Zenker’s Diverticulum: Endoscopic Staple-Assisted Diverticulotomy

CHAPTER 1

All right, so we're going to try and get exposure over our esophageal inlet and the Zenker's opening using the large Weerda scope. So we're working our way down towards the esophageal inlet, posterior to the larynx. Once you're there, then open up and see if we can advance in to get a good view. What - you want to open it up some more? Not yet? We want to open that as wide as we can so we can get our instruments inside. You'll have to do both. That's the nice thing about the Weerda too, you have your 2 points of opening. Yes. You still have a good view? Yeah, want to take a look? Yeah, but let's make sure we're good and open. You've got that scope, Dave, if you want to show through on the screen. To your left there. Get that out of the way. Do you have maybe the open tip? That's a lot of debris. Clean up the debris, and then we can get a better visualization of our common wall, esophagus, and pouch. She does have a wide opening on the barium swallow. I'm surprised she doesn't have a pneumonia. All right, so that looks like you are in the pouch. And the esophageal lumen is likely up there. So what we need to - you can try, by opening this up some more. It's possible you may have to slightly adjust it a little bit more, you can try with a - spatula, just to see if you can feel into the esophagus, but that looks like you are - it's a wide-mouth diverticulum. What do you feel up there? That still feel like wall? It does still feel like wall. Okay, so we might have to back up. Back it up and then... Yeah. Okay, that's - there you go. Okay. There we go. That's better, yeah. So that's our common wall. There's our esophagus anteriorly. That's the pouch that you just cleaned. So, feel with your spatula up there, just to confirm that - you can pass easily into the esophagus. No obstruction at all. No, no obstruction. Good. You can go ahead and open up the suture. So what we want to do now is, we're going to want to get a stay suture.

CHAPTER 2

And let's make sure we're as wide as we can be here. We're going to want your one suture over here, one suture on this side of the common wall, so we can have some retraction as we put in our staple. We'll take a picture of this for the family. Have you put in staples before? No. All right, well let me show you one. Of course. So I've just adjusted this a little bit more. Tell me when. All right, that's good. I just moved the scope back just a little bit so we have more room to manipulate that common wall to get our sutures in place. Okay, so the way the sutures work. This switches - you have to squeeze that, but this switches where the - the needle goes, with this little device here. And so it's always best to - come in from the pouch side with the needle, and up, and then once you're there, then you switch it, and you often have to kind of twist - this - so that the suture is going posteriorly to twist to get it out. And you put these out as laterally as you can. As lateral as we can go, so that we have room in between to get our staple in. So there's my suture. So I'm going to try and slide as laterally as I can in here and engage, then flip the suture. And then we have to do kind of a little twist to get that suture out. And then what we'll do is we'll cut this end here. And then a hemostat, please? And so there is one of our sutures. And so - we now want to get one kind of in this area over here and then we should have ample room to go in between to put our staple. So, suture coming in from the pouch, and see if you can slide in as much as you can, and sometimes - we'll see - it's possible I didn't engage the muscle enough, I might redo my suture, but let's - you have enough traction there to go ahead and get yours in. We don't want to pull through the mucosa. So I'll take a feel of that. Mine looks - maybe it's not quite as deep as I thought I was. So you have to… Yep, so you want to go in like that, so you have to close it a little bit. And then you'll slide in, and then switch it. Okay. Cool. Okay? So go as laterally as you can. So close it a little bit so you can get in there. That looks good. It looks better than mine. Good, so close. Okay, I'll switch it for you. Thanks. Okay. And then come out, and then take that top tine - yep. A little twist - okay, good. Good. Scissors, please. And then a hemostat. Now, your suture - looks better positioned than mine. Mine looks a little too superficial. So we're going to take out this suture and redo it. One more suture, please. One more suture coming in. See how mine was a little superficial? And yours is - you've got good engagement of the muscle. So yours will have better retraction than what we had at first, so - it's all about the set-up. So take the time to make sure you have what you want. If we're pulling and we shred and have a little hole, or a tear, we don't want that. So we're going to redo that. So, close the instrument a little bit to get down where you need to be. We're going to try and slide out laterally. As lateral as you can. Yep. And then swing that inferior tine - that looks better. Okay, close. Are you closed? Yep, closed. I'll switch the needle for you. Okay. Good. Yep, nice, gentle twists, and it will come. You're good. It's coming. Yep. Keep twisting. There you go. There you go, good. Maybe a touch better, but not too much. I think it's better. Take it out. Scissors? Okay, and we're going to take a staple. So now we have good retraction and better positioning of your - that left lateral suture. Now we're going to get our staple device.

