Modified overtube insertion technique to facilitate safe endoscopic cricopharyngeal myotomy for management of Zenker’s diverticulum

A 73-year-old woman with a history of progressively worsening dysphagia presented with the inability to tolerate solids or liquids. In the past month, she had lost 10 pounds (4.5 kg) of weight. Gastroscopy revealed a 2-cm Zenker’s diverticulum, located at 19 to 21 cm from the incisors and centered on the 9 o’clock position. Residual solid food was visualized within the diverticulum ([ Fig. 1 ]). We proceeded to perform an endoscopic Zenker’s diverticulotomy ([ Video 1 ]). Peroral endoscopic myotomy was not considered because of the short nature of the diverticulum. Fig. 1 Endoscopic diagnosis of Zenker’s diverticulum. a Residual food within the diverticulum. b Diverticulum after endoscopic cleaning. Quality: mobile 360 480 720 Download Endoscopic Zenker’s diverticulotomy performed for a symptomatic 2-cm Zenker’s diverticulum using a modified overtube insertion technique.Video 1 We first cleaned the diverticulum and then placed a 0.035-inch guidewire into the stomach. We used a Zenker’s diverticulum overtube (ZDO-22-30; Cook Medical, Bloomington, USA). The 40-mm length of the ZDO distal flap is designed to protect the anterior esophageal wall, whilst the 30-mm length distal flap protects the posterior diverticular wall. To help facilitate safe insertion of the ZDO we modify it by creating a hole using a 22G needle at the apex of the 40-mm length distal flap ([ Fig. 2 ] a, b ). The guidewire is then passed through the hole, allowing wire-guided insertion of the ZDO ([ Fig. 2 ] c, d ). Once placed correctly, the ZDO isolates the muscular septum ([ Fig. 3 ]). Fig. 2 a, b Using a 22G needle, a hole is created at the apex of the 40-mm length distal flap. c The 0.035-inch guidewire is inserted through the hole. d Wire-guided insertion of the Zenker’s overtube towards the diverticulum. Fig. 3 The Zenker’s overtube successfully isolates the muscle septum. The 0.035-inch guidewire can be seen along the anterior esophageal wall (yellow arrow). A complete myotomy of the cricopharyngeal muscle was then performed with the DualKnife J (Olympus, Tokyo, Japan). The myotomy defect was closed with 6 through-the-scope metal clips. Endoscopic evaluation post clip closure revealed complete flattening of the diverticulum and easy passage of the gastroscope into the esophagus. Within a few days the patient’s dysphagia for solids and liquids completely resolved. Freehand or cap-assisted endoscopic Zenker’s diverticulotomy can be technically challenging. The anatomical position of the diverticulum can result in endoscope instability and unstable endoscopic views. A ZDO can be placed to safely expose, stretch, and fix the septum, whilst also protecting the anterior esophageal wall and posterior diverticular wall. This allows a safer and more stable endoscopic myotomy [ 1 ] [ 2 ]. ZDO placement however can be difficult, even with endoscopic guidance. We present a simple modification to the ZDO that we have used for more than 5 years that facilitates an easier, more accurate, and less traumatic insertion. Endoscopy_UCTN_Code_TTT_1AO_2AP Endoscopy E-Videos https://eref.thieme.de/e-videos E-Videos is an open access online section of the journal Endoscopy , reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/ ). This section has its own submission website at https://mc.manuscriptcentral.com/e-videos . Publication History Article published online: 29 November 2024 © 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

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