DÄ internationalArchive39/2008Therapy of Zenker’s diverticulum: Endoscopic Diverticulotomy

Correspondence

Therapy of Zenker’s diverticulum: Endoscopic Diverticulotomy

Dtsch Arztebl Int 2008; 105(39): 672. DOI: 10.3238/arztebl.2008.0672

Weerda, G

LNSLNS Endoscopic mucomyotomy fell into disfavor in Germany in the 1950's as the result of three fatal hemorrhages.

In the 1980's, van Overbeek and Hoeksma (1982, 1984) and van Overbeek (1994) reported on 545 cases of mucomyotomy with a CO2 laser that was directed by mirrors through the operating microscope. Thus, after the development of the Weerda spreading diverticuloscope—not the Weerda laryngoscope, as was stated in the article—and of other new instruments, we were able to start performing endoscopic mucomyotomy in Germany once again. An intraluminal Doppler ultrasonography device was used to localize large blood vessels (1, 2).

A residual septum remains in the fundus when division is performed with the Endo-GIA-30 stapler, because the foot of the stapler is 1 cm in size (2).

An important complication was not mentioned: The mediastinum is always opened, and this happens to the greatest extent in the area of the fundus. This situation is depicted incorrectly in figure 3. The consequences occasionally include dramatic subcutaneous and mediastinal emphysema. These phenomena are not due to microscopic openings, as was stated in the article.

In a group of patients that had not undergone surgery, we observed fever in 53.1%, as a sign of mediastinal irritation; 1.6% developed mediastinitis (2, 3).

We attribute the high recurrence rates to two causes: (a) the septum is not divided all the way to the fundus, and (b) after division, the cut edges come together again and fuse, particularly in the vicinity of the fundus (2).

In order to minimize these complications, we have proposed the following measures (13):

- After mucomyotomy with the CO2 laser, the mediastinum should be sealed with fibrin glue under optimal vision through the spreading diverticuloscope.
- Superfluous mucosa should be resected.
- The fundus and the cut edges should be closed microsurgically.

We recommend a liquid diet postoperatively. For medicolegal reasons, we also recommend a brief period of in-hospital observation.
If all of these recommendations are followed, endoscopic mucomyotomy becomes a low-risk operation, but not a risk-free one. It remains superior to open surgery.
DOI: 10.3238/arztebl.2008.0672


Prof. emer. Dr. med. Dr. med. dent. Geerd-Hilko Weerda
Steinhalde 48
79117 Freiburg, Germany
hubweerda@yahoo.de

Conflict of interest statement
The author receives license fees from the Storz company.
1.
Weerda H, Ahrens KH, Schlenter WW: Maßnahmen zur Verringerung der Komplikationsrate bei der endoskopischen Operation des Zenkerschen Divertikels. Laryngo Rhino Otol 1989; 68: 675–7. MEDLINE
2.
Weerda H, Sommer KD, Weerda N: Die endoskopische Chirurgie des Zenker-Divertikels. Eine Übersicht über heute gebräuchliche Techniken. Tuttlingen: Endo Press 2006.
3.
Sommer KD, Ahrens KH, Reichenbach M, Weerda H: Vergleich zweier endoskopischer Operationstechniken für eine sichere Therapie des Zenkerschen Divertikels. Laryngo Rhino Otol 2001; 80: 470–7. MEDLINE
1. Weerda H, Ahrens KH, Schlenter WW: Maßnahmen zur Verringerung der Komplikationsrate bei der endoskopischen Operation des Zenkerschen Divertikels. Laryngo Rhino Otol 1989; 68: 675–7. MEDLINE
2. Weerda H, Sommer KD, Weerda N: Die endoskopische Chirurgie des Zenker-Divertikels. Eine Übersicht über heute gebräuchliche Techniken. Tuttlingen: Endo Press 2006.
3. Sommer KD, Ahrens KH, Reichenbach M, Weerda H: Vergleich zweier endoskopischer Operationstechniken für eine sichere Therapie des Zenkerschen Divertikels. Laryngo Rhino Otol 2001; 80: 470–7. MEDLINE