Skip to main content
SpringerLink
Log in

Indication, Technique, and Results of Endoscopic Cricomyotomy

  • Chapter
  • First Online:
Innovative Endoscopic and Surgical Technology in the GI Tract

  • 720 Accesses

Abstract

The treatment of Zenker diverticulum has faced a substantial evolution during the last century. The traditional open surgical approach has been progressively flanked and subsequently almost completely overcome by the less invasive and easier transoral approach.

Transoral stapling of the septum between the diverticulum and the esophagus and laser diverticulotomy has gained consensus, being minimally invasive, relatively inexpensive, and associated with very few complications. However, they require the placement of a rigid diverticuloscope and general anesthesia. The placement of the diverticuloscope is not possible in all the patients and especially in the elderly.

Since its introduction in 1995, flexible endoscope-assisted cricopharyngeal myotomy quickly became one of the first-line treatments for the Zenker diverticulum. The procedure is performed by using a 9-mm endoscope, under sedation. Age of patients, previous treatments, and impossibility to hyperextend the neck are no longer limits for the transoral treatment. The outcomes of the procedure are excellent. The advent of peroral endoscopic myotomy additionally expanded the therapeutic possibilities, with promising results also in the treatment of the smallest pouches.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 129.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 169.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 249.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Simic AP, Gurski RR, Pesko PM. The story beyond the Zenker’s pouch. Acta Chir Iugosl. 2009;56:9–16.

    CAS  PubMed  Google Scholar 

  2. Haddad N, Agarwal P, Levi JR, et al. Presentation and management of Killian Jamieson diverticulum: a comprehensive literature review. Ann Otol Rhinol Laryngol. 2020;129:394–400.

    Article  PubMed  Google Scholar 

  3. Sutherland HD. Cricopharyngeal achalasia. J Thorac Cardiovasc Surg. 1962;43:114–26.

    Article  CAS  PubMed  Google Scholar 

  4. Belsey R. Functional disease of the esophagus. J Thorac Cardiovasc Surg. 1966;52:164–88.

    Article  CAS  PubMed  Google Scholar 

  5. Veenker EA, Andersen PE, Cohen JI. Cricopharyngeal spasm and Zenker’s diverticulum. Head Neck. 2003;25:681–94.

    Article  PubMed  Google Scholar 

  6. Ferreira LE, Simmons DT, Baron TH. Zenker’s diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. Dis Esophagus. 2008;21:1–8.

    Article  CAS  PubMed  Google Scholar 

  7. Bizzotto A, Iacopini F, Landi R, et al. Zenker’s diverticulum: exploring treatment options. Acta Otorhinolaryngol Ital. 2013;33:219–29.

    CAS  PubMed  PubMed Central  Google Scholar 

  8. Watemberg S, Landau O, Avrahami R. Zenker’s diverticulum: reappraisal. Am J Gastroenterol. 1996;91:1494–8.

    CAS  PubMed  Google Scholar 

  9. Cook IJ, Gabb M, Panagopoulos V, et al. Pharyngeal (Zenker’s) diverticulum is a disorder of upper esophageal sphincter opening. Gastroenterology. 1992;103:1229–35.

    Article  CAS  PubMed  Google Scholar 

  10. Law R, Katzka DA, Baron TH. Zenker’s Diverticulum. Clin Gastroenterol Hepatol. 2014;12:1773–82. quiz e1111–1772.

    Article  PubMed  Google Scholar 

  11. Siddiq MA, Sood S, Strachan D. Pharyngeal pouch (Zenker’s diverticulum). Postgrad Med J. 2001;77:506–11.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Sen P, Kumar G, Bhattacharyya AK. Pharyngeal pouch: associations and complications. Eur Arch Otorhinolaryngol. 2006;263:463–8.

    Article  PubMed  Google Scholar 

  13. Khan AS, Dwivedi RC, Sheikh Z, et al. Systematic review of carcinoma arising in pharyngeal diverticula: a 112-year analysis. Head Neck. 2014;36:1368–75.

