Safe duodenoscopic intubation in a patient with a large Zenker's diverticulum

Abstract

A Zenker's diverticulum may make endoscopic intubation of the esophagus difficult, and despite a catheter-assisted guided intubation, perforations have occurred.1Tsang T-K Chodash HB. Perforation after catheter-guided endoscopic intubation.Gastrointest Endosc. 1994; 40 ([Letter]): 780-781Google Scholar The difficulty and potential for complications is compounded when an ERCP is attempted, inasmuch as the intubation by its very nature is partially blind. We describe a method used for safe duodenoscopic intubation in a patient with a previously unrecognized Zenker's diverticulum. The patient was an 89-year-old nursing home resident with dementia who had been admitted three times to a local hospital with recurrent cholangitis. An ultrasound examination revealed a dilated common bile duct and choledocholithiasis. The patient was transferred to our hospital for management. Initial attempts at esophageal intubation with the duodenoscope were unsuccessful because the side-viewing endoscope would not pass easily into the esophagus. In an attempt to visualize the posterior pharynx, a standard forward-viewing endoscope was passed and a 4 cm Zenker's diverticulum was noted. The lumen of the esophagus appeared to be at the edge of the visual field; however, the forward-viewing endoscope could not be passed into the esophagus. Under fluoroscopic and endoscopic guidance a 0.035-inch guide wire was passed into the esophagus and stomach. Nevertheless, the acute angulation of the entrance into the esophagus combined with a buckling of the guide wire prevented passage of the endoscope. An ERCP catheter was then passed over the guide wire. This stiffened the guide wire and allowed passage of the upper endoscope. No other pathology was noted on the esophagogastroduodenoscopy. A similar maneuver (i.e., passage of an ERCP catheter over a previously placed guide wire) was attempted with the ERCP scope, but the side-viewing scope would not pass, again due to the acute angulation. This procedure was repeated with the forward-viewing endoscope and an overtube “backloaded” on the endoscope. Under fluoroscopic guidance the overtube was passed several centimeters beyond the upper esophageal sphincter; the endoscope was removed and the duodenoscope was passed through the overtube. The patient underwent an uneventful sphincterotomy and stone removal and was discharged to the nursing home. Catheter-guided endoscopic intubation (CAGEIN) has been described as a safe method when intubation is difficult.2Tsang T-K Buto SK. Catheter-guided endoscopic intubation: a new technique for intubating a difficult esophagus.Gastrointest Endosc. 1992; 38: 49-51Abstract Full Text PDF Scopus (24) Google Scholar Tsang and Buto2Tsang T-K Buto SK. Catheter-guided endoscopic intubation: a new technique for intubating a difficult esophagus.Gastrointest Endosc. 1992; 38: 49-51Abstract Full Text PDF Scopus (24) Google Scholar note that when a side-viewing endoscope is passed, “unlike direct intubation, the esophageal inlet usually cannot be inspected for the presence of additional anomalies during indirect passage of the endoscope using CAGEIN.” Thus they recommend that “if resistance is encountered, and especially if the duodenoscope tip becomes caught at the esophageal inlet, the intubation attempt should be terminated.”2Tsang T-K Buto SK. Catheter-guided endoscopic intubation: a new technique for intubating a difficult esophagus.Gastrointest Endosc. 1992; 38: 49-51Abstract Full Text PDF Scopus (24) Google Scholar Dabezies3Dabezies MA. Esophageal intubation over a guide wire.Gastrointest Endosc. 1993; 39 ([Letter]): 597Abstract Full Text PDF Scopus (11) Google Scholar noted several advantages of using a guide wire instead of a catheter.3Dabezies MA. Esophageal intubation over a guide wire.Gastrointest Endosc. 1993; 39 ([Letter]): 597Abstract Full Text PDF Scopus (11) Google Scholar Our method of duodenoscopic intubation both allows for direct inspection of the pharynx and esophagus (during placement of the forward viewing scope) and employs the use of guide wire and catheter if necessary. It allows the safe passage of the duodenoscope through the pharynx by guiding the scope through the overtube and bypassing the Zenker's diverticulum. We suggest that patients with a known or suspected Zenker's diverticulum who require ERCP first undergo fluoroscopically guided wire-assisted intubation with a standard endoscope and then passage of an overtube several centimeters beyond the upper esophageal sphincter. The endoscope can then be removed and the duodenoscope can be passed in a safe and controlled fashion through the overtube. Our case also emphasizes the need for gentle passage of the duodenoscope into the esophagus. If any resistance is encountered we recommend changing to a forward-viewing scope and viewing the anatomy prior to proceeding with esophageal intubation.