Endoscopic treatment of Zenker's diverticulum by LigaSure scalpel.

Treatment of Zenker’s diverticulum by flexible endoscopy is considered to be feasible, effective, and safe [1,2]. Endoscopic treatment consists of the division of the septum between the diverticulum and the esophagus, within which the cricopharyngeus muscle is contained [1,2]. This report describes the novel use of a LigaSure scalpel (Valleylab, Boulder, Colorado, USA) to perform flexible endoscopic diverticulectomy in a 3-cm Zenker’s diverticulum in a 62-year-old woman with symptoms of dysphagia for both solids and liquids (●" Fig.1). We chose the LigaSure scalpel, which has been employed in laparoscopic surgery and provides adequate tissue dissection while achieving efficient and safe hemostasis, sealing vessels up to 7mm in size [3]. This bipolar electrosurgical device delivers high-current, low-voltage electrical energy along with pressure that is exerted from the jaws of the device onto the tissue. The system monitors the energy expended while denaturing the collagen and elastinwithin the vessel walls [3]. A transparent overtube usually used for injection sclerotherapy of esophageal varices (Kawano overtube, 16mm diameter) was modified and used as a “duckbeak diverticuloscope.” The overtube allowed for excellent exposure of the septum and protection of the anterior esophageal and posterior diverticular walls, allowing the passage of the LigaSure scalpel (●" Fig.2). A standardvideogastroscope (GIF-CV-160, 9.2mm;Olympus, Tokyo, Japan) and a stiff guidewire (Savary-Gilliard; Wilson Cook, Winston Salem, North Carolina, USA) were used to insert the diverticuloscope and achieve an adequate exposure of the septum of the Zenker’s diverticulum. The LigaSure was then introduced through the diverticuloscope with endoscopic assistance (●" Fig.3a). The septum of the Zenker’s diverticulum was then safely cut up to the fundus of the diverticular sac without bleeding or perforation (●" Fig.3b). The procedure was completed by placing endoclips (Resolution Clip; Boston Scientific, Massachusetts, USA) at the base of the dissection (●" Fig.3c). The patient made good progress, being able to tolerate liquids and pureed diet satisfactorily within 1 week, and progressing to a full diet the followingweekwith no symptoms of dysphagia (●" Fig.4). Diathermic monopolar current, argon plasma coagulation, laser, and coagulation with an ultrasonically activated scalpel (Harmonic scalpel; Ethicon EndoSurgery) have all been used for the endoscopic treatment of Zenker’s diverticulum with satisfactory results [1,2,4]. This case shows that endoscopic treatment of Zenker’s diverticulum using a LigaSure scalpel