    PubMed  Google Scholar 

  14. Bowdler DA, Stell PM. Carcinoma arising in posterior pharyngeal pulsion diverticulum (Zenker’s diverticulum). Br J Surg. 1987;74:561–3.

    Article  CAS  PubMed  Google Scholar 

  15. Bradley PJ, Kochaar A, Quraishi MS. Pharyngeal pouch carcinoma: real or imaginary risks? Ann Otol Rhinol Laryngol. 1999;108:1027–32.

    Article  CAS  PubMed  Google Scholar 

  16. Grant PD, Morgan DE, Scholz FJ, et al. Pharyngeal dysphagia: what the radiologist needs to know. Curr Probl Diagn Radiol. 2009;38:17–32.

    Article  PubMed  Google Scholar 

  17. Weusten B, Barret M, Bredenoord AJ, et al. Endoscopic management of gastrointestinal motility disorders - part 2: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020;52:600–14.

    Article  PubMed  Google Scholar 

  18. Costantini M, Zaninotto G, Rizzetto C, et al. Oesophageal diverticula. Best Pract Res Clin Gastroenterol. 2004;18:3–17.

    Article  PubMed  Google Scholar 

  19. Lixin J, Bing H, Zhigang W, et al. Sonographic diagnosis features of Zenker diverticulum. Eur J Radiol. 2011;80:e13–9.

    Article  PubMed  Google Scholar 

  20. Shanker BA, Davidov T, Young J, et al. Zenker’s diverticulum presenting as a thyroid nodule. Thyroid. 2010;20:439–40.

    Article  PubMed  Google Scholar 

  21. Skrobic OM, Simic AP, Radovanovic NS, et al. Current concepts in the anatomy and origin of pharyngeal diverticula. Acta Chir Iugosl. 2009;56:17–24.

    Article  CAS  PubMed  Google Scholar 

  22. Herbella FA, Patti MG. Modern pathophysiology and treatment of esophageal diverticula. Langenbeck’s Arch Surg. 2012;397:29–35.

    Article  Google Scholar 

  23. Ishioka S, Felix VN, Sakai P, et al. Manometric study of the upper esophageal sphincter before and after endoscopic management of Zenker’s diverticulum. Hepato-Gastroenterology. 1995;42:628–32.

    CAS  PubMed  Google Scholar 

  24. Zaninotto G, Narne S, Costantini M, et al. Tailored approach to Zenker’s diverticula. Surg Endosc. 2003;17:129–33.

    Article  CAS  PubMed  Google Scholar 

  25. Rizzetto C, Zaninotto G, Costantini M, et al. Zenker’s diverticula: feasibility of a tailored approach based on diverticulum size. J Gastrointest Surg. 2008;12:2057–64; discussion 2064-2055.

    Article  PubMed  Google Scholar 

  26. Zaninotto G, Costantini M, Boccu C, et al. Functional and morphological study of the cricopharyngeal muscle in patients with Zenker’s diverticulum. Br J Surg. 1996;83:1263–7.

    CAS  PubMed  Google Scholar 

  27. Ishioka S, Sakai P, Maluf Filho F, et al. Endoscopic incision of Zenker’s diverticula. Endoscopy. 1995;27:433–7.

    Article  CAS  PubMed  Google Scholar 

  28. Gutschow CA, Hamoir M, Rombaux P, et al. Management of pharyngoesophageal (Zenker’s) diverticulum: which technique? Ann Thorac Surg. 2002;74:1677–82; discussion 1682-1673.

    Article  PubMed  Google Scholar 

  29. Bonavina L, Bona D, Abraham M, et al. Long-term results of endosurgical and open surgical approach for Zenker diverticulum. World J Gastroenterol. 2007;13:2586–9.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Simic A, Radovanovic N, Stojakov D, et al. Surgical experience of the national institution in the treatment of Zenker’s diverticula. Acta Chir Iugosl. 2009;56:25–33.

