Flexible Endoscopic Zenker’s Diverticulotomy After Recurrence of Dysphagia Following Open and Rigid Endoscopic Stapled Diverticulotomies: Presidential Poster

Abstract

SymbolIntroduction: Zenker’s diverticulum (ZD) is a posterior pouch through the wall of the Killian triangle due to high pressure at the crycopharyngel (CP) bar. It is more common in males >70 who present with dysphagia. Open diverticulotomies are becoming less frequent with the available rigid and flexible endoscopic approaches. All these procedures have primary success rates >90%, but more than 1 treatment may be necessary. We report 2 cases of recurrence of dysphagia in 2 patients with ZD; 1 following open diverticulotomy and the other after 2 rigid stapled diverticulotomies, both treated successfully by flexible endoscopic diverticulotomy.SymbolMethods: We perform flexible endoscopic Zenker’s diverticulotomies and we are seeing more patients after recurrence of dysphagia. Two recent cases are presented. The procedures are performed under general anesthesia and a NGT is passed under direct endoscopic visualization or via guidewire. A transparent hood is placed on the tip of the endoscopes. Assorted wire knives are used to perform the diverticulotomies. The NGT is removed once patients are awake, deny pain, and have no SC emphysema or bleeding. Patients are instructed to observe a soft diet and hold antiplatelet medication for 48 hours. Patients are typically discharged the same day. We do not routinely perform barium esophagrams post-procedure. Results: Case 1: A 72-year-old male had an open Zenker’s diverticulotomy with recurrence of dysphagia and food regurgitation 6 months later. Scarring and clips from the previous intervention caused traction of the CP, which appeared obliquely oriented, and a second smaller diverticulum had also formed. A combination of dual and IT wire knives (Olympus America, Center Valley, PA) were used to perform the diverticulotomy. The procedure took 24 minutes. The patient reported immediate resolution of the dysphagia. Case 2: An 82-year-old male had 2 previous rigid stapled Zenker’s diverticulotomies with immediate recurrence of dysphagia. The diverticulum was actually shallow, but a prominent scar was seen at the previous intervention sites, and the remnant CP bar was prominent, creating a shelf which was likely causing the dysphagia. The dual knife was used to perform the diverticulotomy. The procedure took 12 minutes. The patient reported gradual improvement of dysphagia over 1 week. Conclusion: Flexible endoscopic treatment of ZD is successful, and may become the choice, especially after recurrence of dysphagia following other procedures. The flexibility of the scope, the ability to approach the CP bar, the various instruments now available, and efficacy comparable to other interventions make flexible endoscopy an attractive option to treat ZD and recurrence of dysphagia.