Endoscopic Zenker diverticulotomy using the window technique: a technical trick to improve the field of view.

Endoscopic diverticulotomy is a safe, effective, and simple technique to treat patients with symptomatic Zenker’s diverticulum [1]. The endoscopic management was demonstrated to be as effective as surgical external diverticulotomy in most cases and can be recommended as the first choice [2]. Diverticuloscope-assisted diverticulotomy has been demonstrated to be safer and more effective than the capassisted procedure [3]. The main benefit of the diverticuloscope is to improve exposure of themuscular fibers by stretching them [4]. In our practice, we additionally use a technical trick called the “window technique” to improve the field of view before the myotomy. After insertion of the diverticuloscope, we initially cut a small square of mucosa to enlarge the space and expose the muscular fibers (●" Fig.1). This step usually takes 1 minute. A square, measuring approximately 5mm, is cut on the four sides and then removed. We usually use a Hook-knife (Olympus, Tokyo, Japan) to create this window with Endocut electric current (ERBE VIO 300D, Tübingen, Germany). Thanks to this mucosal window, the cricopharyngeal fibers are stretched and visible (●" Fig.2). Without the mucosal window, the two sides of the sectioned mucosa can obscure the myotomy site and prevent perfect control of the depth of cutting. In contrast, the mucosal window helps to Fig.1 Endoscopic views of the initial step in endoscopic Zenker diverticulotomy with mucosal cutting to create the window showing: a the lateral sides cut; b the inferior incision being made; c the appearance after three sides have been cut; d the final appearance after removal of the mucosal flap.