Septotomía endoscópica del divertículo de Zenker mediante Stag-Beetle-KnifeTM: estudio observacional descriptivo y revisión de la literatura / Endoscopic septotomy of Zenker's diverticulum with Stag-Beetle Knife™: A descriptive observational study and literature review

Introducción: El divertículo de Zenker (DZ) es una protrusión de la mucosa hipofaríngea con una prevalencia de 2/100.000 habitantes. La clínica condiciona la necesidad del tratamiento, pudiendo ser quirúrgico o endoscópico. Este último, denominado septotomía o diverticulotomía endoscópica (DE), consiste en la disección del septo diverticular, pudiendo realizarse con distintos dispositivos disectores. Objetivo: El objetivo del estudio es evaluar la eficacia y seguridad de la DE mediante el dispositivo Stag-Beetle Knife™, así como realizar una revisión de la literatura para valorar el posicionamiento de la técnica en el panorama científico actual. Material y métodos: Estudio retrospectivo descriptivo que incluye pacientes intervenidos mediante DE con SB-Knife™ entre junio de 2017 y febrero de 2020. Revisión de la literatura de la evidencia disponible entre enero de 2013 y abril 2020 de la DE mediante la técnica con SB-Knife™ y sus variantes. Resultados: Se recopilaron 12 pacientes (66% varones) con una mediana de 70,5 años. El tamaño diverticular fue de 32,5mm de mediana y la remisión completa se objetivó en el 75% de los casos. Se realizaron 14 intervenciones con un éxito técnico del 92,8%. No se produjeron complicaciones graves. Se realizó una revisión de la literatura encontrando 13 trabajos de los cuales se incluyeron finalmente 8 (6 estudios retrospectivos, una serie de casos y un caso clínico). Conclusiones: En función de nuestra experiencia y a la bibliografía revisada, consideramos que la DE mediante SB-Knife™ es una técnica segura, eficaz y reproducible, pudiendo ser una mejor alternativa a la cirugía en pacientes con DZ.(AU)

Introduction: Zenker's diverticulum (ZD) is a protrusion of the hypopharyngeal mucosa with a prevalence of 2/100,000 inhabitants. The symptoms of the patients determine the need for treatment, which can be surgical or endoscopic. The latter, known as endoscopic septotomy or diverticulotomy (ED), this involves dissecting the diverticular septum, which can be performed with different dissection devices. AimThe aim of our study was to evaluate the efficacy and safety of ED with Stag-Beetle-Knife™ device, as well as to conduct a literature review to assess the position of the technique in the current scientific panorama. Material and methods: Descriptive retrospective study that includes patients who underwent ED with SB-Knife™ between June 2017 and February 2020. Literature review of the available evidence between January 2013 and April 2020 of ED with SB-Knife™ technique and its variants. Results: Twelve patients (66% male) with a median age of 70.5 years were collected. The median size of diverticular was 32.5mm and complete remission was observed in 75% of the cases. Fourteen interventions were performed with a technical success of 92.8. There were no serious complications. A literature review was carried out, finding 13 papers, of which 8 were finally included (6 retrospective studies, a series of cases and a clinical case). Conclusion: Based on our experience and the reviewed literature, we consider ED with SB-Knife™ is a safe, effective and reproducible technique, and may be a better alternative to surgery in patients with ZD.(AU)

Endoscopic septotomy of Zenker's diverticulum with Stag-Beetle Knife™: A descriptive observational study and literature review. / Septotomía endoscópica del divertículo de Zenker mediante Stag-Beetle-KnifeTM: estudio observacional descriptivo y revisión de la literatura.

INTRODUCTION: Zenker's diverticulum (ZD) is a protrusion of the hypopharyngeal mucosa with a prevalence of 2/100,000 inhabitants. The symptoms of the patients determine the need for treatment, which can be surgical or endoscopic. The latter, known as endoscopic septotomy or diverticulotomy (ED), this involves dissecting the diverticular septum, which can be performed with different dissection devices. AIM: The aim of our study was to evaluate the efficacy and safety of ED with Stag-Beetle-Knife™ device, as well as to conduct a literature review to assess the position of the technique in the current scientific panorama. MATERIAL AND METHODS: Descriptive retrospective study that includes patients who underwent ED with SB-Knife™ between June 2017 and February 2020. Literature review of the available evidence between January 2013 and April 2020 of ED with SB-Knife™ technique and its variants. RESULTS: Twelve patients (66% male) with a median age of 70.5 years were collected. The median size of diverticular was 32.5mm and complete remission was observed in 75% of the cases. Fourteen interventions were performed with a technical success of 92.8. There were no serious complications. A literature review was carried out, finding 13 papers, of which 8 were finally included (6 retrospective studies, a series of cases and a clinical case). CONCLUSION: Based on our experience and the reviewed literature, we consider ED with SB-Knife™ is a safe, effective and reproducible technique, and may be a better alternative to surgery in patients with ZD.

