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Endoscopic suturing for repair of an obstructing Zenker’s diverticulum using a bidirectional endoscopic approach for lumen delineation

Open AccessPublished:May 02, 2022DOI:https://doi.org/10.1016/j.vgie.2022.03.006

      Video

      (mp4, (69.96 MB)

      Endoscopic suturing of an obstructing Zenker’s diverticulum.

      Abbreviation:

      LAMS (lumen-apposing metal stent)

      Introduction

      Endoscopic suturing is a technique that can be applied to several disease processes, such as repair of fistulae or perforations, endoluminal stent anchoring, and for endobariatric procedures. We describe a case of suturing to repair an obstructing Zenker's diverticulum (Video 1, available online at www.giejournal.org).

      Case description

      A 69-year-old man with a history of heroin abuse was referred to our interventional gastroenterology clinic for evaluation of dysphagia and immediate regurgitation of all solids and liquids noted since his arrival at a skilled nursing facility. Two months before presentation, he had a prolonged intensive care admission for acute respiratory failure in the setting of heroin overdose and COVID-19 pneumonia, during which he received a tracheostomy. Before endoscopy, CT of the chest and abdomen were performed, which demonstrated proximal esophageal dilation with an air fluid level and incomplete assessment of the mid and distal esophagus. Oral intolerance to contrast precluded a thorough oral contrasted CT (Fig. 1).
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      Figure 1CT of the chest and abdomen before endoscopy.
      An outpatient upper endoscopy was performed, revealing a blind esophageal pouch without any discernible esophageal lumen in spite of the procedure being conducted with the patient under general anesthesia with endotracheal intubation. Contrast injection resulted in stasis of contrast in the proximal esophagus without opacification of more distal esophageal segments (Fig. 2). Retrograde endoscopy was performed through the gastrostomy tube site and, with advancement, revealed a large, obstructing Zenker's diverticulum. Using a balloon catheter advanced through an anterograde gastroscope, we passed a guidewire through the anterograde scope into the retrograde pediatric scope to safely advance the anterograde gastroscope beyond the level of previous obstruction (Fig. 3). After luminal delineation (Fig. 4; single arrow delineating the esophageal lumen), endoscopic suturing was performed to successfully expose the esophageal lumen (Fig. 5). Contrast was injected to confirm patency (Fig. 6).
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      Figure 2Intraprocedural esophagram demonstrating blind esophageal pouch.
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      Figure 3Advancing guidewire via the anterograde gastroscope through the retrograde ultraslim gastroscope for safe advancement of the anterograde scope beyond the obstruction.
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      Figure 4Esophageal lumen delineation with the guidewire (single arrow demonstrates the esophageal lumen; double arrow demonstrates the diverticulum).
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      Figure 5Endoscopic appearance after endoscopic suturing.
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      Figure 6Postsuturing intraprocedural esophagram demonstrating esophageal patency.
      A repeat upper endoscopy was performed 2 weeks later, confirming patency (Fig. 7). The patient was followed for 16 months, demonstrating weight gain of 41 pounds at 16 months (Fig. 8) and complete resolution of all dysphagia and regurgitative and obstructive symptoms. At 12 months, an esophagram demonstrated continued esophageal luminal patency (Fig. 9).
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      Figure 7Patent esophageal lumen at 2-week follow-up endoscopy.
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      Figure 9Twelve-month postsuturing esophagram.

      Conclusion

      Endoscopic suturing is a safe, feasible outpatient approach to repair obstructing Zenker's diverticuli that can be performed in centers that are not able to perform Zenker’s peroral endoscopic myotomy (Fig. 10).
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      Figure 10Comparison of surgical and endoscopic modalities for treatment of Zenker’s diverticuli. Z-POEM, Zenker’s peroral endoscopic myotomy.A

      Disclosure

      Dr Villa is a consultant for Medtronic PLC and Olympus Corp. All other authors disclosed no financial relationships.

      Supplementary data