Harmonic scalpel for endoscopic treatment of Zenker's diverticulum: a critical review of the literature


Zenker’s diverticulum
Pharyngoesophageal diverticulum
Pharyngeal pouch


Introduction: Endoscopic staple-assisted diverticulostomy (ESD) is generally accepted as the preferred treatment option for patients with Zenker’s diverticulum (ZD). However, anatomical factors may preclude the use of ESD in certain patients. In recent years, the harmonicscalpel has been introduced as an alternative device for endoscopic management of ZD, which may be useful in certain cases where diverticulum anatomy prevents the use of ESD. This review aims to assess the efficacy and safety of endoscopic ZD-repair using the harmonic-scalpel, including comparative analysis of the harmonic and staple assisted approaches in terms of their surgical outcomes. Conclusion: Most studies support the use of the harmonic-scalpel as a safe and effective treatment option for ZD. Although the harmonic-assisted technique may not replace ESD as the initial treatment of choice for ZD, it may serve as a useful adjunct to treatment in selected cases. However, given the low quality of evidence and concerns regarding treatment complications, large prospective randomised trials comparing the harmonic and staple-assisted techniques are necessary in order to determine whether the harmonic-scalpel is truly a viable option for endoscopic ZD-management.



Nuno-Guzman CM, Garcia-Carrasco D, Haro M, et al. Zenker’s Diverticulum: diagnostic approach and surgical management. Case Rep Gastroenterol 2014;8(3):346-52. Available from: https://doi.org/10.1159/000369130

Bizzotto A, Iacopini F, Landi R, Costamagna G. Zenker’s diverticulum: exploring treatment options. Acta Otorhinolaryngol Ital 2013;33(4):219-29.

Siddiq MA, Sood S, Strachan D. Pharyngeal pouch (Zenker’s diverticulum). Postgrad Med J 2001;77(910):506-11. Available from: https://doi.org/10.1136/pmj.77.910.506

Nehring P, Krasnodebski IW. Zenker’s diverticulum: aetiopathogenesis, symptoms and diagnosis. Comparison of operative methods. Prz gastroenterol 2013;8(5):284-9. Available from: https://doi.org/10.5114/pg.2013.38729.

Yuan Y, Zhao YF, Hu Y, Chen LQ. Surgical treatment of Zenker’s diverticulum. Dig Surg 2013;30(3):207-18. Available from: https://doi.org/10.1159/000351433

Ferreira LE, Simmons DT, Baron TH. Zenker’s diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. Dis Esophagus 2008;21(1):1-8. Available from: https://doi.org/10.1111/j.1442-2050.2007.00795.x

Fama AF, Moore EJ, Kasperbauer JL. Harmonic scalpel in the treatment of Zenker’s diverticulum. Laryngoscope 2009;119(7):1265-9. Available from: https://doi.org/10.1002/lary.20247

Hillel AT, Flint PW. Evolution of endoscopic surgical therapy for Zenker’s diverticulum. Laryngoscope 2009;119(1):39-44. Available from: https://doi.org/10.1002/lary.20019

Sasaki CT, Ross DA, Hundal J. Association between Zenker diverticulum and gastroesophageal reflux disease: development of a working hypothesis. Am J Med 2003;115 Suppl 3A:169S-71S. Available from: https://doi.org/10.1016/s0002-9343(03)00218-3

Brucher BL, Sarbia M, Oestreicher E, et al. Squamous cell carcinoma and Zenker diverticulum. Dis Esophagus 2007;20(1):75-8. Available from: https://doi.org/10.1111/j.1442-2050.2007.00648.x

Sen P, Lowe DA, Farnan T. Surgical interventions for pharyngeal pouch. Cochrane Database of Syst Rev. 2005(3):CD004459. Available from: https://doi.org/10.1002/14651858.CD004459.pub2

Aiolfi A, Scolari F, Saino G, Bonavina L. Current status of minimally invasive endoscopic management for Zenker diverticulum. World J Gastrointest Endosc 2015;7(2):87-93. Available from: https://doi.org/10.4253/wjge.v7.i2.87

Repici A. Endoscopic treatment of zenker diverticulum. Gastroenterol Hepatol 2010;6(10):628-30.

May JT, Padhya TA, McCaffrey TV. Endoscopic repair of Zenker’s diverticulum by harmonic scalpel. Am J Otolaryngol 2011;32(6):553-6. Available from: https://doi.org/10.1016/j.amjoto.2010.11.009

Dzeletovic I, Ekbom DC, Baron TH. Flexible endoscopic and surgical management of Zenker’s diverticulum. Expert Rev of Gastroenterol Hepatol 2012;6(4):449-65; quiz 66. Available from: https://doi.org/10.1586/egh.12.25

Constantin A, Mates IN, Predescu D, et al. Principles of surgical treatment of Zenker diverticulum. J Med Life 2012;5(1):92-7.

