Lost in the Giant Diverticulum - A Turn in Time of Need

Abstract

Background Large Zenker's diverticulum (ZD) forms in a midline (posterior to esophagus) and compress the esophagus. Therefore, visualization of the esophageal inlet (EI) is sometimes not possible doing endoscopy in left lateral decubitus position. Under direct vision the catheter/guidewire can be advanced through the endoscope into the EI followed by insertion of endoscope over the catheter/guidewire (where the EI is visualized). Swallowassisted advancement of catheter/wire blindly into EI followed by insertion of endoscope has been described in case of non-visualization of EI. Aim To describe a novel technique of esophageal intubation in a patient of giant ZD. Methods and Result A 70-year-old female presented with dysphagia, weight loss and cachexia. Barium swallow and CT-scan demonstrated a massive ZD (size 10.18 × 6.52 cm) that reached up to the level of aortic arch. Endoscopy attempts were unsuccessful due to preferential passage of endoscope into the diverticulum. The patientwas then turned to the supine position and the slight angulation of endoscope and gentle pull back manoeuvre (nearly similar to ileocecal valve intubation) in the diverticulum was done to locate EI. We succeeded in visualization of EI and esophageal intubation. We didn't use sedation to reduce risk of aspiration. A nasogastric tube was inserted (over a guidewire) into the stomach. Conclusion We described is a simple technique (without fluoroscopic assistance) for esophageal intubation in one of the largest reported case of ZD. This method should be tried first. Compression of the esophagus is reduced in supine position and thus facilitates visualization of EI.