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Later, in the 60s, Dohlman used diathermy to successfully cut through the septum.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1,3,4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The difficulty of the procedure lies in removing the diverticular septum without making a deep dissection that could perforate the oesophagus. For this reason, various techniques have been developed in order to reduce the risk of perforation. In the largest published series of endoscopic diverticulotomy, the needle-knife or hook-knife were used for dissection, with high success rates. Other techniques, such as the EndoGIA Autosuture<span class="elsevierStyleSup">&reg;</span> stapler, lasers, argon plasma coagulation and, more recently, the dissect and seal technique using the Ligasure&#8482; vessel sealing system have also been used.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">We conducted a retrospective study of all patients with Zenker diverticulum seen in the Gastroenterology Department of R&iacute;o Carri&oacute;n Hospital in Palencia between 2009 and 2015, who were treated with endoscopic diverticulotomy using the Ligasure&#8482; system.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The following parameters were analysed: sex, age, ASA, preoperative symptoms, size of the diverticulum, technical success (defined as nearly total resection of the septum with no immediate complications), hospital stay, complications, outcomes of the endoscopic procedure, follow-up and need for surgery.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Patients were instructed to fast for at least 6<span class="elsevierStyleHsp" style=""></span>h prior to the procedure. A few minutes before the endoscopy, they were given a dose of antibiotic (i.v. ceftriaxone 1<span class="elsevierStyleHsp" style=""></span>g or i.v. amoxicillin/clavulanic acid 1<span class="elsevierStyleHsp" style=""></span>g/125<span class="elsevierStyleHsp" style=""></span>mg). The endoscopic technique was performed under deep sedation, using intravenous administration of propofol (Propofol Lipuro 10<span class="elsevierStyleHsp" style=""></span>mg/ml, Braun) controlled by the endoscopist. The flexible endoscope (Fujinon EG-590WR Standard) was introduced to visualize the diverticulum and the oesophagus. A guide wire (0.035<span class="elsevierStyleHsp" style=""></span>in.<span class="elsevierStyleHsp" style=""></span>&times;<span class="elsevierStyleHsp" style=""></span>450<span class="elsevierStyleHsp" style=""></span>cm, Jagwire&#8482; High Performance Guidewire, Boston Scientific) was introduced through the working channel to the stomach, and the endoscope was removed. A hole was made, manually, in the long flap of the 30<span class="elsevierStyleHsp" style=""></span>cm long<span class="elsevierStyleHsp" style=""></span>&times;<span class="elsevierStyleHsp" style=""></span>22<span class="elsevierStyleHsp" style=""></span>mm diameter double-lipped overtube (ZDO-22-30, Cook Medical, Limerick, Ireland) and the guide wire was threaded through this opening. Then the overtube was positioned under direct endoscopic vision. Threading the guide wire through the hole ensures that the long flap is positioned in the oesophageal lumen and the short flap is in the diverticulum, exposing the diverticular septum between the 2 flaps (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Diverticulum depth was measured from the start of the septal wall to the base of the diverticulum. Then, a smaller endoscope (Fujinon EG-270N5) was introduced into the diverticuloscope. With the septum clearly visualized, the Ligasure&#8482; (5<span class="elsevierStyleHsp" style=""></span>mm to 37<span class="elsevierStyleHsp" style=""></span>cm, LS1500, Covidien, Medtronic) was introduced into the diverticuloscope in parallel with the endoscope. With a 2/3 seal setting (ForceTriad&#8482; Energy Platform, COVIDIEN, Medtronic), the septum is initially coagulated and sealed laterally and then coagulated, sealed and cut in the centre in several cycles up to 2&#8211;3<span class="elsevierStyleHsp" style=""></span>mm from the base of the diverticulum (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>). Approximately 1<span class="elsevierStyleHsp" style=""></span>cm of septum was resected in each cycle, except in diverticula measuring 1<span class="elsevierStyleHsp" style=""></span>cm, in which shorter cuts of about 2&#8211;3<span class="elsevierStyleHsp" style=""></span>mm were made, due to the increased risk of perforation. At the end of each cycle, the area was inspected for signs of bleeding. Once the procedure was completed, patients were kept under observation for at least 24<span class="elsevierStyleHsp" style=""></span>h. After this, if there were no signs of complications such as fever, chest pain or haematemesis, oral tolerance began with liquids at 6<span class="elsevierStyleHsp" style=""></span>h, a soft diet at 24<span class="elsevierStyleHsp" style=""></span>h, and normal diet was resumed after 7 days. Patients were followed up as outpatients.