.

Figure 2. Endoscopic view of 1 endoclip (InScope multiclip applier) placed on each side of the cricopharyngeal bar.

Figure 4. Endoscopic view of the upper esophagus during follow-up endoscopy. No visible septum or bar was noted.

use in ZDs less than 25 mm in diameter.12 We believe that ECD can be performed in combination with the diverticuloscope or cap-fitted method. The diverticuloscope or cap is used to expose and stabilize the septum, while the clips are used to secure the septum before dissection. As in free-hand needle-knife precutting (in ERCP) and in traditional endoscopic diverticulotomy, the endoscopist needs to keep a steady hand with smooth needle strokes during dissection. We do not think there will be significant damage even if the needle unintentionally touches the clip. In fact, preexisting clips can potentially minimize accidental injury to the adjacent mucosa by diffusing the heat across the entire clip, forming a mechanical barrier, and guiding dissection. With appropriate techniques, endoclips can be used to approximate tissues and mucosal defects. With the availability of endoclips, endoscopists can manage iatrogenic perforations nonoperatively.12,15-17 Endoclips suit the anatomy of the Zenker septum and may be better at exposing the bar in cases of smaller ZDs, where current staplers are unable to reach (Fig. 5). There are 3 commercially available endoclips suitable for this procedure: InScope multiclip applier, Olympus Quickclip, and Boston Scientific Resolution Clip (Fig. 6). The lengths of the clip

arms and tail of these clips are 5.4 and 2.2 mm (InScope multiclip applier), 4.75 and 6 mm (Quickclip), and 5.16 and 10.6 mm (Resolution Clip). The multiclip applier was chosen because it has the longest clip arm and the shortest tail; thus it is less likely to obscure the view of bar and dissection. Longer-tailed endoclips may cause local throat symptoms and interfere with subsequent clip application. The multiclip applier is also rotatable and the jaws may be opened and closed before the clip is applied, thus allowing confirmation of tissue approximation before clip deployment. The multiple clip application is also attractive because no time is lost removing or passing another clip device through the endoscope. Ideally, a longer clip arm may approximate the septum with a deeper pouch mimicking the surgical stapler (1-step ECD). Because of the limited arm length of about 5 mm of all currently available endoclips, repeated clipping and dissection can be performed for any septum greater than 6 mm to overcome this inconvenience (stepwise ECD). Before each round of dissection, 1 clip can be placed on each side of the divided mucosal and muscular edges. Alternatively, staged ECD with 1 clip applied on each side followed by a single session of dissection can be performed.

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Zenker’s diverticulotomy

TABLE 1. Comparison between 1-clip method and ECD in ZD One-clip method Location of clip

Apex of the septum

ECD Two sides of the septum

Sequence of clipping Cut and clip and dissection

Clip and cut

Complete septum dissection

No

Yes

Secured 2 sides of the septum

No

Yes

Figure 5. Schematic illustration of stepwise and bottom ECD. Green bars, The last or bottom 2 clips placed in V configuration; blue arrow, needle-knife dissection.

Complete or on-demand flexible endoscopic diverticulotomy can be accomplished in several sessions of flexible endoscopy. To carry out a stepwise dissection in a large diverticulum, we recommend placing the clips on 2 sides of the septum. The distance between the 2 clips should be at least 5 to 7 mm apart proximally to permit easy dissection. It is probably better to place the last or bottom 2 clips in V configuration: the distal ends of 2 clips are close to each other (Fig. 5). This clip configuration permits minimal unsecured septal walls after dissection, resulting in potentially lower risks of complication. We recommend 3 to 4 weeks between each ECD to allow for reduction of acute tissue edema and better visualization. During this period, significant scarring has not yet formed after the previous ECD. Because the highest risk of perforation is associated with dissecting the lower part and the bottom of the septum,10-13 ECD should be considered when dissecting at these locations (bottom ECD) (Fig. 5). We can potentially dissect the septum down to the bottom until we www.giejournal.org

Figure 6. Comparison of 3 commercially available endoclips. The lengths of the clip arms and tail of these clips are 5.40 and 2.20 mm (multiclip applier, InScope), 4.75 and 6.0 mm (Quickclip, Olympus), and 5.16 and 10.6 mm (Resolution Clip, Boston Scientific).

