P1805 - Successful Flexible Endoscopic Septotomy for the Treatment of Zenker’s Diverticulum After Failed Surgical Attempts

Award: Presidential Poster Award

Sanjay Palat, MD¹, Harsh Singh, MD², Mahmoud Y. Madi, MD³, Maya Mahmoud, MD⁴, Ahmad Najdat Bazarbashi, MD^5
1Washington University in St. Louis, St. Louis, MO; ²University of Missouri Kansas City, Kansas City, MO; ³Saint Louis University Hospital, St. Louis, MO; ⁴Saint Louis University, St. Louis, MO; ⁵Washington University in St. Louis/Barnes Jewish Hospital, St. Louis, MO

Introduction: Zenker’s diverticulum (ZD) is an acquired prolapse of the posterior pharyngeal wall in the hypopharynx. Historically, ZD was treated with surgical techniques including rigid endo-staplers and open transcervical approaches. However, these approaches lost their popularity due to the substantial rate of complications and risk of recurrence. As such, endoscopic septotomy has become an increasingly common approach with robust data on its efficacy as first line therapy. There remains a paucity of literature on patients undergoing endoscopic treatment of ZD after failed surgical intervention. We present a case in which a patient was treated with endoscopic septotomy of ZD after two unsuccessful surgeries.

Case Description/Methods:

A 65 year old man with a history of ZD previously treated with transoral staple myotomy and subsequent revisional transcervical cricopharyngeal myotomy with diverticular imbrication for recurrence presented to our clinic with dysphagia, regurgitation and weight loss. A Barium esophagogram confirmed recurrent ZD. Decision was made to proceed with flexible endoscopic zenker septotomy (Video 1). Endoscopy demonstrated a large ZD with impacted food and staples from previous surgery. Orogastric (OG) tube placement was unsuccessful due to narrow esophageal lumen; a 0.035” guidewire was then placed, and a 14 French OG tube was placed over the wire. With the OG tube in place, the septum was dissected using a scissor-type electrocautery knife (Endo Cut, Effect 1, Duration 1, Interval 1). Significant scarring was noted from prior surgery. During dissection, a staple was dislodged and retrieved using rat-tooth forceps. Three hemostatic clips were placed to reduce risk of post-operative bleeding and leak. The OG tube was removed and at the end of the procedure luminal diameter was significantly increased. Esophagram one day post-procedure showed improved contrast flow past the diverticulum without evidence of leak. At one month follow-up, he reported normal swallowing and ability to tolerate of regular diet.

Discussion: Endoscopic treatment of ZD has largely replaced surgical interventions as primary therapy, given high clinical success and low rates of adverse events. This case demonstrates that endoscopic septotomy is safe and feasible for the treatment of patients with ZD that are recurrent and refractory to surgical intervention. While scarring and staples may be encountered, endoscopic septotomy is still possible and should be considered in this patient population.


Disclosures:


Sanjay Palat, MD¹, Harsh Singh, MD², Mahmoud Y. Madi, MD³, Maya Mahmoud, MD⁴, Ahmad Najdat Bazarbashi, MD⁵. P1805 - Successful Flexible Endoscopic Septotomy for the Treatment of Zenker’s Diverticulum After Failed Surgical Attempts, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.