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 8 patients (3 men and 5 women) were included, with a mean age of 78<span class="elsevierStyleHsp" style=""></span>&plusmn;<span class="elsevierStyleHsp" style=""></span>15 years, 25% were ASA I, 36% were ASA II, 14% were ASA III, and 25% were ASA IV.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the ASA IV group, due to their high-risk clinical status, propofol for sedation was administered at a slower rate (150<span class="elsevierStyleHsp" style=""></span>ml/h vs 200<span class="elsevierStyleHsp" style=""></span>ml/h) to prevent secondary complications such as respiratory depression. We would add that the diverticuloscope helps protect the airway and prevents bronchoaspiration, which is often fatal in these patients.</p><p id="par0060" class="elsevierStylePara elsevierViewall">It should be noted that all patients presented symptoms, mostly dysphagia and regurgitation, and the diverticula ranged in size from 1 to 7<span class="elsevierStyleHsp" style=""></span>cm.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Average time from reaching the target level of sedation to completion of the procedure was 30<span class="elsevierStyleHsp" style=""></span>min. The technical success rate was 100%, with an average stay of 24<span class="elsevierStyleHsp" style=""></span>h.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In general, the patients presented no complications during hospitalization, except for one patient who was seen in the emergency room for non-severe haematemesis about a week after discharge. In this case, an upper gastrointestinal endoscopy was performed, which showed a clot attached to the resection site. No endoscopic therapy was required.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Of all the patients treated, only one presented partial clinical improvement. Diverticulotomy was repeated 3 months after the first intervention, following which the patient was asymptomatic.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Patients were followed up for an average of 20<span class="elsevierStyleHsp" style=""></span>&plusmn;<span class="elsevierStyleHsp" style=""></span>16 months, without any clinical recurrence or need for reintervention.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The pathophysiology of Zenker diverticulum is not entirely clear. Some authors have suggested that it is caused by obstructive pathophysiology at the upper oesophageal sphincter that causes uncoordinated swallowing and impaired relaxation and spasm of the cricopharyngeal muscle. Other hypotheses point to histological alterations, such as muscle degeneration and fibrosis.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Malignant transformation, however, is rare (0.5&#8211;1.5% of cases) due to the slow progression of the diverticulum. When it does occur, it most frequently manifests as squamous cell carcinoma.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">6</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The ideal treatment for this disease, taking into account both safety and efficacy, has been much debated in recent years; however, there is insufficient scientific evidence on which to base a definitive strategy. Generally, surgery is preferred in young and/or low-risk patients, and endoscopic techniques in other patient groups.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In 2011, Lopes da Silveira et al. published a meta-analysis reviewing 5 comparative studies with a total of 630 patients diagnosed with Zenker diverticulum; 339 were treated with surgery and 291 endoscopically. The group treated endoscopically showed a mortality rate of 0.29%, 7% morbidity and 84% efficacy, while the surgical group showed a mortality of 0.35%, 5% morbidity and 85% efficacy.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> Outcomes, therefore, were largely similar between the two groups. However, none of the studies included in this meta-analysis were randomized and none used the Ligasure&#8482; system.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Ca&ntilde;ete-G&oacute;mez et al., meanwhile, described a series of 33 cases undergoing diverticulectomy and myotomy using open surgery. This group reported an immediate postoperative morbidity rate of 27.2% due to partial dehiscence of the diverticulectomy suture line and oesophagocutaneous fistula.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">In a more recent (2016) meta-analysis of 20 studies reporting endoscopic diverticulotomy in a total of 813 patients, the authors concluded that endoscopic resection of the diverticular septum was effective and safe, with a pooled success, adverse events, and recurrence rate of 91%, 11.6%, and 11%, respectively. In this study, nearly all complications were resolved conservatively, and no patient required surgery. It should be added that the endoscopic instruments and techniques used did not differ significantly, and only the use of a soft diverticuloscope was associated with a higher success rate.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a> This meta-analysis did not include studies in which Ligasure&#8482; was used.