can see the other side of the esophageal mucosa from above without any tissues/bar between the bottom of the septum and outside (distal) mucosa. With ECD, endoscopists have another option to treat ZD with or without complete septum dissection with potentially lower risks of complications. Secure mucosal closure can prevent or minimize leakage. With currently available endoclips, we propose that the ECD is best suited in these clinical scenarios: (1) a small ZD less than 2 cm, (2) symptomatic residual or recurrent ZD that needs complete septum dissection, (3) sequential or staged ECD with stepwise dissection in patients with larger ZD who prefer flexible endoscopic diverticulotomy (stepwise ECD), and (4) ECD for dissection of the lower parts and the bottom of the septum (bottom ECD). For endoscopists who use cap-fitted method or diverticuloscope with a needle knife, ECD is complementary. The cap or diverticuloscope is used for better visualization and avoidance of injury to the surrounding tissues during needle dissection, while ECD secures the septum before dissection. DISCLOSURE The authors report that there are no disclosures relevant to this publication. REFERENCES 1. van Overbeek JJ. Pathogenesis and methods of treatment of Zenker’s diverticulum. Ann Otol Rhinol Laryngol 2003;112:583-93. 2. Veenker E, Cohen JI. Current trends in management of Zenker diverticulum. Curr Opin Otolaryngol Head Neck Surg 2003;11:160-5. 3. Richtsmeier WJ. Endoscopic management of Zenker diverticulum: the staple-assisted approach. Am J Med 2003;115(3A Suppl):175S-8S. 4. Sen P, Bhattacharyya AK. Endoscopic stapling of pharyngeal pouch. J Laryngol Otol 2004;118:601-6. 5. Collard JM, Otte JB, Kestens PJ. Endoscopic stapling technique of esophagodiverticulostomy for Zenker’s diverticulum. Ann Thorac Surg 1993;56:573-6.

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Upper intestinal anastomotic leaks 6. Zaninotto G, Narne S, Costantini M, et al. Tailored approach to Zenker’s diverticula. Surg Endosc 2003;17:129-33. 7. Wirth D, Kern B, Guenin MO, et al. Outcome and quality of life after open surgery versus endoscopic stapler-assisted esophagodiverticulostomy for Zenker’s diverticulum. Dis Esophagus 2006;19: 294-8. 8. Miller FR, Bartley J, Otto RA. The endoscopic management of Zenker diverticulum: CO2 laser versus endoscopic stapling. Laryngoscope 2006;116:1608-11. 9. Richtsmeier WJ. Myotomy length determinants in endoscopic stapleassisted esophagodiverticulostomy for small Zenker’s diverticula. Ann Otol Rhinol Laryngol 2005;114:341-6. 10. Vogelsang A, Preiss C, Neuhaus H, et al. Endotherapy of Zenker’s diverticulum using the needle-knife technique: long-term follow-up. Endoscopy 2007;39:131-6. 11. Rabenstein T, May A, Michel J, et al. APC for flexible endoscopic Zenker’s diverticulotomy. Endoscopy 2007;39:141-5. 12. Costamagna G, Iacopini F, Tringali A, et al. Flexible endoscopic Zenker’s diverticulotomy: cap-assisted technique vs. diverticuloscope-assisted technique. Endoscopy 2007;39:146-52. 13. Feussner H. Endoscopic therapy for Zenker diverticulum. Endoscopy 2007;39:154-5.

Wedemeyer et al 14. Evrard S, Le Moine O, Hassid S, et al. Zenker’s diverticulum: a new endoscopic treatment with a soft diverticuloscope. Gastrointest Endosc 2003;58:116-20. 15. Technology Assessment Committee. Endoscopic clip application devices. Gastrointest Endosc 2006;63:746-50. 16. Shimizu Y, Kato M, Yamamoto J, et al. Endoscopic clip application for closure of esophageal perforations caused by EMR. Gastrointest Endosc 2004;60:636-9. 17. Minami S, Gotoda T, Ono H, et al. Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video). Gastrointest Endosc 2006;63:596-601.

Received April 24, 2007. Accepted November 6, 2007. Current affiliations: Division of Digestive Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA. Reprint requests: Shou-jiang Tang, MD, Division of Digestive Diseases, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8887.

Endoscopic vacuum-assisted closure of upper intestinal anastomotic leaks Jochen Wedemeyer, MD, Andrea Schneider, MD, Michael P. Manns, MD, Steffan Jackobs, MD Hannover, Germany

Background: Management of intrathoracic anastomotic leaks remains an interdisciplinary challenge. Established treatment options include percutaneous drainage, endoscopic closure, or even surgical revision. All these procedures are associated with high morbidity and mortality rates. Objective: We report a new, effective endoscopic treatment option for intrathoracic esophageal anastomotic leaks by using an endoscopic vacuum-assisted closure system. Patients: Two patients with intrathoracic anastomotic leaks after esophagectomy and gastrectomy were included. Methods: Surgical reinterventions failed to seal the leaks in 1 patient, whereas in the other patient the anastomotic leakage persisted after endoscopic placement of 2 covered self-expanding metal stents. We endoscopically placed transnasal draining tubes that were armed with a size-adjusted sponge at their distal tip in the necrotic anastomotic cavities. Continuous suction was applied. Sponge and drain were changed twice a week. Results: No complications were noted during the course of treatment. After a median of 15 days, closure of the wound cavities was achieved in all cases. A median of 5 endoscopic interventions was necessary. Both patients returned gradually to a solid diet without recurrence of the leaks. Conclusion: Endoscopic vacuum-assisted closure might be an effective alternative in the treatment of upper intestinal anastomotic leaks.

Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.10.064

Intrathoracic anastomotic leakage is one of the most serious complications after esophagectomy. The reported incidence of esophageal anastomotic leaks ranges from 5% to almost 30% after gastrectomy and esophagectomy.1-6 Endoscopic interventions that have been reported to successfully

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Abbreviations: SEMS, self-expanding metal stent; SEPS, self-expanding plastic stent; VAC, vacuum-assisted closure.