Divertículo de Zenker: manejo endoscópico con o sin diverticulotomo / Zenker's diverticulum: endoscopic treatment with or without diverticulotome

Resumen El divertículo de Zenker se define como un divertículo localizado en la pared esofágica posterior que tiene como cuello proximal al músculo cricofaríngeo. La mayoría de los pacientes presenta síntomas después de los 60 años de edad. Antes el manejo estándar se realizaba la diverticulotomía quirúrgica, pero desde hace más de 20 años se introdujo el manejo endoscópico. Desde hace más de 15 años se introdujo un diverticulotomo que facilita la realización del procedimiento, pero su uso no se ha instaurado ampliamente en Colombia. Por ello, el objetivo de este estudio es evaluar si la diverticulotomía endoscópica con el uso de este dispositivo es más fácil (rápida) que el método estándar. Materiales y métodos: se realizó un estudio prospectivo evaluando dos métodos endoscópicos para tratar el divertículo de Zenker, con el objetivo principal de conocer en cuál de ellos el tiempo de incisión del tabique era menor. El tiempo del procedimiento se contaba después de la colocación de la sonda en el método estándar o después de colocar el diverticulotomo en posición (método con diverticulotomo), ya que es el momento exacto en el cual se inicia el corte del tabique y se contabilizaba el tiempo (registro en video) cuando este corte terminaba. Resultados: de enero de 2015 a diciembre de 2018 en total se incluyeron 20 pacientes. El diagnóstico de Zenker fue realizado por una endoscopia y esofagograma para clasificar el tamaño del mismo. El promedio de edad de los pacientes fue de 61 años (46-85). En cada uno de los grupos se asignaron 10 pacientes. En 7 pacientes del grupo método estándar se resolvieron los síntomas, en comparación con 9 del grupo del método con diverticulotomo. Los tres pacientes que no respondieron presentaron en el seguimiento a 18 meses un estadio II de la escala de deglución de resultados funcionales. El tiempo promedio del procedimiento fue de 32 (25-45) minutos en el grupo del método estándar y 12 (7-15) minutos en el grupo de método con diverticulotomo (p < 0,001). Conclusiones: La miotomía del divertículo de Zenker con el uso de endoscopia flexible utilizando el diverticulotomo tiene beneficios potenciales en términos de tiempos operatorios más cortos, estancias posoperatorias más cortas y un inicio más temprano de la dieta. Desde el punto de vista técnico, permite una mejor exposición del tabique, lo que facilita su corte, pero se necesitan estudios más grandes para confirmar estos resultados.

Abstract Zenker's diverticulum is defined as a diverticulum located in the posterior esophageal wall, just above the cricopharyngeal muscle. Most patients experience symptoms in this area after the age of 60. In the past, the standard treatment was surgical diverticulotomy, but endoscopic treatment was introduced over 20 years ago. For more than 15 years, overtubes are introduced to facilitate the procedure, but their use is not been widely established in our country. Therefore, this study aims to evaluate whether endoscopic diverticulotomy with the use of this device is easier (faster) than the standard method. Materials and methods: A prospective study was conducted to establish which of the two endoscopic methods to treat Zenker's diverticulum (ZD) made the septum incision time shorter. The time count was done using video recording and started when the probe -standard method (SM)- or the overtube (MD) were placed, as this is the exact moment when septum cutting begins. The count stopped when the cut was finalized. Results: A total of 20 patients were treated from January 2015 to December 2018. Zenker's diverticulum diagnosis was achieved by endoscopy and esophagogram to classify the size of the tumor. The average age of the patients was 61 years (46-85). Ten patients were assigned to each group. Symptoms resolved in 7 patients of the SM group, compared to 9 in the MD group. The three patients who did not respond to the treatment were classified as stage II in the functional outcome swallowing scale at 18 months of follow-up. The average time of the procedure was 32 (25-45) minutes in the SM group and 12 (7-15) minutes in the MD group (p <0.001). Conclusions: ZD myotomy with flexible endoscopy using an overtube has potential benefits in terms of shorter operative times, shorter post-operative stays, and an earlier reintroduction of food. From a technical point of view, this method allows for better exposure of the septum, which facilitates cutting. However, more extensive studies are needed to confirm these results.

Endoscopic diverticulotomy using Ligasure™. / Diverticulotomía endoscópica utilizando Ligasure™.

INTRODUCTION: Endoscopic treatment of Zenker diverticulum is considered feasible, effective and safe. The use of the Ligasure™ vessel sealer provides adequate and quick dissection of tissue, achieving effective haemostasis. PATIENTS AND METHODS: Retrospective, descriptive study of all patients with Zenker diverticulum who were treated by endoscopic diverticulotomy using Ligasure™. The procedure was performed in the endoscopy unit under deep sedation controlled by the endoscopist. Patients were subsequently admitted for observation and, after discharge, were followed-up in the outpatient clinic. RESULTS: Eight patients, 5 women and 3 men, mean age 78±15 years, 25% ASA I, 36% ASA II, 14% ASA III and 25% ASA IV. Main symptom: dysphagia. Diverticula size: 1-7cm. Technical success: 100%. COMPLICATIONS: one patient with upper gastrointestinal bleeding. Average stay: 24h. Seven patients: asymptomatic; one patient with partial improvement, requiring repeat endoscopic intervention. Surgery and morbidity and mortality: 0%. CONCLUSION: The treatment of Zenker diverticulum by endoscopic diverticulotomy using the Ligasure™ vessel sealer is highly effective, fast and safe, and could be considered the treatment of choice.