Transoral endoluminal approach to Zenker's diverticulum using Ligasure™. Early clinical experience.

The development of minimally invasive procedures has rekindled interest in endoluminal techniques for the management of Zenker's diverticulum. Tissue sealers as employed in laparoscopic surgery have not been previously used for Zenker's diverticulum septotomy.Supported by the established safety of linear cutters, bipolar forceps, and ultrasonic scalpels, we have started a procedure using the Ligasure 5™ tissue sealer. Safety and efficacy results in our early clinical experience are shown for a prospective series of 5 consecutive Zenker's diverticulum cases that were perorally managed with tissue sealing.The procedure was quickly and safely performed in the endoscopy room under sedation. Mean number of seals per patient was 2, and mean procedure duration was 33 minutes. No complications developed during or after the procedure, and patients were discharged with immediate dysphagia relief and adequate oral tolerance. No diverticular relapses occurred after a mean follow-up of 21 months (range 18-30). This procedure may be repeated as often as desired with no need for hospital admission. Safety should be prospectively assessed by further studies using a higher number of procedures.

[Use of multidetector computed tomography for locating the site of gastrointestinal tract perforations]. / Utilidad de la tomografía computarizada multidetector para identificar la localización de las perforaciones gastrointestinales.

INTRODUCTION: The purpose of this study was to evaluate the accuracy of multidetector computed tomography (MDCT) for locating the site of gastrointestinal tract perforations and to determine the most predictive signs in this diagnosis. MATERIAL AND METHODS: A total of 98 patients with pneumoperitoneum on MDCT were retrospectively analysed. Two experienced radiologists reviewed the presence or absence of direct signs (extravasation of oral contrast, focal defect in the bowel wall, focal defect with multiplanar reformations images) and indirect signs (free air in supramesocolic, inframesocolic, supramesocolic and inframesocolic compartments, concentration of extraluminal air bubbles adjacent to the bowel wall, extraluminal fluid, segmental bowel-wall thickening, perivisceral fat stranding, abscess) to identify the site of the perforation. The Kappa index was evaluated between radiologists to determine the site of perforation and for each predictive sign, as well as Kappa index between the site of perforation detected with MDCT and the site proven at surgery. The frequency, sensitivity, specificity and positive and negative predictive value (PPV and NPV, respectively) were calculated. RESULTS: The perforation site was identified correctly in 80.4% of cases. Kappa index between radiologists to identify the site was excellent (0.919), varying between 0.5-1.0 for each radiological sign. The most frequent site of perforation at surgery (33.7%) and in MDCT (40.82%) was the sigmoid colon/rectum. Concentration of extraluminal air bubbles adjacent to the bowel wall was the most sensitive (91%) sign and "segmental bowel-wall thickening" had the highest PPV (90%). CONCLUSION: MDCT is useful for locating the site of GI perforation, with a high sensitivity (80%) and an excellent agreement between radiologists.