Double incision and snare resection in symptomatic Zenker’s diverticulum: a modification of the stag-beetle knife technique

We read with great interest the article entitled “Double incision and snare resection in symptomatic Zenker’s diverticulum: a modification of the stag beetle knife technique” by Gölder et al. [1]. Although not acknowledged or cited, this appears to be an adaptation of the double-incision and snare technique first described by our group [2].

This is what we described: two parallel incisions were made to dissect the mucosa and the horizontal fibers of the cricopharyngeal muscle using the SB Knife (Sumitomo Bakelite Ltd., Tokyo, Japan); a monopolar snare was used to remove the portion of the septum in between. Endocut currents were used throughout the procedure (VIO 200D; ERBE Electromedizin, Tübingen, Germany). The depth of the incision was variable from patient to patient, dependent on the size of the diverticulum, and was balanced to achieve a near-complete cricopharyngeal myotomy but without the risk of perforation. Two or three clips (Clip HX-610-090L; Olympus, Tokyo, Japan) were deployed at the site of the incision to prevent mucosal dissection and perforation ([Fig. 1]). There was no further dissection of the cricopharyngeal muscle, as this had already been resected with the snare.

Fig. 1 Endoscopic division of the septum using the SB Knife (Sumitomo Bakelite Ltd., Tokyo, Japan). a After the diverticuloscope has been positioned, the SB Knife is used to make the two incisions on the septum 1 cm apart; b a monopolar snare is used to remove the remaining septum between the incisions and the septum is therefore fully divided; and c two clips are positioned at the bottom of the incision.

What Gölder et al. describe is a suboptimal version of our technique in which two parallel incisions are carried out and the mucosa between the incisions and some of the muscle fibers are snared; dissection of the cricopharyngeal muscle is then performed afterward [1]. This is no different to the single-incision technique, which is commonly used, as it does not physically remove the septal wall to improve the emptying of the diverticular pouch, as is described in our technique.

• References

• 1 Gölder SK, Brueckner J, Ebigbo A. et al. Double incision and snare resection in symptomatic Zenker’s diverticulum: a modification of the stag beetle knife technique. Endoscopy
• 2 Battaglia G, Antonello A, Realdon S. et al. Flexible endoscopic treatment for Zenker’s diverticulum with the SB Knife. Preliminary results from a single-center experience. Dig Endosc 2015; 27: 729-734