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DOI: 10.1055/a-2436-1113
Modified overtube insertion technique to facilitate safe endoscopic cricopharyngeal myotomy for management of Zenker’s diverticulum
Authors
A 73-year-old woman with a history of progressively worsening dysphagia presented with the inability to tolerate solids or liquids. In the past month, she had lost 10 pounds (4.5 kg) of weight. Gastroscopy revealed a 2-cm Zenker’s diverticulum, located at 19 to 21 cm from the incisors and centered on the 9 o’clock position. Residual solid food was visualized within the diverticulum ([Fig. 1]). We proceeded to perform an endoscopic Zenker’s diverticulotomy ([Video 1]). Peroral endoscopic myotomy was not considered because of the short nature of the diverticulum.
We first cleaned the diverticulum and then placed a 0.035-inch guidewire into the stomach. We used a Zenker’s diverticulum overtube (ZDO-22-30; Cook Medical, Bloomington, USA). The 40-mm length of the ZDO distal flap is designed to protect the anterior esophageal wall, whilst the 30-mm length distal flap protects the posterior diverticular wall. To help facilitate safe insertion of the ZDO we modify it by creating a hole using a 22G needle at the apex of the 40-mm length distal flap ([Fig. 2] a, b). The guidewire is then passed through the hole, allowing wire-guided insertion of the ZDO ([Fig. 2] c, d). Once placed correctly, the ZDO isolates the muscular septum ([Fig. 3]).
A complete myotomy of the cricopharyngeal muscle was then performed with the DualKnife J (Olympus, Tokyo, Japan). The myotomy defect was closed with 6 through-the-scope metal clips. Endoscopic evaluation post clip closure revealed complete flattening of the diverticulum and easy passage of the gastroscope into the esophagus. Within a few days the patient’s dysphagia for solids and liquids completely resolved.
Freehand or cap-assisted endoscopic Zenker’s diverticulotomy can be technically challenging. The anatomical position of the diverticulum can result in endoscope instability and unstable endoscopic views. A ZDO can be placed to safely expose, stretch, and fix the septum, whilst also protecting the anterior esophageal wall and posterior diverticular wall. This allows a safer and more stable endoscopic myotomy [1] [2]. ZDO placement however can be difficult, even with endoscopic guidance. We present a simple modification to the ZDO that we have used for more than 5 years that facilitates an easier, more accurate, and less traumatic insertion.
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Publication History
Article published online:
29 November 2024
© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
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References
- 1 Schoeman S, Kobayashi R, Marcon N. et al. Outpatient flexible endoscopic diverticulotomy for the management of Zenker’s diverticulum: a retrospective analysis of a large single-center cohort. Gastrointest Endosc 2023; 97: 226-231
- 2 Bizzotto A, Iacopini F, Landi R. et al. Zenker’s diverticulum: exploring treatment options. Acta Otorhinolaryngol Ital 2013; 33: 219-229