Post written by Shou-jiang Tang, MD, from the Division of Digestive Diseases and Division of Cardiology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA.

We report a 75 year-old-man with a large symptomatic Zenker’s diverticulum (ZD, 4-5 cm in length) who also needed a Transesophageal echocardiography (TEE). We first performed a flexible endoscopic diverticulotomy. His esophageal and throat symptoms completely resolved without procedural adverse events. Then we applied a novel method by taping a wire catheter on the backside of the probe. The TEE probe was advanced over a wire guide placed in the esophagus. Under gastroscopic guidance, the TEE probe was advanced through the esophageal introitus and opening on the septal wall. There was no reported artifact in the TEE images, even the catheter and wire were at the TEE scope tip. This is because the TEE scope has a linear scanning probe.

ZD is the posterior pulsion diverticulum below the esophageal introitus through or above the cricopharyngeal muscle. The TEE probe is larger than a standard gastroscope with an external diameter of 13 mm, and it does not have a camera to guide its passage through the esophageal introitus. In addition, there is no channel port for wire guidance.  Contraindications of TEE include Zenker’s diverticulum, stenosis, tumors, and advanced esophageal varices because of the technical difficulties associated with probe advancement and the risk of esophageal perforation, bleeding, and false tract formation. Perforation and tracheal intubation by the TEE probe have been reported. We report a simple and novel endoscopic-guided TEE probe insertion technique.

We propose that the wire and endoscopic guided TEE probe insertion technique can be utilized in patients with suspected diverticulum and stenosis to reduce procedural adverse events and time. The cardiologists and gastrointestinal endoscopists can work together when difficult TEE intubation is encountered or anticipated.

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