    Article  CAS  PubMed  Google Scholar 

  31. Mantsopoulos K, Psychogios G, Kunzel J, et al. Evaluation of the different transcervical approaches for Zenker diverticulum. Otolaryngol Head Neck Surg. 2012;146:725–9.

    Article  PubMed  Google Scholar 

  32. Nehring P, Krasnodebski IW. Zenker’s diverticulum: aetiopathogenesis, symptoms and diagnosis. Comparison of operative methods. Prz Gastroenterol. 2013;8:284–9.

    PubMed  PubMed Central  Google Scholar 

  33. Yuan Y, Zhao YF, Hu Y, et al. Surgical treatment of Zenker’s diverticulum. Dig Surg. 2013;30:207–18.

    Article  PubMed  Google Scholar 

  34. Collard JM, Otte JB, Kestens PJ. Endoscopic stapling technique of esophagodiverticulostomy for Zenker’s diverticulum. Ann Thorac Surg. 1993;56:573–6.

    Article  CAS  PubMed  Google Scholar 

  35. Mulder CJ, den Hartog G, Robijn RJ, et al. Flexible endoscopic treatment of Zenker’s diverticulum: a new approach. Endoscopy. 1995;27:438–42.

    Article  CAS  PubMed  Google Scholar 

  36. Dohlman G, Mattsson O. The endoscopic operation for hypopharyngeal diverticula: a roentgencinematographic study. AMA Arch Otolaryngol. 1960;71:744–52.

    Article  CAS  PubMed  Google Scholar 

  37. Hoeksema PE, van Overbeek JJ. The CO2 laser in laryngeal diseases. Acta Otorhinolaryngol Belg. 1981;35:23–7.

    CAS  PubMed  Google Scholar 

  38. van Overbeek JJ, Hoeksema PE, Edens ET. Microendoscopic surgery of the hypopharyngeal diverticulum using electrocoagulation or carbon dioxide laser. Ann Otol Rhinol Laryngol. 1984;93:34–6.

    Article  PubMed  Google Scholar 

  39. Kos MP, David EF, Mahieu HF. Endoscopic carbon dioxide laser Zenker’s diverticulotomy revisited. Ann Otol Rhinol Laryngol. 2009;118:512–8.

    Article  PubMed  Google Scholar 

  40. Helmstaedter V, Engel A, Huttenbrink KB, et al. Carbon dioxide laser endoscopic diverticulotomy for Zenker’s diverticulum: results and complications in a consecutive series of 40 patients. ORL J Otorhinolaryngol Relat Spec. 2009;71:40–4.

    Article  PubMed  Google Scholar 

  41. Verdonck J, Morton RP. Systematic review on treatment of Zenker’s diverticulum. Eur Arch Otorhinolaryngol. 2015;272:3095–107.

    Article  PubMed  Google Scholar 

  42. Bonavina L, Bona D, Aiolfi A, et al. Transoral septum stapling of Zenker diverticulum is feasible and safe through a soft overtube. Surg Innov. 2015;22:207–9.

    Article  PubMed  Google Scholar 

  43. Provenzano L, Salvador R, Cutrone C, et al. Traction on the septum during transoral septotomy for Zenker diverticulum improves the final outcome. Laryngoscope. 2020;130:637–40.

    Article  PubMed  Google Scholar 

  44. Wilken R, Whited C, Scher RL. Endoscopic staple diverticulostomy for Zenker’s diverticulum: review of experience in 337 cases. Ann Otol Rhinol Laryngol. 2015;124:21–9.

    Article  PubMed  Google Scholar 

  45. Fama AF, Moore EJ, Kasperbauer JL. Harmonic scalpel in the treatment of Zenker’s diverticulum. Laryngoscope. 2009;119:1265–9.

    Article  PubMed  Google Scholar 

  46. Hondo FY, Maluf-Filho F, Giordano-Nappi JH, et al. Endoscopic diverticulotomy by harmonic scalpel (Ultracision): an experimental model. Endoscopy. 2009;41(Suppl 2):E104–5.

