Gastrointestinal: Endoscopic septoplasty for Zenker's diverticulum in a nonagenarian

This case reports on an elderly patient with symptomatic Zenker's diverticulum who was successfully treated with endoscopic septoplasty. A 91 year old male presented with recurrent dysphagia to solids, regurgitation associated with coughing and choking attacks. The symptoms had been present for approximately 12 months and were recently becoming more bothersome. Barium swallow suggested a Zenker's diverticulum (Figure 1a). Initial oesophagogastroduodenoscopy (OGD) confirmed a 20 mm Zenker's diverticulum with some retained food debris. The patient was referred for a surgical opinion, however he was deemed not to be a surgical candidate. The surgical team referred the patient to our unit for consideration of endoscopic treatment. We repeated OGD under conscious sedation with titrated doses of Midazolam and Fentanyl and identified the diverticulum (Figure 1b, black arrow) and the septum (Figure 1B, white arrow). After insertion of a nasogastric tube into the stomach we performed endoscopic myotomy with a needle knife (Figure 1c, white arrow). When the myotomy was completed an Olympus endoclip was placed at the apex of the incision. The patient was discharged from hospital on the same day without any complication. Due to residual symptoms, the procedure was repeated three months later and the myotomy extended. Following the second procedure he had complete symptom resolution and was able to consume a normal diet. He has remained symptom free after 18 months of follow-up. Surgery is the mainstay of treatment for patients with a symptomatic Zenker's diverticulum and is associated with symptom resolution in up to 96%. The surgical options include open diverticulectomy or diverticulopexy with cricopharyngeal myotomy or alternatively endoscopic stapling. In symptomatic non-operative candidates or patients unwilling to undergo surgery, endoscopic Zenker's septoplasty is safe alternative with acceptable outcomes. Studies report complete symptom resolution in up to 82% of patients and a low complication rate with major complications (perforation, neck abscess) in 1.6% and minor complications in 6.1%. Mortality from this procedure has not been reported in the literature. Due to the nature of the procedure there is a learning curve, however this learning curve is unknown, and the opportunity for training is limited. An animal model has been described that may allow for further training in this technique and potentially more widespread application. Contributed by

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