1

Introduction

Zenker’s diverticulum (ZD), or pharyngeal pouch, was first described in 1769 and then further elucidated in 1878 by the man for whom the pathologic entity was named. Treatment for this disorder is surgical and has evolved with advances in understanding the underlying pathophysiology as well as the introduction of new devices and techniques.

Traditional open repair of ZD involves either diverticulectomy or diverticulopexy combined with cricopharyngeal myotomy through a transcervical incision. However, ZD largely occurs in elderly patients, many of whom are not good candidates for and have limited ability to handle the potential complications of an open procedure. For this reason, multiple less invasive techniques has been described.

An endoscopic approach to treat ZD was first described in 1917 . This technique involved using a knife to endoscopically divide the common wall between the esophagus and diverticulum. However, the technique was abandoned after several patients died of mediastinitis. It was not until 1960 that endoscopic treatment became safe enough for use. Dohlman and Mattsson described an endoscopic approach using electrocautery to divide the common wall, with markedly decreased morbidity and mortality compared with earlier endoscopic attempts. This approach became known as the Dohlman technique and was later modified by using a CO ₂ laser rather than electrocautery .

Although several centers used these techniques, it was not until the introduction of endoscopic staple–assisted esophagodiverticulostomy (ESED) that endoscopic treatment of ZD became common. First seen in Europe in 1993 , and later brought to the United States in 1996 by Scher and Richtsmeier , ESED has since been shown to be safe and efficacious , such that now it is considered by many to be the treatment of choice .

However, ESED not only involves familiarity with the instruments and technique but also depends on anatomical factors. Patients with small mandibles, retrognathia, prominent incisors, and limited neck extension may not allow for the exposure required in this approach. In addition, shallow diverticula may not be amenable to endoscopic repair using the stapler because this device does not cut at its distal tip, resulting in the residual pouch being left behind and inadequate cricopharyngeal myotomy ( Fig. 1 ). Modifications of common stapling devices have been performed but may not significantly decrease residual pouch length .

Photograph of the harmonic scalpel (A) and the stapling device (B) demonstrates the difference in size of the cutting surfaces. The white bracket marks the distal portion of the stapling device that does not cut.

We describe a technique for endoscopic repair of ZD using the harmonic scalpel in a series of patients who for anatomical reasons could not otherwise undergo ESED.

2

Materials and methods

A retrospective review of all patients treated for ZD by the Department of Otolaryngology—Head and Neck Surgery at the University of South Florida was approved by the University of South Florida institutional review board. Patients who underwent endoscopic repair with the harmonic scalpel were identified from this group. Data were abstracted from clinic notes, surgical records, and hospital charts.

2

Materials and methods

A retrospective review of all patients treated for ZD by the Department of Otolaryngology—Head and Neck Surgery at the University of South Florida was approved by the University of South Florida institutional review board. Patients who underwent endoscopic repair with the harmonic scalpel were identified from this group. Data were abstracted from clinic notes, surgical records, and hospital charts.