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Magnetic compression resulting in serosa-to-serosa apposition followed by pressure necrosis has been shown to be able to create solid anastomostic connections and has been reported in conditions such as oesophageal atresia, benign biliary strictures and malignant gastric outlet obstruction. This first series evaluated this technique for the management of large intrathoracic oesophageal diverticula by creating a communication between the bottom of the diverticulum and the distal oesophagus followed, in a second endoscopy session, by the transection of the proximal septum. Four patients underwent this procedure without complications and with excellent clinical outcome, suggesting that this might be a very promising endoscopic approach avoiding surgery in these difficult cases (figure 1).

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Figure 1

(A) Fluoroscopic view of a gastroscope advanced to the level of a large lower oesophageal diverticulum. (B) Endoscopic view after placement of two magnets, with one magnet at the base of the diverticulum and the other at the opposite side of the septum, in the oesophagus. (C) Ten days following their endoscopic placement, the magnets have joined together, have migrated into the diverticulum and have been removed. The magnet-induced anastomosis between the diverticulum and the oesophagus is clearly visualised. (D) A control gastroscopy is performed 24 h after completion of the diverticulotomy and demonstrates the complete section of the septum between the diverticulum and the oesophagus.

In more detail

While peroral endotherapy for Zenker's diverticulum has been largely described and is now accepted as a first-line treatment (Huberty V et al. Gatrointest Endosc 2013;77:701–7), various endoscopic treatments for mid and lower oesophageal diverticula have only occasionally been reported and consisted in a ‘clip and cut’ technique which usually does not allow to perform a transection of the oesophageal wall to be large enough to avoid food stagnation in larger diverticula (Bak YT et al. Gastrointest Endosc 2003;57:777; Shubert D et al. Endoscopy 2004;36:735). A fully peroral approach would however be attractive in this indication since the current transthoracic and/or transhiatal approaches are associated with morbidity rates around 25% and a mortality of 1.5% (Gonzalez-Calatayud MJ et al. Minim Access Surg 2014;10:169).

Magnetic compression anastomosis consists in placement of two magnets which induce a serosa-to-serosa apposition followed by pressure necrosis and creation of an orifice between these two adjacent parts of the GI tract. This technique has been shown feasible in several conditions including gastric outlet obstruction (Van Hooft JE et al. Gastrointest Endosc 2010;72:530–5; ASGE technology Committee. Gastrointest Endosc 2013;78:561–7). Here, magnets have been used to create an anastomosis between the bottom of large symptomatic diverticulum in the upper (n=1), middle (n=1) and distal (n=2) oesophagus on the one side and the oesophageal lumen on the other side. In a second endoscopy session, performed 10–14 days later, magnets were removed after creation of the anastomosis in the form of a connecting hole, and the remaining part of the septum proximally to the connection was cut by diathermy to allow full marsupialisation of the diverticulum. Four patients have been treated without complications, and we found complete symptom relief in three of them and a major clinical improvement in the fourth case within a mean follow-up of 26 months (range 2–36 months).

Find more details on online supplementary methods and results.

Comments

A transoral flexible endoscopic approach has already been shown to be a viable alternative to surgery in patients with proximal oesophageal diverticulum (Zenker diverticulum), providing a similar efficacy with fewer adverse events, shorter hospital stay and faster return to oral intake and lower morbidity rates as compared with surgery (Aly A et al. Br J Surg 2004;91:657; Huberty V et al. Gatrointest Endosc 2013;77:701). However, for other large diverticula located in the mid or distal oesophagus, endoscopic treatment is not considered standard therapy because of the lack of equipment allowing for a safe transection of the oesophageal wall to reach complete marsupialisation. Most patients are treated surgically and surgical treatment may be difficult, requiring thoracotomy in many cases (Gonzalez-Calatayud M et al. J Minim Access Surg 2014;10(4):169). Even more than for Zenker diverticula, a transoral endoscopic option would avoid major surgery for a minor anatomical problem.

Magnetic compression anastomosis has been successfully used in gastric outlet obstruction resulting in solid tissue apposition, necrosis and formation of a connecting orifice, but was associated with a tendency of anastomotic narrowing (restenosis) after magnet removal (Van Hooft JE et al. Gastrointest Endosc 2010;72:530). For our application, this appears much less likely, since magnets are used only to transiently open the bottom of the diverticulum towards the distal oesophageal lumen without the risk of mediastinal leak. This connection is then used for a subsequent full transection of the septum between the oesophageal lumen and the diverticulum proximally to this anastomosis. We initially used the current technique to treat a patient with an ‘extra large’ symptomatic Zenker diverticulum with no symptomatic relief after standard endoscopic proximal diverticulotomy. The results presented here in the three additional patients suggest that the same technique, combining magnetic anastomosis followed by septotomy, can be safely performed in patients with large mid/lower oesophageal diverticula, who were up to now candidates for surgery. The time needed to have a solid anastomosis allowing for easy removal of the magnets is about 10–14 days. Then, during a second endoscopy, the transection of the remaining septum must be performed in the same axis as the anastomosis, preferably from the top to the created hole. With this technique, the risk of cutting to deep, leading to perforation and mediastinitis, is mostly avoided.

Our limited experience suggests that this technique is effective and safe. All four patients had partial (n=1) or complete (n=3) resolution of symptoms after endoscopic treatment and no complications were encountered. It is of course too early to recommend this approach as a routine, but the present results should stimulate further investigations in a group of patients who would definitively benefit of a minimally invasive approach. Industry partners working on magnetic anastomotic devices should also include oesophageal diverticula among their potential future indications or consider limited production for compassionate use.