554236
research-article2015
SRIXXX10.1177/1553350614554236Surgical InnovationBonavina et al
Letter to the Editor
Transoral Septum Stapling of Zenker Diverticulum Is Feasible and Safe Through a Soft Overtube
Surgical Innovation 2015, Vol. 22(2) 207–209 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1553350614554236 sri.sagepub.com
Luigi Bonavina, MD, FACS1, Davide Bona, MD1, Alberto Aiolfi, MD1, and Andrea Sironi, MD1 Pharyngoesophageal Zenker’s diverticulum typically occurs in middle-aged and elderly patients. Treatment options include open surgery through a left cervical incision (cricopharyngeal myotomy with or without pouch resection), transoral division of the septum through rigid endoscopy (with stapler, CO2 laser, or harmonic scalpel), or by means of flexible endoscopy (free hand or assisted). The transoral techniques are increasingly used over the open surgical approach because of the low morbidity and the fast recovery time; in addition, this approach can be safely repeated in case of symptom persistence or recurrence. Transoral septum stapling of Zenker diverticulum has gained widespread acceptance and is often considered the upfront therapeutic choice.1-3 However, the rigid Weerda diverticuloscope is difficult to handle and requires a steep learning curve. In addition, some patients cannot accommodate this device because of anatomical variability in jaw opening and/or neck extension. A flexible endoscopic approach using a needle-knife,4 harmonic scalpel,5 or insulated-tip needle6 with the assistance of a soft overtube has been previously reported and may overcome some of the technical limitations of rigid endoscopy. A 79-year-old woman was referred to our center because of a 1-year history of inability to swallow, significant weight loss, and recurrent pneumonia episodes. Previous attempt at endoscopic treatment of a Zenker diverticulum failed and the patient underwent percutaneous gastrostomy and tracheostomy in another hospital. Instead of using the rigid diverticuloscope, we decided to attempt transoral septum stapling using a soft overtube under flexible endoscopic assistance because of the the very limited mouth opening and the potential difficulty to access the esophagus. Under general anesthesia, with the patient in the supine position, a soft diverticuloscope (ZD overtube; Cook Endoscopy, Winston-Salem, NC) was advanced into the hypopharynx over a standard 9-mm endoscope (Olympus Optical Co, Hamburg, Germany). This transparent soft-rubber device has 2 distal flaps (40 mm and 30 mm) that respectively protect the anterior esophageal wall and the posterior diverticular wall. The overtube
flaps should straddle the septum of the diverticulum. The overtube has a black marker indicating the average distance of 16 cm from its tip. Once the esophagus was entered, the endoscope was slowly withdrawn and the Zenker’s septum identified. The upper and lower valves of the overtube were positioned into the esophageal lumen (longer flap) and the diverticulum, respectively. The endoscope was then withdrawn and replaced by a 5-mm 0° telescope (Figure 1A and B). A linear articulated endostapler (ETS 35 mm, Ethicon Endosurgery, Cincinnati, OH) was introduced and positioned across the septum in the midline. The septum was easily divided under view of the 0° telescope with 1 blue cartridge of Endo-GIA and the suture line was checked for hemostasis (Figure 2). The procedure was well tolerated. A soft oral diet was resumed after 24 hours. A gastrografin swallow study was performed on postoperative day 1 (Figure 3A and B) and the patient was discharged home on a semisolid diet. The percutaneous gastrostomy was removed 3 weeks later. Using a soft overtube instead of the rigid bivalved Weerda diverticuloscope is feasible and safe for transoral stapling. The soft branches of the overtube allow optimal septum exposure and complete opening of the endostapler jaws. The incidence of device-related complications, such as dental avulsions and lip lacerations, is minimized compared to the rigid diverticuloscope. In patients with limited mouth opening and head extension, this hybrid transoral approach that combines flexible endoscopy with assistance of a soft overtube and stapling under vision of a 0° telescope may effectively replace the rigid Weerda diverticuloscope. 1
IRCCS Policlinico San Donato, University of Milan Medical School, 20097 San Donato Milanese, Milano, Italy Corresponding Author: Luigi Bonavina, Department of Biomedical Sciences for Health, University of Milano Medical School, Division of General Surgery Divisione Universitaria di Chirurgia e Centro per le Malattie dell’Esofago, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy. Email: [email protected]
Downloaded from sri.sagepub.com at DEAKIN UNIV LIBRARY on November 14, 2015
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Surgical Innovation 22(2)
Figure 1. The soft Zenker overtube is applied over the endoscope (A). Both the linear endostapler and the 5-mm telescope are accommodated within the overtube and the 2 jaws of the stapler can be completely opened.