    Article  PubMed  Google Scholar 

  47. Nielsen HU, Trolle W, Rubek N, et al. New technique using LigaSure for endoscopic mucomyotomy of Zenker’s diverticulum: diverticulotomy made easier. Laryngoscope. 2014;124:2039–42.

    Article  PubMed  Google Scholar 

  48. Andersen MF, Trolle W, Anthonsen K, et al. Long-term results using LigaSure™ 5 mm instrument for treatment of Zenker’s diverticulum. Eur Arch Otorhinolaryngol. 2017;274:1939–44.

    Article  PubMed  Google Scholar 

  49. Pons-Beltrán V, García Morales N, Sáez-González E, et al. A long-term prospective study of the efficacy and safety of endoscopic septotomy using the LigaSure® system for the treatment of Zenker’s diverticulum. Rev Esp Enferm Dig. 2019;111:378–83.

    PubMed  Google Scholar 

  50. Wahab PJ, Mulder CJ, den Hartog G, et al. Argon plasma coagulation in flexible gastrointestinal endoscopy: pilot experiences. Endoscopy. 1997;29:176–81.

    Article  CAS  PubMed  Google Scholar 

  51. Bremner CG, DeMeester TR. Endoscopic treatment of Zenker’s diverticulum. Gastrointest Endosc. 1999;49:126–8.

    Article  CAS  PubMed  Google Scholar 

  52. Repici A, Pagano N, Fumagalli U, et al. Transoral treatment of Zenker diverticulum: flexible endoscopy versus endoscopic stapling. A retrospective comparison of outcomes. Dis Esophagus. 2011;24:235–9.

    Article  CAS  PubMed  Google Scholar 

  53. Mulder CJ, Costamagna G, Sakai P. Zenker’s diverticulum: treatment using a flexible endoscope. Endoscopy. 2001;33:991–7.

    Article  CAS  PubMed  Google Scholar 

  54. Christiaens P, De Roock W, Van Olmen A, et al. Treatment of Zenker’s diverticulum through a flexible endoscope with a transparent oblique-end hood attached to the tip and a monopolar forceps. Endoscopy. 2007;39:137–40.

    Article  CAS  PubMed  Google Scholar 

  55. Mittal C, Diehl D, Draganov P, et al. Practice patterns, techniques, and outcomes of flexible endoscopic myotomy for Zenker’s diverticulum: retrospective, multi-center study. Endoscopy. 2020. https://doi.org/10.1055/a-1219-4516.

  56. Rabenstein T, May A, Michel J, et al. Argon plasma coagulation for flexible endoscopic Zenker’s diverticulotomy. Endoscopy. 2007;39:141–5.

    Article  CAS  PubMed  Google Scholar 

  57. Ishaq S, Hassan C, Antonello A, et al. Flexible endoscopic treatment for Zenker’s diverticulum: a systematic review and meta-analysis. Gastrointest Endosc. 2016;83:1076–89.e1075

    Article  PubMed  Google Scholar 

  58. Diez Redondo P, Núñez Rodríguez H, de Benito Sanz M, et al. Endoscopic treatment of Zenker’s diverticulum with Ligasure: simple, safe and effective. Endosc Int Open. 2019;7:E203–e208.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Costamagna G, Iacopini F, Tringali A, et al. Flexible endoscopic Zenker’s diverticulotomy: cap-assisted technique vs. diverticuloscope-assisted technique. Endoscopy. 2007;39:146–52.

    Article  CAS  PubMed  Google Scholar 

  60. Bresteau C, Barret M, Guillaumot MA, et al. Do we still need a diverticuloscope for the flexible endoscopic septotomy of Zenker’s diverticulum? J Gastroenterol Hepatol. 2020;35:630–3.

    Article  PubMed  Google Scholar 

  61. Li QL, Chen WF, Zhang XC, et al. Submucosal tunneling endoscopic septum division: a novel technique for treating Zenker’s diverticulum. Gastroenterology. 2016;151:1071–4.

