Endoscopic submucosal dissection with metal clip closure for the treatment of a mid-esophageal diverticulum: a case report

Currently, the primary technique employed for endoscopic treatment of a mid-lower esophageal diverticulum is diverticular peroral endoscopic myotomy (D-POEM) [1] [2]. The surgery dissects the diverticulum septum through a submucosal tunnel, thereby preventing food and liquid retention. However, the pouch persists and may continuously cause symptoms [3]. Since 2023, our team has been innovatively utilizing endoscopic submucosal dissection (ESD) with metal clips to treat Zenker's diverticulum and reporting corresponding complications [4] [5]. Here we further applied the surgery to treat a mid-esophageal diverticulum and ultimately resolved the symptoms.

The case presented a 54-year-old man diagnosed four years previous with a 2.0-cm mid-esophageal diverticulum and adjacent mucosal high-grade intraepithelial neoplasia underwent endoscopic submucosal dissection (ESD) treatment and recovered satisfactorily. After discharge, the patient occasionally experienced 5- to 10-minute episodes of chest pain, tightness, and palpitations, relieved by rest. Angina was suspected, but percutaneous transluminal coronary angioplasty did not alleviate it. Symptoms worsened over the past month, becoming more frequent and severe. An upper gastrointestinal barium radiography revealed a 3.0-cm mid-esophageal diverticulum ([Fig. 1]). Considering the symptoms are caused by the enlarged diverticulum pressing on the heart, D-POEM may result in esophageal cystic dilation, which remains near the heart and poses challenges in relieving symptoms. ESD was therefore performed ([Video 1]).

Fig. 1 Preoperative upper gastrointestinal barium radiography showed a 3.0-cm mid-esophageal diverticulum.

Endoscopic submucosal dissection with metal clip closure to treat a mid-esophageal diverticulum.Video 1

After marking the surrounding mucosa of the esophageal diverticulum and submucosal injection, we gradually dissected the mucosal and submucosal layers inside the diverticulum ([Fig. 2] a–d). Significant adhesions at the diverticulum base limited dissection space. The mucosal layer was excised in two stages using a snare trap ([Fig. 2] e,h). Finally, we use through-the-scope twin clips (TTS-TCs) and multiple metal clips to close the diverticulum and repair the esophageal muscular layer ([Fig. 2] f,g). The patient had no chest tightness or fever post-operation and experienced less severe chest pain than before. Repeat upper gastrointestinal radiography showed resolution of the esophageal diverticulum ([Fig. 3]). The patientʼs preoperative symptoms disappeared and did not recur within a month on a regular diet.

Fig. 2 Endoscopic submucosal dissection with metal clip closure for mid-esophageal diverticulum. a The mid-esophageal diverticulum. b Marking the surrounding mucosa of the opening of diverticulum. c Circumferentially incising the mucosa around the opening of diverticulum. d Dissecting the submucosal layer inside the diverticulum. e Excising the mucosal layer with a snare trap.  f Residual cavity of diverticulum. g Closure of the muscle layer at the opening of diverticulum. h Excised specimen of diverticulum.

Fig. 3 After 48 hours, upper gastrointestinal radiography showed resolution of the mid-esophageal diverticulum, and no contrast agent extravasation was observed.

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Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

We would like to express our heartfelt gratitude to all team members for their exceptional collaboration and invaluable contributions. Without their collective efforts, this work would not have been possible. We sincerely thank everyone who has dedicated their time and wisdom to this paper.

• References

• 1 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
• 2 Kamal F, Khan MA, Lee-Smith W. et al. Peroral endoscopic myotomy is a safe and feasible option in management of esophageal diverticula: Systematic review and meta-analysis. Dig Dis Sci 2021; 66: 3242-3249
• 3 Albéniz E, Estremera-Arévalo F, Gómez Alonso M. et al. Peroral endoscopic myotomy, septotomy, and restoration of esophageal lumen with over-the-scope clips: closing the circle of esophageal diverticula management. Endoscopy 2022; 54: E666-E667
• 4 Chen N, Shi L, Ge J. et al. Endoscopic mucosal dissection with metal clip closure for esophageal Zenker diverticulum: a case report (with video). Chin J Dig Endosc 2023; 40: 930-932
• 5 Shi L, Long F, Xu H. et al. Chronic esophagotracheal fistula secondary to esophageal diverticulum successfully treated by endoscopic submucosal dissection and dual action tissue clip. Endoscopy 2023; 55: E1128-E1130

Publication History

Article published online:
04 September 2024