Figure 2. The septum is stapled under view of the 5-mm telescope.
Figure 3. Preoperative (A) and postoperative (B) gastrographin swallow study showing near complete contrast outflow after transoral stapling. Downloaded from sri.sagepub.com at DEAKIN UNIV LIBRARY on November 14, 2015
209
Bonavina et al References 1. Aly A, Devitt P, Jamieson J. Evolution of surgical treatment for pharyngeal pouch. Br J Surg. 2004;91:657-664. 2. Leong SC, Wilkie MD, Webb CJ. Endoscopic stapling of Zenker’s diverticulum: establishing national baselines for auditing clinical outcomes in the United Kingdom. Eur Arch Otorhinolaryngol. 2012;269:1877-1884. 3. Bonavina L, Rottoli M, Bona D, Siboni S, Russo IS, Bernardi D. Transoral stapling for Zenker diverticulum: effect of the traction suture-assisted technique on long-term outcomes. Surg Endosc. 2012;26:2856-2861.
4. Costamagna G, Iacopini F, Tringali A, et al. Flexible endoscopic Zenker’s diverticulotomy: cap-assisted technique vs. diverticuloscope-assisted technique. Endoscopy. 2007;39:146-152. 5. Hondo FY, Maluf-Filho F, Giordano-Nappi JH, Neves CZ, Cecconello I, Sakai P. Endoscopic treatment of Zenker’s diverticulum by harmonic scalpel. Gastrointest Endosc. 2011;74:666-671. 6. Manno M, Manta R, Caruso A, et al. Alternative endoscopic treatment of Zenker’s diverticulum: a case series. Gastrointest Endosc. 2014;79:168-170.
Downloaded from sri.sagepub.com at DEAKIN UNIV LIBRARY on November 14, 2015
research-article2015
SRIXXX10.1177/1553350614554236Surgical InnovationBonavina et al
Letter to the Editor
Transoral Septum Stapling of Zenker Diverticulum Is Feasible and Safe Through a Soft Overtube
Surgical Innovation 2015, Vol. 22(2) 207–209 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1553350614554236 sri.sagepub.com
Luigi Bonavina, MD, FACS1, Davide Bona, MD1, Alberto Aiolfi, MD1, and Andrea Sironi, MD1 Pharyngoesophageal Zenker’s diverticulum typically occurs in middle-aged and elderly patients. Treatment options include open surgery through a left cervical incision (cricopharyngeal myotomy with or without pouch resection), transoral division of the septum through rigid endoscopy (with stapler, CO2 laser, or harmonic scalpel), or by means of flexible endoscopy (free hand or assisted). The transoral techniques are increasingly used over the open surgical approach because of the low morbidity and the fast recovery time; in addition, this approach can be safely repeated in case of symptom persistence or recurrence. Transoral septum stapling of Zenker diverticulum has gained widespread acceptance and is often considered the upfront therapeutic choice.1-3 However, the rigid Weerda diverticuloscope is difficult to handle and requires a steep learning curve. In addition, some patients cannot accommodate this device because of anatomical variability in jaw opening and/or neck extension. A flexible endoscopic approach using a needle-knife,4 harmonic scalpel,5 or insulated-tip needle6 with the assistance of a soft overtube has been previously reported and may overcome some of the technical limitations of rigid endoscopy. A 79-year-old woman was referred to our center because of a 1-year history of inability to swallow, significant weight loss, and recurrent pneumonia episodes. Previous attempt at endoscopic treatment of a Zenker diverticulum failed and the patient underwent percutaneous gastrostomy and tracheostomy in another hospital. Instead of using the rigid diverticuloscope, we decided to attempt transoral septum stapling using a soft overtube under flexible endoscopic assistance because of the the very limited mouth opening and the potential difficulty to access the esophagus. Under general anesthesia, with the patient in the supine position, a soft diverticuloscope (ZD overtube; Cook Endoscopy, Winston-Salem, NC) was advanced into the hypopharynx over a standard 9-mm endoscope (Olympus Optical Co, Hamburg, Germany). This transparent soft-rubber device has 2 distal flaps (40 mm and 30 mm) that respectively protect the anterior esophageal wall and the posterior diverticular wall. The overtube
