Flexible endoscopic Zenker's diverticulotomy: approach that involves thinking outside the box (with videos).

Abstract

BACKGROUND: Flexible endoscopic treatment for Zenker's diverticulum (ZD) focuses on releasing the cricopharyngeal spasm by performing diverticulotomy on the septum. Current flexible endoscopic devices and techniques in ZD treatment require advanced endoscopic expertise and skills. Dedicated devices for directed and expedited septal dissection are lacking. This study aimed to develop and test prototypes for flexible endoscopic diverticulotomy. METHODS: An in vivo flexible endoscopic diverticulotomy was performed in a nonsurvival swine model (n = 6; 110-lb animals). Two iterations of the diverticulotomy device were used to perform the diverticulotomy: a diverticulum cap with a swinging needleknife and a diverticulotome or septotome. The diverticulotome consisted of a diverticulum cap and a built-in cutting wire. The study evaluated the feasibility and efficiency of septal dissection with these devices. RESULTS: Efficient (<1-2 min) midline septal dissection was achieved using both devices without failure or immediate bleeding. A diverticulum cap with a swinging needleknife provides targeted and more precise septal dissection than a diverticulotome. The diverticulotome requires higher power settings due to the wider contact area between the septal tissues and the cutting wire. CONCLUSIONS: Flexible endoscopic diverticulotomy is feasible and efficient using the aforementioned diverticulotomy devices. The techniques in diverticulotomy using these devices are similar to those in biliary sphincterotomy using a sphincterotome, endoscopic needleknife, or both.