</p><p id="par0115" class="elsevierStylePara elsevierViewall">Endoscopic treatment has several advantages compared with surgery. Firstly, a shorter intervention; in our hospital the procedure lasted about 30<span class="elsevierStyleHsp" style=""></span>min; this is in line with the study published by Noguera-Aguilar et al. who reported an average of 33<span class="elsevierStyleHsp" style=""></span>min for each procedure.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> Secondly, neither general anaesthesia nor hyperextension of the neck is required; the hospital stay is shorter, and return to oral intake takes place earlier. Furthermore, endoscopic re-intervention, if needed, is equally safe, and if unsuccessful, surgical treatment is not contraindicated.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> Another advantage of this technique is cost. Shane et al. showed that, although the cost of endoscopy and surgery is similar, the shorter hospital stay associated with diverticuloscopy significantly reduces the total cost of the treatment.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Diverticulotomy, involving myotomy with the needle-knife scalpel and later with the hook-knife, has been the gold standard for many years, and has a high success rate. However, it is not without its drawbacks: on the one hand, the needle-knife presents risk of perforation or abscess formation in up to 23% of cases due to the downward pressure used during incision, and up to 12 cycles may be needed to achieve complete septostomy in particularly fatty septa.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> If bleeding occurs, coagulation is delayed and other methods, such as argon plasma coagulation (APC), are needed.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">13,14</span></a> On this subject, Huberty et al. and Brueckner et al. each published an article on diverticulotomy using the needle-knife and hook-knife, respectively, and reported a similar rate of successful outcomes and complication with both techniques. Both studies observed a high recurrence rate of 23% vs 30%, respectively. This could be related to incomplete resection of the diverticulum. In both cases, most recurrences were resolved with further endoscopic procedures.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Another technique is EndoGIA Autosuture<span class="elsevierStyleSup">&reg;</span> stapler. This has proven difficult to handle with the endoscope, and its diameter (12<span class="elsevierStyleHsp" style=""></span>mm) can obstruct visualization during the procedure, leaving around 1<span class="elsevierStyleHsp" style=""></span>cm of the distal end of the diverticulum unresected.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1,4,10</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Similarly, the laser method requires a microscope and tissue is left virtually unsealed. In addition, several studies have shown a high risk of recurrence and endoscopic perforation.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">1,3,4,10</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The Ligasure&#8482; system uses heat and pressure to coagulate and seal vessels and tissue bundles up to 7<span class="elsevierStyleHsp" style=""></span>mm in diameter without dissection or isolation. A blade located on the shaft can be used to divide the sealed tissue. The instrument has several advantages over the techniques described above: with a diameter of just 5<span class="elsevierStyleHsp" style=""></span>mm it takes up little space and is very easy to handle. It is also highly precise and can deliver small, controlled septal incisions of up to 1<span class="elsevierStyleHsp" style=""></span>cm in length. The tissue is dissected and sealed in the same movement. In addition, the Ligasure Impact&#8482; includes electrocoagulation for improved control of the bleeding that may occur during the procedure.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Other strategies can also increase the safety of the procedure, such as incomplete resection of the septum (leaving around 3&#8211;5<span class="elsevierStyleHsp" style=""></span>mm at the distal end to avoid oesophageal perforation and mediastinitis) and the possibility of placing endoscopic clips to ensure the resected septum is properly sealed. Nevertheless, we did not need to use clips in any patients included in our study. This was an added advantage over other techniques, in which clips are placed as a matter of course. In conclusion, the Ligasure speeds up endoscopic diverticulotomy, improves safety, delivers good septum resection and minimizes postoperative recovery time.</p><p id="par0145" class="elsevierStylePara elsevierViewall">In addition, comparing studies using Ligasure&#8482;, despite their small sample size, with studies using the needle-knife or hook-knife shows a significantly lower rate of recurrence in the former. In both our study and that of Noguera-Aguilar et al. in 2014, no patient presented recurrence of symptoms during the follow-up period.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> Nielsen et al., however, published a study with 15 patients, and reported a recurrence rate of 13% (2 patients)<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a>; we attribute our zero recurrence rate to a more complete resection of the septum in the first procedure.