A LARGE PERFORATION IN THE SINUS PIRIFORM DURING ZENKER DIVERTICULOTOMY EFFECTIVELY CLOSED WITH “CLIPS-AND-RUBBER BAND” TECHNIQUE

Endoscopic treatment of Zenker diverticulum (ZD) by diverticulotomy consists in cutting the septum between the esophageal lumen and the diverticulum, thus restoring bolus transit. This technique is being increasingly preferred to surgical treatment as it is safe and minimizes the in-hospital stay, especially in patients with important comorbidities [1,2]. Nevertheless, endoscopic diverticulotomy carries a risk of perforation and delayed bleeding [1].

We report here the case of a 94-year-old woman referred for endoscopic treatment of a ZD causing dysphagia for solids and liquids. We first introduced the diverticuloscope (Cook, Ireland) but the progression was difficult and the patient experienced a cough during introduction. We removed the diverticuloscope and noticed a large transmural perforation of the sinus piriform. However, before closing the perforation, we decided to perform the diverticulotomy without the diverticuloscope using the window technique[3]. After this, we tried to close the perforation but usual clipping appeared impossible, since it was difficult to catch the two edges of the defect. Therefore, as already described to close resected area after EMR [4], we placed the first clip with attached a rubber band on the lower edge of the perforation by folding the not perforated mucosa. Then, a second clip grasped the rubber band and was attached on the upper edge of the perforation. Due to elastic force, the margins of the defect were stretched and approached each other and the entire defect was closed with two additional clips. After 3 days of diet, patient feed again and was discharged at day seven. At one month after the operation, she was asymptomatic for dysphagia and no sepsis occurred.

In conclusion, the “clip-and-rubber band” technique allows to approach closely the edges of large perforation also in difficult positions such as the sinus piriform, thus facilitating the complete closure.