title: Trans-oral cricomyotomy using a flexible endoscope: technique and clinical outcomes.
abstract: BACKGROUND
  Zenker's diverticulum (ZD) is a rare upper esophageal pathology that is most prevalent in the sixth and seventh decade. Three different therapeutical options are available: (1) open trans-cervical approach, (2) rigid endoscopy and (3) flexible endoscopy. Our hypothesis is that a flexible endoscopic cricomyotomy represents a safe and effective treatment of ZD as well as cricopharyngeal spasm.
  
  
  METHODS
  A retrospective analysis of all patients that underwent a flexible endoscopic cricomyotomy at our institution between October 2008 and May 2014 was performed. Preoperative and postoperative (1 month and long-term follow-up) symptom scores and clinical outcomes were collected. Briefly, the ZD is carefully identified endoscopically and the common wall is divided using needle knife cautery with the help of an endoscopic cap. Clips are used to close the mucosal defect starting with the apex.
  
  
  RESULTS
  Twenty-six patients underwent a flexible endoscopic myotomy for a ZD. Of 26 patients, five (19.2 %) had a history of previous open or stapled trans-oral myotomy and four (15.4 %) underwent a concomitant foregut procedure. Mean length of stay was 1.5 days (range 1-11). Mean operative time was 68 min (range 28-149). One patient presented with a postoperative leak, and one patient presented with a retained clip. Both were treated endoscopically. Recurrent weekly dysphagia was present in 3/26 (11.5 %). One patient (3.8 %) underwent an endoscopic bougie dilatation postoperatively. With regard to clinical outcomes, there was a statistically significant improvement in both short-term (1 month) and long-term (median follow-up 21.8 months; range 1-68.2 months) dysphagia (p < 0.001; p < 0.001), regurgitation (p = 0.001; p = 0.017), cough (p = 0.006; p = 0.025) and aspiration (p = 0.013; p = 0.013).
  
  
  CONCLUSIONS
  Flexible endoscopic cricomyotomy offers durable relief of dysphagia, regurgitation, cough and aspiration in ZD patients. It appears to have a good safety profile with symptomatic recurrence occurring in up to 11.5 % of cases.
authors.affiliation: Department of General Surgery, Hopital Sacre-Coeur, 5400, Blvd Gouin Ouest, Montreal, QC, H4J 1C5, Canada. radupes@yahoo.com.
authors.forename: Radu
authors.identifier: http://orcid.org/0000-0002-0523-4311
authors.initials: R
authors.lastname: Pescarus
authors.affiliation: Division of General Surgery, Toronto General Hospital, 585 University Ave, Toronto, ON, M5G 2N2, Canada.
authors.forename: Eran
authors.initials: E
authors.lastname: Shlomovitz
authors.affiliation: Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.
authors.forename: Ahmed M
authors.initials: AM
authors.lastname: Sharata
authors.affiliation: Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.
authors.forename: Maria A
authors.initials: MA
authors.lastname: Cassera
authors.affiliation: Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Reavis
authors.affiliation: Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.
authors.forename: Christy M
authors.initials: CM
authors.lastname: Dunst
authors.affiliation: Gastrointestinal and Minimally Invasive Surgery Division, The Oregon Clinic, 3805 NE Glisan St, Suite 6N60, Portland, OR, 97213, USA.|IHU-Strasbourg (Institute for Image Guided Surgery), 1, Place de l'Hopital, 67091, Strasbourg, France.
authors.forename: Lee L
authors.initials: LL
authors.lastname: Swanström
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D020701:Esophagoscopes; D004945:Esophagoscopy / Q000295:instrumentation* / Q000379:methods; D004947:Esophagus / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000295:instrumentation* / Q000379:methods; D012008:Recurrence; D012189:Retrospective Studies; D016896:Treatment Outcome; D016672:Zenker Diverticulum / Q000150:complications / Q000601:surgery*
keywords: Cricomyotomy; Dysphagia; Flexible endoscopy; Therapeutic endoscopy; Zenker