Endoscopy 2021; 53(09): E318-E319
DOI: 10.1055/a-1273-7390
E-Videos

Endoscopic stag beetle knife treatment for symptomatic Zenker’s diverticulum

Epifanio Silvino do Monte
Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
,
Edson Ide
Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
,
Vitor Massaro Takamatsu Sagae
Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
,
Igor Braga Ribeiro
Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
,
Mateus Pereira Funari
Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
,
Pedro Victor Aniz Gomes de Oliveira
Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
,
Eduardo Guimarães Hourneaux de Moura
Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
› Author Affiliations
 

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 [1]. 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 [2].

Flexible endoscopic treatment, preferred over open surgical treatment, is the first-line therapy for patients with a symptomatic Zenker’s diverticulum of any size [3]. 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. [4] and Goelder et al. [5] 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.

Zoom Image
Fig. 1 Barium study demonstrates a 1.7- × 1.0-cm diverticulum arising from the posterior wall of the upper esophagus.

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.

Zoom Image
Fig. 2 Endoscopic views, left to right: before the procedure; stag beetle (SB) knife grasping the septum; septum division using the SB knife; after septum division.

Video 1 Endoscopic stag beetle knife treatment for symptomatic Zenkerʼs diverticulum: a safe and feasible approach.


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Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Igor Braga Ribeiro, MD
Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
Av. Dr Enéas de Carvalho Aguiar, 225, 6o andar, bloco 3
Cerqueira Cesar
ZIP Code 05403-010 – São Paulo, SP
Brazil   
Fax: +55-11-26616467   

Publication History

Publication Date:
19 October 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Barium study demonstrates a 1.7- × 1.0-cm diverticulum arising from the posterior wall of the upper esophagus.
Zoom Image
Fig. 2 Endoscopic views, left to right: before the procedure; stag beetle (SB) knife grasping the septum; septum division using the SB knife; after septum division.