Postendoscopic Zenker Esophagodiverticulostomy Leaks Associated With a Specific Stapler Cartridge

OBJECTIVE: To determine the cause of postoperative leaks in 2 patients with Zenker diverticula treated with endoscopic staple-assisted esophagodiverticulostomy. DESIGN: Medical chart review and simulated surgery. SETTING: Teaching hospital. PATIENTS AND METHODS: Two case reports of postoperative leaks in patients treated with endoscopic staple-assisted esophagodiverticulostomy and experimental simulated surgery to investigate the possible cause of this complication. Use of a TR45B, 3.5-mm cartridge for an Endopath ETS Flex45 Endoscopic Articulation Linear Cutter stapler was associated with complications, whereas use of a TR45W, 2.5-mm cartridge in the same stapler was not. RESULTS: In a simulated surgery model, the 3.5-mm cartridge staple line leaked from the incision apex with pressure of less than 20 cm H(2)O, whereas the apex remained dry when using the 2.5-mm cartridge. When pressure was increased to 30 cm H(2)O, the staple line of the 2.5-mm cartridge had diffuse weeping of fluid but no focal, apical leak. CONCLUSIONS: Endoscopic staple-assisted esophagodiverticulostomy continues to be a relatively safe procedure; however, to provide maximum safety at the apex, the surgeon needs to be aware of stapler cartridge differences.