</p><p id="par0150" class="elsevierStylePara elsevierViewall">The only disadvantage of this technique, in our opinion, is the need to introduce the Ligasure&#8482; in parallel with the diverticuloscope, which can reduce visualization of the diverticular septum.</p><p id="par0155" class="elsevierStylePara elsevierViewall">In our hospital, we have used Ligasure&#8482; for dissection of the septum since endoscopic diverticulotomy was introduced in 2009, and we therefore cannot compare our results with those obtained from other techniques in our setting. Similarly, there are no prospective, randomized studies comparing this technique with other endoscopic or surgical strategies; however, our experience has been highly satisfactory, since only 1 patient in our series required re-intervention, and in that case the outcome was also successful.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0160" class="elsevierStylePara elsevierViewall">In conclusion, we believe that diverticulotomy performed using Ligasure&#8482; is a minimally invasive technique with excellent results in the treatment of Zenker diverticulum. We also believe that this technique will become the strategy of choice in this pathology, irrespective of patient age and surgical risk. More prospective, randomized studies are needed to explore the benefits of this technique, although this is scarcely feasible given the low incidence of this disease.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest.</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Endoscopic treatment of Zenker diverticulum is considered feasible, effective and safe. The use of the Ligasure&#8482; vessel sealer provides adequate and quick dissection of tissue, achieving effective haemostasis.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective, descriptive study of all patients with Zenker diverticulum who were treated by endoscopic diverticulotomy using Ligasure&#8482;. The procedure was performed in the endoscopy unit under deep sedation controlled by the endoscopist. Patients were subsequently admitted for observation and, after discharge, were followed-up in the outpatient clinic.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Eight patients, 5 women and 3 men, mean age 78<span class="elsevierStyleHsp" style=""></span>&plusmn;<span class="elsevierStyleHsp" style=""></span>15 years, 25% ASA I, 36% ASA II, 14% ASA III and 25% ASA IV. Main symptom: dysphagia. Diverticula size: 1&#8211;7<span class="elsevierStyleHsp" style=""></span>cm. Technical success: 100%. Complications: one patient with upper gastrointestinal bleeding. Average stay: 24<span class="elsevierStyleHsp" style=""></span>h. Seven patients: asymptomatic; one patient with partial improvement, requiring repeat endoscopic intervention. Surgery and morbidity and mortality: 0%.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The treatment of Zenker diverticulum by endoscopic diverticulotomy using the Ligasure&#8482; vessel sealer is highly effective, fast and safe, and could be considered the treatment of choice.</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&oacute;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El tratamiento endosc&oacute;pico del divert&iacute;culo de Zenker es considerado viable, efectivo y seguro. La utilizaci&oacute;n de la t&eacute;cnica sellado-secci&oacute;n mediante Ligasure&#8482; proporciona una adecuada y r&aacute;pida disecci&oacute;n del tejido, logrando una hemostasia efectiva.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&eacute;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo, descriptivo, de todos los pacientes con divert&iacute;culo de Zenker que fueron tratados a trav&eacute;s de una diverticulotom&iacute;a endosc&oacute;pica utilizando el Ligasure&#8482;. El procedimiento se realiz&oacute; en la unidad de endoscopias, bajo sedaci&oacute;n profunda controlada por el endoscopista. Posteriormente, los pacientes ingresaron para observaci&oacute;n y, despu&eacute;s del alta, se realiz&oacute; un seguimiento por consultas externas.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ocho pacientes, 5 mujeres y 3 hombres, edad media: 78<span class="elsevierStyleHsp" style=""></span>&plusmn;<span class="elsevierStyleHsp" style=""></span>15 a&ntilde;os; 25% ASA I; 36% ASA II; 14% ASA III, y 25% ASA IV. S&iacute;ntoma principal: disfagia. Tama&ntilde;o de los divert&iacute;culos: 1 a 7<span class="elsevierStyleHsp" style=""></span>cm. &Eacute;xito t&eacute;cnico: 100%. Complicaciones: un paciente con HDA. Estancia media: 24<span class="elsevierStyleHsp" style=""></span>h. Siete pacientes: asintom&aacute;ticos; un paciente con mejor&iacute;a parcial, necesitando reintervenci&oacute;n endosc&oacute;pica. Cirug&iacute;a y morbimortalidad: 0%.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&oacute;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El tratamiento del divert&iacute;culo de Zenker mediante diverticulotom&iacute;a endosc&oacute;pica con Ligasure&#8482; proporciona una gran eficacia, rapidez y seguridad, por lo que podr&iacute;a plantearse como primera elecci&oacute;n de tratamiento.</p></span>"
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