Flexible endoscopic Zenker’s diverticulotomy: cap-assisted technique vs. diverticuloscope-assisted technique

BACKGROUND AND STUDY AIM: The standard treatment for a Zenker's diverticulum is diverticulotomy, either using the endostapling approach or by surgery. Flexible endoscopic diverticulotomy has similar efficacy and is associated with fewer complications but this technique is still under investigation. The aim of this study was to compare the technical results and efficacy of two flexible endoscopic diverticulotomy techniques. PATIENTS AND METHODS: A total of 39 patients with a Zenker's diverticulum were treated using either cap or diverticuloscope assistance to expose the septum, which was then cut with a needle-knife and endocut currents. The severity of symptoms was graded according to their frequencies before the procedure, after 1 month, and to June 2006. RESULTS: Of the 39 patients enrolled into the study, 28 patients were treated with the cap and 11 with the diverticuloscope, the two groups showing no statistical difference in baseline features. The median length of the Zenker's diverticulum was 4 cm (range 2-8 cm). The procedure time was significantly longer with the cap than with diverticuloscope assistance (P = 0.002). Complications occurred in 9/28 patients in the cap group and in none of the patients in the diverticuloscope group (P = 0.04); the perforations that occurred in five patients (18%) were managed endoscopically and conservatively. The median inpatient stay was 3 days (range 2-8 days). The clinical remission rate, evaluated using a pool of symptoms, was significantly higher after the diverticuloscope-assisted procedure compared with the cap technique (82% vs. 29%, P = 0.004). Multivariate analysis showed that the diverticuloscope-assisted technique was the only significant prognostic factor for efficacy (odds ratio 13.09, 95% CI 2.07-82.53). CONCLUSION: The use of the soft diverticuloscope to expose and fix the septum seems to be the optimal approach in terms of increasing the safety and clinical efficacy of flexible endoscopic diverticulotomy.