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Outpatient flexible endoscopic diverticulotomy for the management of Zenker’s diverticulum: a retrospective analysis of a large single center cohort.

  • Scott Schoeman
    Affiliations
    The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, Division of Gastroenterology and Hepatology, Department of Medicine, St. Michael’s Hospital, Toronto, Canada

    Division of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, Australia
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  • Ryosuke Kobayashi
    Affiliations
    The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, Division of Gastroenterology and Hepatology, Department of Medicine, St. Michael’s Hospital, Toronto, Canada

    Yokohama City University Medical Center, Yokohama, Japan
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  • Norman Marcon
    Affiliations
    The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, Division of Gastroenterology and Hepatology, Department of Medicine, St. Michael’s Hospital, Toronto, Canada
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  • Gary May
    Affiliations
    The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, Division of Gastroenterology and Hepatology, Department of Medicine, St. Michael’s Hospital, Toronto, Canada
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  • Jeffrey Mosko
    Affiliations
    The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, Division of Gastroenterology and Hepatology, Department of Medicine, St. Michael’s Hospital, Toronto, Canada
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  • Christopher Teshima
    Correspondence
    Corresponding Author: Christopher Teshima, MD PhD, The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, St. Michael’s Hospital, Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Canada
    Affiliations
    The Center for Advanced Therapeutic Endoscopy and Endoscopic Oncology, Division of Gastroenterology and Hepatology, Department of Medicine, St. Michael’s Hospital, Toronto, Canada
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Published:October 10, 2022DOI:https://doi.org/10.1016/j.gie.2022.09.022
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      ABSTRACT

      Backgrounds and aims

      Flexible endoscopic Zenker’s diverticulotomy (EZD) is well established as a safe and effective technique. Due to rare but concerning complications, most centers admit patients for observation and barium swallow study. Our center routinely performs EZD as a day procedure, discharging appropriate patients on the same day following clinical review. This study evaluates outcomes of this cohort compared to previously published studies where patients are admitted for observation.

      Methods

      A retrospective analysis was performed of EZD procedures performed at our center using a flexible endoscope, and in most cases, a diverticulotomy overtube, under moderate sedation and general anesthesia. Patients were observed for two hours and discharged if no clinical concerns. Patient comorbidities, ASA physical status, and endoscopic complications were recorded against the ASGE severity grading system.

      Results

      240 EZD procedures performed between January 2015 and February 2021. Eleven (4.6%) intraprocedural adverse events occurred: 4 perforations, 4 bleeds and one post-procedural pain, delirium and vomiting respectively. All were recognized within the two-hour observation period and were managed conservatively, except one patient who required surgery. Six (2.5%) patients presented with delayed adverse events: 2 bleeds, 2 perforations and 2 patients with post-procedural pain. All recovered uneventfully with supportive care.

      Conclusions

      All significant adverse events requiring endoscopic or surgical intervention were identified prior to discharge. Delayed adverse events occurred in 2.5% of cases, all of which were managed supportively. Our data are comparable to published cohorts of admitted patients, demonstrating that appropriately selected patients may be managed as outpatients while maintaining similar safety outcomes.

      Key Words

      Acronyms:

      ZD (Zenker’s diverticulum), EZD (Endoscopic Zenker’s diverticulotomy), ESD (Endoscopic submucosal dissection), ASA (American Society of Anesthesiologists), uCCI (Updated Charleson comorbid index), ASGE (American society of gastrointestinal endoscopy), Z-POEM (Zenker’s – per oral endoscopic myotomy), DAPT (dual antiplatelet therapy), DOAC (direct acting oral anticoagulant)
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