    Article  PubMed  Google Scholar 

  62. Brewer Gutierrez OI, Moran R, Yang J, et al. Successful single-session cricopharyngeal and Zenker’s diverticulum peroral endoscopic myotomy. Endoscopy. 2018;50:E220–e221.

    Article  PubMed  Google Scholar 

  63. Brewer Gutierrez OI, Ichkhanian Y, Spadaccini M, et al. Zenker’s diverticulum per-oral endoscopic myotomy techniques: changing paradigms. Gastroenterology. 2019;156:2134–5.

    Article  PubMed  Google Scholar 

  64. Repici A, Spadaccini M, Belletrutti PJ, et al. Peroral endoscopic septotomy for short-septum Zenker’s diverticulum. Endoscopy. 2020;52:563–8.

    PubMed  Google Scholar 

  65. Klingler MJ, Landreneau JP, Strong AT, et al. Endoscopic mucosal incision and muscle interruption (MIMI) for the treatment of Zenker’s diverticulum. Surg Endosc. 2020. https://doi.org/10.1007/s00464-020-07861-5.

  66. Li LY, Yang YT, Qu CM, et al. Endoscopic needle-knife treatment for symptomatic esophageal Zenker’s diverticulum: a meta-analysis and systematic review. J Dig Dis. 2018;19:204–14.

    Article  PubMed  Google Scholar 

  67. Costamagna G, Iacopini F, Bizzotto A, et al. Prognostic variables for the clinical success of flexible endoscopic septotomy of Zenker’s diverticulum. Gastrointest Endosc. 2016;83:765–73.

    Article  PubMed  Google Scholar 

  68. Jones D, Aloraini A, Gowing S, et al. Evolving management of Zenker’s diverticulum in the endoscopic era: a North American experience. World J Surg. 2016;40:1390–6.

    Article  PubMed  Google Scholar 

  69. Delis K, Robotis J, Sachitzi E, et al. Submucosal tunneling endoscopic septum division of a Zenker’s diverticulum. Ann Gastroenterol. 2018;31:634.

    PubMed  PubMed Central  Google Scholar 

  70. Hajifathalian K, Dawod Q, Saumoy M, et al. Submucosal tunneling endoscopic septum division for treatment of Zenker’s diverticulum. Endoscopy. 2018;50:E340–e341.

    Article  PubMed  Google Scholar 

  71. Hernández Mondragón OV, Solórzano Pineda MO, Blancas Valencia JM. Zenker’s diverticulum: submucosal tunneling endoscopic septum division (Z-POEM). Dig Endosc. 2018;30:124.

    Article  PubMed  Google Scholar 

  72. Yang J, Novak S, Ujiki M, et al. An international study on the use of peroral endoscopic myotomy in the management of Zenker’s diverticulum. Gastrointest Endosc. 2020;91:163–8.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy

    Guido Costamagna, Pietro Familiari & Rosario Landi

Authors
  1. Guido Costamagna
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Pietro Familiari
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Rosario Landi
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Guido Costamagna .

Editor information

Editors and Affiliations

  1. Division of Minimally Invasive Surgery, Center for Fluorescence-Guided Surgery, Department of Surgery, University of California San Diego, La Jolla, CA, USA

    Santiago Horgan

  2. Center for the Future of Surgery, University of California San Diego, La Jolla, CA, USA

    Karl-Hermann Fuchs

Rights and permissions

Reprints and permissions

Copyright information

© 2021 Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Costamagna, G., Familiari, P., Landi, R. (2021). Indication, Technique, and Results of Endoscopic Cricomyotomy. In: Horgan, S., Fuchs, KH. (eds) Innovative Endoscopic and Surgical Technology in the GI Tract . Springer, Cham. https://doi.org/10.1007/978-3-030-78217-7_9

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-78217-7_9

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-78216-0

  • Online ISBN: 978-3-030-78217-7

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation