Lianyong Li, MD, PhD and Qiang Cai, MD, PhD, from the Department of Gastroenterology, PLA 306^th Hospital, Beijing, China and the Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia, USA, respectively, present this video case.

A 62-year-old male with Zenker’s diverticulum (ZD) underwent endoscopic diverticulectomy for dysphagia and weight loss. During the procedure, a 5 cm ZD was identified at 17cm from the incisor.  Diverticulectomy was successfully performed by a simplified needle-knife technique without any assist devices such as plastic over-tube or diverticuloscope, etc. In the procedure, only a gastroscope (GIF−290) with a standard mucosectomy cap on the tip of the scope and a needle-knife were used. The entire procedure was completed within 30 minutes.

The etiology of ZD is considered to be malfunction of the cricopharyngeus muscle that, over a long period of time, causes an outpouching of mucosa through a weak point in the pharyngeal musculature secondary to elevated hypopharyngeal intrabolus pressure. It typically takes decades to form a ZD, and therefore, ZD is primarily a disease of the elderly. Open surgery was considered the treatment of choice before the endoscopic approach gained acceptance as a valid treatment modality in the 1990s. Numerous refinements of the endoscopic approach have ensued since then.  Endoscopic approach may be superior to surgery because of shorter operative time, less time in the hospital, and a faster return to oral intake for the elderly patients. The reported endoscopic procedure for ZD diverticulectomy usually requires assist devices as mentioned above. Our approach with the simplified needle-knife technique provided a simple, efficient, and safe method for ZD diverticulectomy. Most importantly, the patient’s symptoms, including dysphagia, regurgitation, and halitosis, were resolved after the procedure, and he remained symptom free a year after the procedure.

Figure 1: Endoscopic treatment steps. A, Zenker’s diverticulum under endoscopic view. B, C, Septotomy with a needle-knife. D, Endoscopic view after septomy.

At the present time, there are not many gastroenterologists in the United States who offer patients endoscopic diverticulotomy for Zenker’s diverticulum. In general, endoscopic techniques for treatment of ZD have fewer complications than surgical approaches. We hope more and more gastroenterologists will learn this procedure and use it as a therapeutic modality for patients with ZD.

This simplified needle-knife technique works well in our experience. However, it is reported in the literature that, in general, the failure rate of flexible endoscopic diverticulotomy for Zenker’s diverticulum was 29%, and the overall complication rate was 14.3%. The main reported complications were emphysema and mediastinitis.

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