CHAPTER 3

And the staple device is going to go right in between these two. So these sutures allow us to have a good purchase so that as we push the staple in, we can retract the common wall towards us proximally, and that will allow us to engage the common wall. Because the key is to have a complete division of the upper esophageal sphincter. And so, the way this works - This allows you to twist the orientation here and we always have the staple, the blue part, in the lumen. Okay. This closes. Okay. And then this one fires. Okay. But we don't do this until we are 100% positioned and certain of where we want to be. Okay. So we go in like this. The assistant will hold some gentle traction on the sutures. You'll have to close it a little bit to engage. Okay. And then you just want to advance it as far as you can. And sometimes you need more than one staple line, which we'll find out once we're done, but most likely we'll need at least two, looking at this Zenker's here. Is it a ratcheted firing, or is it just a single application? A single application. So you have to close that a little bit to get it in there. Good. And then as you get close - perfect. So we're going to engage. So now you can open up all the way. You want to just gently slide that in a little bit more if you can. I'm holding good traction here. And then as far as it can go, then we'll stop then we'll fire this one. Can you get it any further in, do you think, or - does it feel about as...? I was hoping to be able to get a little bit more, but… Okay, well we can start here. So go ahead and close. Now, yep, pull the blue all the way down. Good. Now before you fire - we're good on that side, look at the other side. That looks perfect. Okay. Okay, so we'll get your camera back so we can see. Okay, and then it's a nice - you want to squeeze that all the way in. Keep going, all the way. All the way. You all the way squeezed? Yep. Okay, then you can let go of that one. And then you're going to release the top blue. All the way up. Good, and then you should be able to slide out. Good. And so there's our first division. So that's good, but we're going to take one more staple line. Looks good. Just so we can get a little deeper, go ahead into the pouch there. So we can see lumen. Yeah. But if we can get this division to be a little bit more towards that base, we're going to see if we can slide in more with a little bit more retraction of our common wall. This is why the staple's nice. We've divided it and we've sealed as well. Okay. So one more good placement of that staple cartridge and that should be complete. You're going to need to retrieve past some of those loose staples. Yeah, so go ahead and - you can see a loose staple right there, go ahead and take that out. It's a nice division though. Good. So again, close it a little bit and make sure it works and opens. Good. Okay, so I'm holding gentle traction as you slide that in as far as it'll go. Okay, that feels good. Go ahead and take it. Close it all the way. Good. And then confirm that you're good, look at the other side. Good. Okay. And then fire. Firing. All the way. Good. Let go. Releasing. Yep, open up the - device all the way. Good. And you can come on out. Great. Okay, so take that out. Maybe - a little bit. So just be a little bit gentle pushing. Okay. But we do want to get a sense of - is there room for more, or - how are we doing? Because we do have this retracted. All right, let me just take a quick look and feel as well, see if we want to do one more staple line or not. And I'll take the suction. So that's all divided there. So we've got division all the way - to there. So if something came here, it should - and there's always a little - the staple line doesn't go all the way to the very bottom. Makes you wonder if you can get one more little… Because there's your last staple, is right there. And that's the bottom. So that's pretty darn good. Let me just see what one more would feel like. If there's any way to get a tiny bit more, just to try to minimize any residual symptoms. Let's just see what it feels like here. So I'm trying to push that down. Okay, give me a little gentle traction now. All right. I think that's about as far as we can go. I'm going to fire. We'll get rid of those excess staples. Here you go, Audrey. And I'll take suction. I'll get rid of those staples in a second, but let me just look. There's a staple right there. So we're divided all the way down now to really that esophageal inlet, which is right here. Mm hmm. So that was a big common wall because we started all the way up here. Yeah. So I think we have a good division there, let me just clean up these staples. And then we'll cut our sutures and take a last look. All right, let's take out our sutures here.

CHAPTER 4

I'll take a scissors, please. No - give me a longer scissors, just so I can cut it closer to - where it's going in. And then I'll take suction. And so, that shows our division from the base right into the esophagus there. But that big wall is all divided there. So again, just showing - so now we have a pouch that should lead into the esophagus there a lot more easily than before. Okay.