Endoscopic treatment of a Zenker's bilocular diverticulum with cap and TT knife catheter.

Abstract

Zenker’s diverticulum is an outpouching of the esophageal mucosa through the cricopharyngeal muscle at the Killian triangle [1]. Endoscopically, the bridge of pseudodiverticulum sits between the esophageal lumen and the pouch and consists of mucosa, submucosa and muscle [2]. Th e rationale is to ablate the septum as much as possible and to open the pouch. A 64-year-old male was referred to our facility because of chronic dysphagia of solids. Gastroscopy along with a barium meal revealed a 2 × 2.7 cm, bilocular Zenker’s diverticulum (Fig. 1). Th e patient asked for endoscopic treatment, carried out under general anesthesia using a conventional Olympus endoscope. A 16-French Levin tube was loaded over a guide wire to separate the esophageal lumen from the diverticulum. We rejected a diverticuloscope because of the small size of the diverticulum. A soft , straight, transparent cap (Olympus, Germany) was mounted on the endoscope tip to further improve the working view. With an Olympus Triangle Tip (TT) knife catheter, applying 35 Watts coagulation current (ERBE, Germany, generator), we cut the Zenker’s septum from the saddle toward the bottom of the pouch in the middle line, applying careful traction movements of the TT knife, and stopped aft er approximately two thirds of the septum had been cut. We considered this suffi cient to relieve the patient’s symptoms, even for the bilocular type of diverticulum. A 12mm endoscopic clip was placed at the end of the cutting site to reduce the perforation risk [3]. Th e Levin tube was removed and the procedure was completed uneventfully, lasting approximately 35 min. Th e patient was kept on nil by mouth over the next 6 h, given broad spectrum antibiotics, and gradually started a liquid and soft food diet. Th ere were no immediate or late complications. Th ree months later, the patient is symptom-free, although a follow-up barium meal depicted a small opacifi cation at the ablated diverticulum (Fig. 2). To our knowledge, there is no randomized control study comparing diverticuloscopes versus caps regarding effi ciency and complications. We clearly showed that a bilocular Zenker’s diverticulum can safely be treated endoscopically by TT knife and cap. Endoscopic treatment of a Zenker’s bilocular diverticulum with cap and TT knife catheter