Endoscopic treatment of Zenker's diverticulum using a stag beetle knife.

Zenker’s diverticulum can be treated successfully using flexible endoscopy [1]. Several methods have been used to cut the septum of the diverticulum, such as LigaSure (Medtronic, Minneapolis, Minnesota, USA), needle-knife, and other submucosal dissection devices. Recently, isolated cases using the stag beetle (SB) knife dissector, SB jr 3.5mm, have been reported [2–4]. We present the case of a patient with a Zenker’s diverticulum who was treated using an SB jr (Sumitomo Bakelite Co., Ltd, Japan) – an unusual device for this procedure. A 72-year-old man with a history of chronic obstructive pulmonary disease was admitted to the hospital because of respiratory failure and weight loss. The patient had been experiencing progressive and severe dysphagia for several months. The barium study showed a Zenker’s diverticulum of 8 cm in size (▶Fig. 1 a). Dissection of the septum was planned. As the patient was a high anesthetic risk, the procedure was performed under sedation with midazolam and propofol controlled by the endoscopist, without tracheal intubation (▶Video1). Initially, a Zenker’s diverticulum overtube was not available, so we decided to perform the procedure using a hood and nasogastric tube with an SB standard 7mm knife. A PSD 60 Olympus Electrosurgical unit (Olympus, Tokyo, Japan) was used at Endocut mode 120W effect 1. The first current pulse was Forced coagulation 30W. However, the exposure of the septum was not adequate and after several cuts we decided to postpone the procedure until a Zenker’s diverticulum overtube became available. After several weeks, a Zenker’s diverticulum overtube was obtained and was placed over a guidewire that had been introduced into the esophagus under endoscopic view. When the Zenker’s diverticulum overtube was in place, the septum was perfectly exposed (▶Fig. 1 b), which allowed us to perform the procedure safely, quickly, and effectively. The procedure duration was 30 minutes and the length of the septum cut was 4 cm. The procedure was very well tolerated by the patient, with oxygen saturation of about 92%. E-Videos