The endoscopic management of Zenker diverticulum: CO₂ laser versus endoscopic stapling

OBJECTIVE: The purpose of this project was to analyze the endoscopic management of Zenker diverticulum (ZD) using both the CO₂ laser and endoscopic stapling techniques. This study compares the two techniques in terms of diverticulum size, onset to oral intake, hospital stay, resolution of symptoms (dysphagia and regurgitation), and complications. STUDY DESIGN: A retrospective consecutive case series was performed at an academic medical center. METHODS: Forty patients underwent an attempted endoscopic resection of the ZD using either the CO₂ laser or the endoscopic stapling technique. The two techniques were compared on a variety of parameters, including diverticulum size, hospital stay, onset to oral intake, resolution of symptoms, and complications. Symptom scores were obtained before and after surgery with a patient self-reported scoring report (scale 0-3 for both dysphagia and regurgitation with 0 indicating asymptomatic and 3 severe symptoms). RESULTS: Forty patients underwent an attempted endoscopic management of ZD. Five patients (12.5%) failed endoscopic exposure (four converted to open, one observed). Sixteen patients underwent CO₂ laser management and 19 underwent endoscopic stapling. The mean diverticulum size (3.8 cm CO ₂ laser versus 4.4 cm stapling) was not significantly different for the two groups. Both groups demonstrated a significant decrease in preoperative versus postoperative dysphagia and regurgitation symptoms scores, respectively, CO₂ laser dysphagia scores decreasing from 2.75 to 1.38 and the regurgitation score dropping from 1.51 to 0.68, whereas endoscopic stapling dysphagia score decreased from 2.74 to 1.21 and the regurgitation score dropped from 1.37 to 0.53. Overall, 86% of patients demonstrated an onset of liquid intake on postoperative day 1 and the average length of stay was 3.4 days in the CO₂ laser group and 1.5 days in the endoscopic stapling (P < .0015). Complications included dental trauma in four patients (two CO ₂ laser and two stapling) and subcutaneous air in three patients (all three CO₂ laser). There were no cases of mediastinitis, recurrent laryngeal nerve injury, fistula, or perioperative death. CONCLUSIONS: The endoscopic management of ZD is a safe and effective technique. The endoscopic stapling technique appears to have an improved efficacy and safety when compared with the CO₂ laser technique. The two techniques are compared and contrasted.