Myotomy length determinants in endoscopic staple-assisted esophagodiverticulostomy for small Zenker's diverticula

A small Zenker's pouch is a major challenge for endoscopic staple-assisted esophagodiverticulostomy (ESED). This study tested the stapler dimensions so as to identify limitations they impose on ESED. Combining ESED with additional endoscopic suturing could extend the incision and consequently the myotomy. Zenker's diverticulum residual pouch measurements were performed with a previously reported latex glove model and in patients undergoing surgery. Two stapler designs were compared by measuring the residual pouch length for both the stock and modified staplers. One other stapler model cannot be modified without damaging the mechanism. The Endostitch was used to place an additional suture at the apex of the staple line, allowing cutting between the staples while leaving a closed distal incision. All three staplers suitable for ESED leave a residual pouch of 1.5 cm when unmodified. The modified anvil staplers gave a smaller residual pouch by 4 to 5 mm. An additional septal reduction can be accomplished by suturing the area distal to the staple line and incising the party wall beyond the stapler cut. The absolute amount of residual pouch with an additional myotomy is 3 mm. The combined staple-suture technique has proven relatively safe thus far. To provide a maximally efficient myotomy in a patient with a short pouch, the surgeon needs to be aware of the stapler differences. Modifications of the staplers may decrease the depth of the residual pouch, but may carry an added liability. A minimum residual pouch can be achieved with a combination of stapler and suture techniques, but is more technically demanding than the original ESED description.