Endoscopy 2016; 48(S 01): E63-E64
DOI: 10.1055/s-0042-101388
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic Zenker diverticulotomy using the window technique: a technical trick to improve the field of view

Jérôme Rivory
1   Gastroenterology and Endoscopy unit, Edouard Herriot Hospital, Lyon, France
,
Ala Almahayawi
1   Gastroenterology and Endoscopy unit, Edouard Herriot Hospital, Lyon, France
,
Sabine Roman
2   Digestive Physiology, Edouard Herriot Hospital, Lyon, France
,
Laura Calavas
1   Gastroenterology and Endoscopy unit, Edouard Herriot Hospital, Lyon, France
,
Jean-Christophe Saurin
1   Gastroenterology and Endoscopy unit, Edouard Herriot Hospital, Lyon, France
,
Thierry Ponchon
1   Gastroenterology and Endoscopy unit, Edouard Herriot Hospital, Lyon, France
3   INSERM U1032, Labtau, Lyon, France
,
Mathieu Pioche
1   Gastroenterology and Endoscopy unit, Edouard Herriot Hospital, Lyon, France
3   INSERM U1032, Labtau, Lyon, France
› Author Affiliations
Further Information

Corresponding author

Mathieu Pioche, MD
Endoscopy Unit – Digestive Disease Department
H Pavillon – Edouard Herriot Hospital
69437 Lyon
France   
Fax: +33-4-72110147   

Publication History

Publication Date:
18 February 2016 (online)

 

Endoscopic diverticulotomy is a safe, effective, and simple technique to treat patients with symptomatic Zenker’s diverticulum [1]. The endoscopic management was demonstrated to be as effective as surgical external diverticulotomy in most cases and can be recommended as the first choice [2]. Diverticuloscope-assisted diverticulotomy has been demonstrated to be safer and more effective than the cap-assisted procedure [3]. The main benefit of the diverticuloscope is to improve exposure of the muscular fibers by stretching them [4].

In our practice, we additionally use a technical trick called the “window technique” to improve the field of view before the myotomy. After insertion of the diverticuloscope, we initially cut a small square of mucosa to enlarge the space and expose the muscular fibers ([Fig. 1]). This step usually takes 1 minute. A square, measuring approximately 5 mm, is cut on the four sides and then removed. We usually use a Hook-knife (Olympus, Tokyo, Japan) to create this window with Endocut electric current (ERBE VIO 300 D, Tübingen, Germany).

Zoom
Fig. 1 Endoscopic views of the initial step in endoscopic Zenker diverticulotomy with mucosal cutting to create the window showing: a the lateral sides cut; b the inferior incision being made; c the appearance after three sides have been cut; d the final appearance after removal of the mucosal flap.

Thanks to this mucosal window, the cricopharyngeal fibers are stretched and visible ([Fig. 2]). Without the mucosal window, the two sides of the sectioned mucosa can obscure the myotomy site and prevent perfect control of the depth of cutting. In contrast, the mucosal window helps to enlarge the field of view and allows us to precisely catch the muscular layer by hooking.

Zoom
Fig. 2 Appearance of the myotomy site with the mucosal window showing: a the exposure of the muscular fibers at the initial stage of the myotomy; b a deeper view; c the view after total myotomy has been performed; d the view following closure with hemoclips.

This technique is commonly used in our unit and we present the case of a 57-year-old woman with a 5-cm diverticulum ([Fig. 1] and [Fig. 2]; [Video 1]). She was successfully treated using this trick without any adverse events and was discharged after 2 nights.

Endoscopic Zenker diverticulotomy procedure using the window technique.

To summarize, endoscopic diverticulotomy is effective and safe but the window technique is a simple trick to improve the field of view and facilitate the myotomy.

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Competing interests: None


Corresponding author

Mathieu Pioche, MD
Endoscopy Unit – Digestive Disease Department
H Pavillon – Edouard Herriot Hospital
69437 Lyon
France   
Fax: +33-4-72110147   


Zoom
Fig. 1 Endoscopic views of the initial step in endoscopic Zenker diverticulotomy with mucosal cutting to create the window showing: a the lateral sides cut; b the inferior incision being made; c the appearance after three sides have been cut; d the final appearance after removal of the mucosal flap.
Zoom
Fig. 2 Appearance of the myotomy site with the mucosal window showing: a the exposure of the muscular fibers at the initial stage of the myotomy; b a deeper view; c the view after total myotomy has been performed; d the view following closure with hemoclips.