A 65-year-old asymptomatic man underwent screening esophagogastroduodenoscopy before
treatment for tongue cancer. Standard gastroscopes (GIF-H290Z and GIF-H290; Olympus)
could not pass through the cervical esophagus. However, an ultra-slim gastroscope
(GIF-XP290N; Olympus) was able to pass through and revealed a Zenkerʼs diverticulum
([Fig. 1 a, b]). A superficial esophageal cancer was detected in the upper thoracic esophagus ([Fig. 2]). Biopsy specimens from the lesion showed squamous cell carcinoma. The patient opted
for endoscopic submucosal dissection (ESD), which requires standard gastroscope insertion
([Video 1]).
Fig. 1 a, b Zenkerʼs diverticulum on the left wall of the cervical esophagus.
Fig. 2 A slightly elevated iodine-unstained lesion in the esophagus on the anal side of
the Zenkerʼs diverticulum.
Video 1 Demonstration of guidewire-assisted technique for standard gastroscope insertion
through Zenker's diverticulum for esophageal endoscopic submucosal dissection.
An ultra-slim gastroscope was introduced through the stricture of the Zenkerʼs diverticulum.
A 0.035-inch guidewire (Hydra Jagwire; Boston Scientific Corporation, Marlborough,
Massachusetts, USA) was advanced and kept in the stomach through the accessory channel
of the ultra-slim gastroscope after its withdrawal ([Fig. 3]). Subsequently, a straight catheter was placed in the accessory channel of the standard
gastroscope. The guidewire was inserted from the tip of the gastroscope through the
catheter in a retrograde fashion. This procedure allowed for scope exchange. The standard
gastroscope passed the stricture of the diverticulum through the guidewire, but the
gastroscope was not able to pass through even with an endoscopic cap. Thus, ESD was
performed without the endoscopic cap using ESD knives (Dual Knife J and IT-knife nano;
Olympus). The lesion was successfully resected en bloc uneventfully ([Fig. 4], [Fig. 5]).
Fig. 3 A 0.035-inch guidewire was advanced and kept in the stomach through the accessory
channel of the ultra-slim gastroscope and the gastroscope withdrawn.
Fig. 4 Endoscopic peripheral markings were performed around the lesion.
Fig. 5 The lesion was resected en bloc uneventfully.
Zenkerʼs diverticulum is a rare anatomic defect characterized by herniation of the
mucosa and submucosa through the Killian triangle located in the esophageal cervical
region. They are usually asymptomatic, but dysphagia, aspiration pneumonia, and stricture
may occur as the diverticulum expands. Endoscopic diverticulotomy has been indicated
for symptomatic Zenkerʼs diverticulum [1]
[2]. In our case, the standard gastroscope could access the lesion beyond the Zenkerʼs
diverticulum, and ESD was performed without endoscopic diverticulotomy. We demonstrate
a method that could be utilized for advanced endoscopy in patients with asymptomatic
Zenkerʼs diverticulum [3].
Endoscopy_UCTN_Code_TTT_1AO_2AH
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