Luis F. Lara, MD, from Cleveland Clinic Florida, in Weston, Florida, USA describes this VideoGIE case “Diamond-shaped flexible endoscopic cricopharyngeal myotomy for treatment of Zenker’s diverticulum.”
A 93-year-old male with cervical kyphosis and osteophytes presented with progressive dysphagia with weight loss due to enlarging Zenker’s diverticulum (3 cm deep). ENT refused surgery. After endotracheal intubation and NGT placement a flexible endoscopic diverticulotomy was performed using Olympus Dualknife and IT-2 needleknife with ERBE unit at Endocut 3-1-1, coagulation 25 W settings. The cut was made starting at the midline in the bottom of the diverticulum in a lateral fashion to the left and right, thus creating a V cut which when performed on both sides of the diverticulum resulted in a diamond shape. The patient had immediate improvement and was discharged the same day. 5 patients have been successfully treated this way with 30 d to over one year follow-up.
Flexible endoscopic diverticulotomies are being performed more frequently but large diverticuli may be a contraindication. Surgeons create rotational flaps to change tension lines in scar tissue. The V cut on each side of the diverticulum results in a wide diamond shaped diverticulotomy which decreases tension of the cricopharyngeal bar, and may obviate the need to perform a long cut to the base of the diverticulum.
Flexible endoscopic Zenker’s diverticulotomy may be an option for patients where the surgical approach is not feasible, such as patients with kyphosis and osteophytes, and the technique described here may achieve improvement of dysphagia without the potential risk of trying to cut to the base of the diverticulum.
Flexible endoscopic Zenker’s diverticulotomy outcomes need to be studied, for example via dysphagia score, but this is an excellent alternative to the surgical approach. Variations of the technique that may apply to patients with fixed necks, large diverticuli or those requiring anticoagulation need to be studied.
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