Endoscopic myotomy in a case of Zenker's diverticulum complicated by recurrent pneumonia and myocardial infarction

A frail 85-year-old patient with atrial fibrillation on direct oral anticoagulants presented with fever and acute dyspnoe and was diagnosed with right upper lobe pneumonia. (Fig. 1A) The patient´s condition stabilized on antibiotics. However, the detailed history included un-investigated dysphagia and nocturnal regurgitation of food was reported. Zenker´s diverticulum was confirmed by esophagogram suggesting a 60 mm hypopharyngeal pouch (Fig. 1B), reproduced on endoscopy (Fig. 1C; arrow esophageal entrance) with food retention at its base. (Fig. 1D) Endoscopic myotomy was scheduled two weeks later to allow for pneumonia resolution. However, the patient was readmitted three days prior with recurrent aspiration pneumonia. The patient additionally reported chest pain with troponin dynamics, suggesting non-ST elevation myocardial infarction. The patient underwent interventional coronary revascularisation with implantation of two drug-eluting stents with triple antithrombotic treatment until discharge. In this complex scenario, the patient was trained by speech therapy and instructed to only eat soft meals, avoid late meals and post-prandial recumbency. Endoscopic treatment was provisionally postponed for three months in case peri-interventional bleeding complications may arose. As a consequence, the patient did not experience further pulmonary complications and presented for endoscopic myotomy under the P2Y12 inhibitor clopidogrel, while apixaban was withheld 24 h. Endoscopic myotomy using a transparent cap to facilitate endoscopic maneuvering started with mucosal incision over the cricopharyngeus muscle, the fibres of which were rapidly identified underneath. (Fig. 2A) The whole procedure was performed using an articulating knife allowing for rapid and precise transection (ClutchCutter device, Fuji, Düsseldorf, Germany). (Fig. 2B) Despite the large size, a complete myotomy, was performed within an estimated 15 min without complications and with complete resolution of the diverticulum. (Fig. 2C) The postinterventional course was unremarkable. At clinical follow up after three months, the patient reported complete absence of dysphagia.

Pneumonia and dysphagia are increasing health issues in the aging population. The relationship between Zenker´s diverticulum and aspiration pneumonia is well established. Other symptoms may include dysphagia, regurgitation, cough and weight loss. Overall, the prevalence in the United States is estimated at .01-.11 % with more males in their seventh and eighth decade affected. Once a diagnosis has been established, endoscopic myotomy has emerged as the first-line treatment due to reduced recurrence rates and lack of the need for extreme neck extension relative to transoral stapling by otolaryngologists. However, open surgical approaches, such as cervical transcervical myotomy with diverticulectomy or diverticulopexy, remain a valid option in selected cases.^,