title: Flexible endoscopic clip-assisted Zenker's diverticulotomy: the first case series (with videos).
abstract: BACKGROUND
  In treating Zenker's diverticulum (ZD), there are potential risks associated with performing flexible endoscopic diverticulotomy without suturing or stapling. We recently introduced flexible endoscopic clip-assisted diverticulotomy (ECD) in treating ZD by securing the septum prior to dissection.
  
  
  OBJECTIVE
  To evaluate the feasibility and safety of ECD for complete septum dissection.
  
  
  METHODS
  Case series at an academic center. Seven consecutive patients (mean age 71 y; range 48-91 y) with symptomatic ZD of various craniocaudal sizes based on radiographic measurements (mean 2.6 cm; range 0.8 cm-4.5 cm) were included. The mean depth of the septum was 1.73 cm (range 0.3 cm-3.1 cm). The mean duration of symptoms was 4.8 years (range 0.5-10 y).
  
  
  METHODS
  After endoclips were placed on either side of the cricopharyngeal bar, the septum was dissected between these two clips down to the inferior end of the diverticulum with a needle-knife. Procedures including "one-step ECD" (n = 1), "stepwise ECD" (n = 3), and "bottom ECD" (n = 2) were performed based on the septum depth of the ZD during endoscopy. ECD was not performed on one patient due to severe mucosal fragility of the esophageal inlet. Iatrogenic blunt dissection of the septum by the endoscopic hood occurred secondary to patient retching during the procedure. Main outcome measurements were symptom resolution and complications.
  
  
  RESULTS
  All patients (n = 6) who underwent ECD had complete resolution of esophageal symptoms at a minimum 6-month follow-up. There were no procedural complications. The patient who did not undergo ECD developed an esophageal perforation. She was managed conservatively without surgical intervention. On follow-up, her dysphagia was completely resolved.
  
  
  CONCLUSIONS
  ECD is feasible, safe, and effective for complete septum dissection. ECD and endoscopic stapler-assisted diverticulotomy are complimentary rather than competing strategies in approaching ZD. Study limitations include the case series design and limited follow-up period.
authors.affiliation: Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas 75390-9151, USA. shou-jiang.tang@utsouthwestern.edu
authors.forename: Shou-jiang
authors.initials: SJ
authors.lastname: Tang
authors.forename: Saad F
authors.initials: SF
authors.lastname: Jazrawi
authors.forename: Edward
authors.initials: E
authors.lastname: Chen
authors.forename: Linda
authors.initials: L
authors.lastname: Tang
authors.forename: Larry L
authors.initials: LL
authors.lastname: Myers
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D004867:Equipment Design; D004939:Esophageal Perforation / Q000209:etiology; D020701:Esophagoscopes; D004945:Esophagoscopy / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D013525:Surgical Instruments; D013528:Surgical Staplers; D016672:Zenker Diverticulum / Q000601:surgery*