Dohlman G, Mattsson O. The endoscopic operation for hypopharyngeal diverticula: a roentgencinematographic study. AMA Arch Otolaryngol. 1960;71:744-52. Available from: https://doi.org/10.1001/archotol.1960.03770050004002

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(1 Pt 1):34-6. Available from: https://doi.org/10.1177/000348948409300108

Collard JM, Otte JB, Kestens PJ. Endoscopic stapling technique of esophagodiverticulostomy for Zenker’s diverticulum. Ann Thorac Sur. 1993;56(3):573-6. Available from: https://doi.org/10.1016/0003-4975(93)90906-x.

Martin-Hirsch DP, Newbegin CJ. Autosuture GIA gun: a new application in the treatment of hypopharyngeal diverticula. J Laryngol Otol 1993;107(8):723-5. Available from: https://doi.org/10.1017/s0022215100124247

Scher RL, Richtsmeier WJ. Endoscopic staple-assisted esophagodiverticulostomy for Zenker’s diverticulum. Laryngoscope 1996;106(8):951-6. Available from: https://doi.org/10.1097/00005537-199608000-00007

Scher RL, Richtsmeier WJ. Long-term experience with endoscopic staple-assisted esophagodiverticulostomy for Zenker’s diverticulum. Laryngoscope 1998;108(2):200-5. Available from: https://doi.org/10.1097/00005537-199802000-00008

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(6):1076-89 e5. Available from: https://doi.org/10.1016/j.gie.2016.01.039

Law R, Katzka DA, Baron TH. Zenker’s diverticulum. Clin Gastroenterol Hepatol 2014;12(11):1773-82; quiz e111-2. Available from: https://doi.org/:10.1016/j.cgh.2013.09.016

Cook RD, Huang PC, Richstmeier WJ, Scher RL. Endoscopic staple-assisted esophagodiverticulostomy: an excellent treatment of choice for Zenker’s diverticulum. Laryngoscope 2000;110(12):2020-5. Available from: https://doi.org/10.1097/00005537-200012000-00008

Philippsen LP, Weisberger EC, Whiteman TS, Schmidt JL. Endoscopic stapled diverticulotomy: treatment of choice for Zenker’s diverticulum. Laryngoscope 2000;110(8):1283-6. Available from: https://doi.org/10.1097/00005537-200008000-00011.

Miller FR, Bartley J, Otto RA. The endoscopic management of Zenker diverticulum: CO2 laser versus endoscopic stapling. Laryngoscope 2006;116(9):1608-11. Available from: https://doi.org/10.1097/01.mlg.0000233508.06499.41

Leong SC, Wilkie MD, Webb CJ. Endoscopic stapling of Zenker’s diverticulum: establishing national baselines for auditing clinical outcomes in the United Kingdom. Eur Arch Otorhinolaryngol 2012;269(8):1877-84. Available from: https://doi.org/10.1007/s00405-012-1945-3

Verdonck J, Morton RP. Systematic review on treatment of Zenker’s diverticulum. Eur Arch Otorhinolaryngol 2015;272(11):3095-107. Available from: https://doi.org/10.1007/s00405-014-3267-0

Allen J, Belafsky PC. Endoscopic cricopharyngeal myotomy for Zenker diverticulum using the harmonic scalpel. Ear Nose Throat J 2010;89(5):216-8.

Sharp DB, Newman JR, Magnuson JS. Endoscopic management of Zenker’s diverticulum: stapler assisted versus Harmonic Ace. Laryngoscope 2009;119(10):1906-12. Available from: https://doi.org/10.1002/lary.20142

Whited C, Lee WT, Scher R. Evaluation of endoscopic harmonic diverticulostomy. Laryngoscope 2012;122(6):1297-300. Available from: https://doi.org/10.1002/lary.23251

Hondo FY, Maluf-Filho F, Giordano-Nappi JH, et al. Endoscopic treatment of Zenker’s diverticulum by harmonic scalpel. Gastrointest Endosc 2011;74(3):666-71. Available from: https://doi.org/10.1016/j.gie.2011.05.007

McGinn JD. Endoscopic approach to cricopharyngeal hypertonicity and hypopharyngeal diverticulum. Operative Techniques in Otolaryngology - Head and Neck Surgery 2016;27(2):67-73. Available from: https://doi.org/10.1016/j.otot.2016.04.003

Richtsmeier WJ. Myotomy length determinants in endoscopic staple-assisted esophagodiverticulostomy for small Zenker’s diverticula. Ann Otol Rhinol Laryngol 2005;114(5):341-6. Available from: https://doi.org/10.1177/000348940511400502