flaps should straddle the septum of the diverticulum. The overtube has a black marker indicating the average distance of 16 cm from its tip. Once the esophagus was entered, the endoscope was slowly withdrawn and the Zenker’s septum identified. The upper and lower valves of the overtube were positioned into the esophageal lumen (longer flap) and the diverticulum, respectively. The endoscope was then withdrawn and replaced by a 5-mm 0° telescope (Figure 1A and B). A linear articulated endostapler (ETS 35 mm, Ethicon Endosurgery, Cincinnati, OH) was introduced and positioned across the septum in the midline. The septum was easily divided under view of the 0° telescope with 1 blue cartridge of Endo-GIA and the suture line was checked for hemostasis (Figure 2). The procedure was well tolerated. A soft oral diet was resumed after 24 hours. A gastrografin swallow study was performed on postoperative day 1 (Figure 3A and B) and the patient was discharged home on a semisolid diet. The percutaneous gastrostomy was removed 3 weeks later. Using a soft overtube instead of the rigid bivalved Weerda diverticuloscope is feasible and safe for transoral stapling. The soft branches of the overtube allow optimal septum exposure and complete opening of the endostapler jaws. The incidence of device-related complications, such as dental avulsions and lip lacerations, is minimized compared to the rigid diverticuloscope. In patients with limited mouth opening and head extension, this hybrid transoral approach that combines flexible endoscopy with assistance of a soft overtube and stapling under vision of a 0° telescope may effectively replace the rigid Weerda diverticuloscope. 1
IRCCS Policlinico San Donato, University of Milan Medical School, 20097 San Donato Milanese, Milano, Italy Corresponding Author: Luigi Bonavina, Department of Biomedical Sciences for Health, University of Milano Medical School, Division of General Surgery Divisione Universitaria di Chirurgia e Centro per le Malattie dell’Esofago, IRCCS Policlinico San Donato, Via Morandi 30, 20097 San Donato Milanese, Milan, Italy. Email: [email protected]
Downloaded from sri.sagepub.com at DEAKIN UNIV LIBRARY on November 14, 2015
208
Surgical Innovation 22(2)
Figure 1. The soft Zenker overtube is applied over the endoscope (A). Both the linear endostapler and the 5-mm telescope are accommodated within the overtube and the 2 jaws of the stapler can be completely opened.
Figure 2. The septum is stapled under view of the 5-mm telescope.
Figure 3. Preoperative (A) and postoperative (B) gastrographin swallow study showing near complete contrast outflow after transoral stapling. Downloaded from sri.sagepub.com at DEAKIN UNIV LIBRARY on November 14, 2015
209
Bonavina et al References 1. Aly A, Devitt P, Jamieson J. Evolution of surgical treatment for pharyngeal pouch. Br J Surg. 2004;91:657-664. 2. Leong SC, Wilkie MD, Webb CJ. Endoscopic stapling of Zenker’s diverticulum: establishing national baselines for auditing clinical outcomes in the United Kingdom. Eur Arch Otorhinolaryngol. 2012;269:1877-1884. 3. Bonavina L, Rottoli M, Bona D, Siboni S, Russo IS, Bernardi D. Transoral stapling for Zenker diverticulum: effect of the traction suture-assisted technique on long-term outcomes. Surg Endosc. 2012;26:2856-2861.
4. Costamagna G, Iacopini F, Tringali A, et al. Flexible endoscopic Zenker’s diverticulotomy: cap-assisted technique vs. diverticuloscope-assisted technique. Endoscopy. 2007;39:146-152. 5. Hondo FY, Maluf-Filho F, Giordano-Nappi JH, Neves CZ, Cecconello I, Sakai P. Endoscopic treatment of Zenker’s diverticulum by harmonic scalpel. Gastrointest Endosc. 2011;74:666-671. 6. Manno M, Manta R, Caruso A, et al. Alternative endoscopic treatment of Zenker’s diverticulum: a case series. Gastrointest Endosc. 2014;79:168-170.
Downloaded from sri.sagepub.com at DEAKIN UNIV LIBRARY on November 14, 2015
