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Endoscopic stag beetle knife treatment for symptomatic Zenker’s diverticulum
Zenker’s diverticulum is a pulsion diverticulum that develops through Killian’s triangle, an area of weakness of the posterior hypopharynx. The reported prevalence of Zenker’s diverticulum is between 0.01 % and 0.11 %, and it is typically seen in middle-aged and older male patients in their seventh or eighth decade of life . Diagnosis is based on clinical symptoms such as dysphagia, the predominant symptom in 80 % to 90 % of patients. The diagnosis of Zenker’s diverticulum is made on a barium swallow examination. Upper endoscopy is not required to confirm the diagnosis but is recommended to exclude malignancy .
Flexible endoscopic treatment, preferred over open surgical treatment, is the first-line therapy for patients with a symptomatic Zenker’s diverticulum of any size . In all, three options are available for treatment: open surgery, rigid endoscopy, and flexible endoscopy. Thanks to flexible endoscopy, many techniques have emerged in recent years, such as Zenker’s diverticulum peroral endoscopic myotomy (Z-POEM). Besides that, some tools have been adapted to perform safe and effective septotomy.
The stag beetle (SB) knife (Sumimoto Bakelite Ltd.) is a scissor-shaped, rotating device with two insulated monopolar blades designed primarily for endoscopic submucosal dissection (ESD). Battaglia et al.  and Goelder et al.  demonstrated that the SB knife is a safe and effective alternative for treating symptomatic Zenker’s diverticulum.
A 69-year-old woman presented with dysphagia. Her symptoms had started 3 years earlier. A barium swallow examination was performed and Zenker’s diverticulum was diagnosed ([Fig. 1]). Zenker’s diverticulotomy was performed with the patient under general anesthesia. We used a 9.8-mm diameter endoscope, an SB knife, a distal attachment cap, a metallic clip (HX-610-135; Olympus, Japan), and a nasoenteral feeding tube.
First, we passed the nasoenteral feeding tube through the esophagus. After grasping the mucosa, we applied a burst of coagulation current before grasping the tissue and dissecting it with Endo Cut Q, effect 3 (Erbe V300 D). We deployed the clip to prevent mucosal dissection and perforation ([Fig. 2]). The procedure was completed without adverse events ([Video 1]). The patient was discharged on the first postoperative day receiving liquids and enteral nutrition. After 7 days, the nasoenteral feeding tube was removed and the patient started a soft diet with no symptoms, and she remains without symptoms until the present date.
Video 1 Endoscopic stag beetle knife treatment for symptomatic Zenkerʼs diverticulum: a safe and feasible approach.
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19 October 2020 (online)
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- 1 Verhaegen VJO, Feuth T, van den Hoogen FJA. et al. Endoscopic carbon dioxide laser diverticulostomy versus endoscopic staple-assisted diverticulostomy to treat Zenker’s diverticulum. Head Neck 2011; 33: 154-159 http://www.ncbi.nlm.nih.gov/pubmed/20848433
- 2 Pang M, Koop A, Brahmbhatt B. et al. Comparison of flexible endoscopic cricopharyngeal myectomy and myotomy approaches for Zenker diverticulum repair. Gastrointest Endosc 2019; 89: 880-886 http://www.ncbi.nlm.nih.gov/pubmed/30342027
- 3 Weusten BLAM, Barret M, Bredenoord AJ. et al. Endoscopic management of gastrointestinal motility disorders – part 2: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 600-614 http://www.ncbi.nlm.nih.gov/pubmed/32462649
- 4 Battaglia G, Antonello A, Realdon S. et al. Flexible endoscopic treatment for Zenker’s diverticulum with the SB Knife. Preliminary results from a single-center experience. Dig Endosc 2015; 27: 728-733 http://www.ncbi.nlm.nih.gov/pubmed/25975384
- 5 Goelder SK, Brueckner J, Messmann H. Endoscopic treatment of Zenker’s diverticulum with the stag beetle knife (sb knife) – feasibility and follow-up. Scand J Gastroenterol 2016; 51: 1155-1158 http://www.ncbi.nlm.nih.gov/pubmed/27218662