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.

Tratamiento endoluminal transoral del divertículo de Zenker con LigasureTM. Experiencia clínica inicial / Transoral endoluminal approach to Zenker's diverticulum using LigasureTM. Early clinical experience

El desarrollo de los procedimientos mínimamente invasivos ha reavivado el interés por las técnicas endoluminales para el tratamiento del divertículo de Zenker. Los selladores titulares empleados en cirugía laparoscópica no han sido empleados previamente en la septotomía del divertículo de Zenker. Avalados por la seguridad previa del empleo de las cortadoras lineales, de las pinzas bipolares y de los bisturís por ultrasonidos, hemos iniciado dicho procedimiento mediante el empleo del sellador tisular Ligasure 5TM. Se muestran los resultados de seguridad y eficacia en la experiencia clínica inicial de una serie prospectiva de 5 casos consecutivos de divertículo de Zenker tratados por vía peroral con el sellador tisular. El procedimiento se realizó en la sala de endoscopia, con sedación, de manera rápida y segura. La media de sellados por paciente fue de 2 y la duración media del procedimiento de 33 minutos. No se presentaron complicaciones durante el procedimiento ni derivadas del mismo, siendo dados de alta los pacientes con desaparición inmediata de la disfagia y correcta tolerancia oral. Con un seguimiento medio de 21 meses (rango 18-30), no existió recidiva del divertículo en ningún caso. Este procedimiento puede ser repetido tantas veces como se desee y ser realizado sin ingreso hospitalario. La seguridad mostrada deberá ser evaluada prospectivamente en estudios posteriores con mayor número de procedimientos (AU)

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 5TM 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 (AU)

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

Introducción Valorar la capacidad de la tomografía computarizada multidetector (TCMD) para identificar la localización de la perforación gastrointestinal (GI).Material y métodos Análisis retrospectivo de 98 pacientes con neumoperitoneo en la TCMD. Dos radiólogos expertos evaluaron la presencia o ausencia de signos radiológicos directos (extravasación del contraste oral; defecto focal de la pared; defecto focal en reconstrucciones multiplanares) e indirectos (aire libre supramesocólico; inframesocólico; supra- e inframesocólico; burbujas de gas adyacentes a la pared; líquido libre; engrosamiento parietal segmentario; trabeculación de la grasa; abscesos) de perforación para identificar su ubicación. Se determinó la concordancia kappa entre los radiólogos para identificar el lugar de la perforación y la presencia o ausencia de cada uno de los signos radiológicos; así como la correlación kappa de la localización detectada mediante TCMD y su confirmación o no en la intervención quirúrgica. Se calculó para cada signo radiológico su frecuencia, sensibilidad, especificidad, valor predictivo positivo (VPP) y negativo (VPN).Resultados Se diagnóstico correctamente el sitio de la perforación en un 80% de los casos. El índice kappa entre radiólogos para la localización fue excelente (0,919), variando para cada signo radiológico entre 0,5 y 1. La localización más frecuente de la perforación en la intervención quirúrgica (33,7%) y en la TCMD (40,8%) fue colon sigmoideo/recto. «Burbujas de gas adyacentes a la pared” fue el signo con mayor S (91%) y el «engrosamiento parietal segmentario» el que tuvo un mayor VPP (90%).Conclusión La TCMD permite localizar las perforaciones gastrointestinales con una alta sensibilidad (80%) y excelente correlación interobservador (AU)

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 (AU)

[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.