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Endoscopy
Endoscopy
10.1055/s-00000012
Endoscopy
Endoscopy
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10.1055/a-2387-4290
E-Videos-2024-06-5153-EV
E-Videos
Endoscopic submucosal dissection with metal clip closure for the treatment of a mid-esophageal diverticulum: a case report
http://orcid.org/0009-0001-9308-552X
Wang Zhenghua
Bai Bing
Jiang Junmei Dr.
http://orcid.org/0000-0001-8118-5307
Xu Hongwei Prof.
Zhao Qi Dr.
Li Bin MD
1 34708 Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
2 Digestive Diseases Hospital of Shandong First Medical University, Jining, China
Correspondence Bin Li, MD Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University324 Jingwu Weiqi RdJinan, Shandong, 250021Chinathin2002@163.com
04 9 2024
12 2024
1 9 2024
56 Suppl 1 E768E769
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/).
2024
The Author(s).
https://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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pmc Currently, the primary technique employed for endoscopic treatment of a mid-lower esophageal diverticulum is diverticular peroral endoscopic myotomy (D-POEM) 1 2 . The surgery dissects the diverticulum septum through a submucosal tunnel, thereby preventing food and liquid retention. However, the pouch persists and may continuously cause symptoms 3 . Since 2023, our team has been innovatively utilizing endoscopic submucosal dissection (ESD) with metal clips to treat Zenker's diverticulum and reporting corresponding complications 4 5 . Here we further applied the surgery to treat a mid-esophageal diverticulum and ultimately resolved the symptoms.

The case presented a 54-year-old man diagnosed four years previous with a 2.0-cm mid-esophageal diverticulum and adjacent mucosal high-grade intraepithelial neoplasia underwent endoscopic submucosal dissection (ESD) treatment and recovered satisfactorily. After discharge, the patient occasionally experienced 5- to 10-minute episodes of chest pain, tightness, and palpitations, relieved by rest. Angina was suspected, but percutaneous transluminal coronary angioplasty did not alleviate it. Symptoms worsened over the past month, becoming more frequent and severe. An upper gastrointestinal barium radiography revealed a 3.0-cm mid-esophageal diverticulum ( Fig. 1 ). Considering the symptoms are caused by the enlarged diverticulum pressing on the heart, D-POEM may result in esophageal cystic dilation, which remains near the heart and poses challenges in relieving symptoms. ESD was therefore performed ( Video 1 ).

Fig. 1 Preoperative upper gastrointestinal barium radiography showed a 3.0-cm mid-esophageal diverticulum.

Endoscopic submucosal dissection with metal clip closure to treat a mid-esophageal diverticulum.

Video 1

After marking the surrounding mucosa of the esophageal diverticulum and submucosal injection, we gradually dissected the mucosal and submucosal layers inside the diverticulum ( Fig. 2 a–d ). Significant adhesions at the diverticulum base limited dissection space. The mucosal layer was excised in two stages using a snare trap ( Fig. 2 e,h ). Finally, we use through-the-scope twin clips (TTS-TCs) and multiple metal clips to close the diverticulum and repair the esophageal muscular layer ( Fig. 2 f,g ). The patient had no chest tightness or fever post-operation and experienced less severe chest pain than before. Repeat upper gastrointestinal radiography showed resolution of the esophageal diverticulum ( Fig. 3 ). The patientʼs preoperative symptoms disappeared and did not recur within a month on a regular diet.

Fig. 2 Endoscopic submucosal dissection with metal clip closure for mid-esophageal diverticulum. a The mid-esophageal diverticulum. b Marking the surrounding mucosa of the opening of diverticulum. c Circumferentially incising the mucosa around the opening of diverticulum. d Dissecting the submucosal layer inside the diverticulum. e Excising the mucosal layer with a snare trap.  f Residual cavity of diverticulum. g Closure of the muscle layer at the opening of diverticulum. h Excised specimen of diverticulum.

Fig. 3 After 48 hours, upper gastrointestinal radiography showed resolution of the mid-esophageal diverticulum, and no contrast agent extravasation was observed.

Endoscopy_UCTN_Code_TTT_1AO_2AP

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Acknowledgement

We would like to express our heartfelt gratitude to all team members for their exceptional collaboration and invaluable contributions. Without their collective efforts, this work would not have been possible. We sincerely thank everyone who has dedicated their time and wisdom to this paper.

Conflict of Interest The authors declare that they have no conflict of interest.
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References

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