Dear Sirs,
We read the article ‘Optimising endoscopic stapling of pharyngeal pouches’ by Moore et al. with great interest.Reference Moore, Vijendren, Rajagopal and Spraggs1 The authors provide an effective technique for the surgical treatment of a challenging entity, the so-called Zenker's diverticulum. We respect their effort to improve the endoscopic approach for this diverticulum.
However, they do not mention the endostitch-assisted diverticulostomy technique, which may enable better exposure with a similar result. Since their stated intent is to facilitate stapling and to increase the number of successful endoscopic procedures, it would have been reasonable to cite an alternative: the use of endostitches to engage the endostapler over the common wall between the diverticulum and the oesophagus.
We too use oesophageal forceps during transoral endoscopic Zenker's diverticulostomy and find this safe and effective. However, two forceps, a rigid endoscope and a stapler can sometimes make the narrow surgical field busy, especially when exposure is limited. In such cases, we prefer to use endostitches. Their use and success has been published recently.Reference Richtsmeier2, Reference Nicholas, Devitt, Rosen, Spiegel and Boon3 In our hands, using endostitches instead of two oesophageal forceps gives the surgeon more room while stapling the cricopharyngeal bar. Furthermore, the surgeon can handle the two endostitches with one hand and provide counter-traction without assistance; then, he or she can advance the stapler and cut the cricopharyngeal bar with the other hand. The risks and complications of endostitches should be similar to those of oesophageal forceps. The major disadvantage of using endostiches might be their cost.
We believe that the use of endostitches should be kept in mind while preparing for transoral endoscopic Zenker's diverticulostomy. We all strive to optimise patient selection and surgical technique when managing pharyngeal dysphagia.Reference Moore, Vijendren, Rajagopal and Spraggs1–Reference Ozgursoy and Salassa5 Hence, describing current and effective surgical alternatives will provide a complementary perspective for the reader, which may help to facilitate the endoscopic approach and to decrease the need for an open approach, in meticulously selected cases.
Author's reply
Dear Sirs,
The endostitch technique is an effective method by which counter-traction can be applied to the cricopharyngeal bar when applying an endoscopic stapling device. It is acknowledged that in certain patients surgical exposure is limited, and in these cases it may not be possible to introduce two pairs of oesophageal forceps and the endostapler, as described in my and my colleagues’ original paper.1 In these situations, a single pair of oesophageal forceps can be used to provide counter-traction. It is stressed that this is sub-optimal, as the asymmetrical application of retraction force may result in non-perpendicular placement of the endostapler. However, the position of the stapler can be checked with a Hopkins rod prior to deploying the staples. This modification provides an alternative method for managing patients in whom surgical access is limited.
