So this is a case of a 76-year-old male with a history of progressive solid food dysphagia over the past two years. He's had associated regurgitation and undigested food in his mouth when waking up. His outside endoscopy report mentioned a narrow stricture with inability to traverse the scope. He underwent a barium esophagogram, which showed a large diverticulum in the cervical esophagus. The differentials to consider include a Killian-Jameson diverticulum versus a Zahnker's diverticulum. The plan is to perform an upper endoscopy with a possible Z-pulling procedure. Over to Dr. Kashab. Okay, so Olympus gastroscope, soft cap, see here, this is the septum. We have a Zahnker's diverticulum, ulcerated at the bottom, probably stasis ulcer, or a medication that got stuck here, caused an ulcer, and the esophagus looks good. So we're going to tunnel over the septum. You know, when we started doing Z-pullings, we were tunneling here in the hypopharynx towards the septum, and closure was difficult. So I think we have a little bit of noise issues, guys. You know, with these masks are creating a lot of, you know, issues, but we can't take them off, unfortunately. So I'm going to inject over the septum here. Let's put a needle out, please. This is, okay, inject, please. I'm going to inject about five cc's. Hold on. Inject. Yes, that's better. Go ahead. So just injection, followed by incision over the septum, more and more, followed by tunneling on the right and the left of the septum, to expose the whole thing, stop. And then we do the septotomy itself. So... Roween, any concerns about tunneling with that ulcer there? Yeah, you know, I'm at the bottom of the septum. We might have issues with tunneling, yes, but we'll see what happens there. But the good thing is at the bottom. So hopefully we should be able to complete the myotomy. I personally have never seen an ulcer at the bottom of the septum. That's a little surprise there, but, you know, things happen. So now I'm going to use the TT knife to, like I showed you before, for incision and tunneling. And then for the myotomy, we'll use the, although we can use the TT knife, but I'm going to show you the use of the scissor-type knife that is, I think, works really, really well for Zanker's outlease. So we're using Endocut Q for the incision. When I get down to the submucosal layer here, just a straight cut, up and down the septum. Maybe a little deep there. These come in different shapes and orientations, et cetera. So not all the poems are the same. So you see pretty thick septum here, and we'll see some submucosal tissue. And here, they call this trimming, just some trimming to create some space. So by that, you mean going underneath the mucosa and just dissecting a little so you can get the cap in? Yeah, exactly. So basically creating space, submucosal space, to get into the tunnel. So Moin, is your incision horizontal? I can't hear you well, Amol. I can't hear you well. He was wondering if your mucosal incision was horizontal or longitudinal along the septum. Yeah, so this is the septum here. So it was a longitudinal incision. You know, the septum in here, it wasn't very symmetric or straight. There's a little bit of deviation to the septum, but that's actually not uncommon here. So I'm just trying to now use my cap to get in. And here we are. So you see, I'm just flooding with water to help me get in. We can, of course, enlarge the incision, but I feel I can get in without that. You see the septum there, guys, right? Yeah, we can see that very well. Okay. So now we are almost in. The mucosa here is very thin. So I'm going to be gentle with pushing and pulling. So now we are inside the tunnel and you see the septum here, right? So now we are on the esophageal side and this is here very similar to a poem. So I'm just going to tunnel close to the muscle as we talked before to protect the mucosa. And here we go. So here you can't tell anything in terms of like, people ask me how much you go here. This is an estimate, but later on we'll be able to tell more. So the tunnel, the septum is about two or three centimeters. So here I'm just going to go maybe four centimeters, but there's no limit here, right? So here if you tunnel, continue to tunnel, there's the injection through the scope, guys. I mean, I make you believers today. Very different, very different submucosa than what you were struggling with in the poem. Yeah, that wasn't the easiest one, but it was a good, I think, example of advanced echolasia what we can do. So now we're coming to the other side of the septum. So you know, the first side, we finished it already. So this here, we're seeing some splitting guys already, huh? See that? Wow. Yeah. So this is very important because the septum is like a double septum and you don't want to miss any muscle. So this is a little weird, but I've seen it with large septum. So with large septum, you see a lot of splitting and it's like double. You see this with, but here just for orientation purposes, we're going to come out by a verticulum on this side here. This is the esophageal lumen. And this is the tunnel here on the esophageal side. This is the septum. You see how this is thick septum and you see here, it's trying to split. And that is a phenomenon that happens. So this is where our eye is on it and when it splits, we want to make sure we go after it and also cut it eventually. So here it's harder to know how deep you want to go on this side. So what I suggest is just a little tunneling to have space for your knives and then start your myotomy. Once you start your myotomy, you can figure it out and it becomes really easy. So give us the SB knife, please, and we'll start the myotomy right away. This shouldn't take too long. This double septum is a great example of one of the advantages of using a Z-POM poem technique for zenkers versus the classic, which leads to the question of, have you converted for all of your zenkers to a poem technique or are there any factors that you look at to make the decision of how you're going to treat those patients? Yeah. So always, I like to do this technique just because it gives me better exposure of the septum and I know what I'm doing. It's not blind. So let's rotate slowly, please. So this, okay. Open up. Just don't close, please. Open. It's fine. It's fine. So rotation with this knife can be a little close. So here I'm using endocut cue while pulling and this is the rest of the septum here, open. So keep it like that, please. Just rotate slowly so that it doesn't go like a helicopter on us here. Good, good. Excellent. So here we, of course, the beauty of the tunnel is like we, the mucosa is away from us, close. So we don't want to make sure we're not capturing mucosa and we just go. The other part of this knife that's is good is that the cutting part is just on the internal portion of the scissors. Is that right? The external side that might be- Yeah, that's what they say. But if you do this, you see it cuts. So yeah, just be careful with that. That's important. Yeah. So here we're just going to catch. So it's very close. It's very thick. So when it's split, I'm unable to capture both, but we're going to go after it. We're using endocut cue here. The nice thing about this knife, you just don't see bleeding or much bleeding. Open, please. This is nice demonstration, Dr. Kashyap. Dr. Nam is almost done with the EST. He will go to Dr. Nam now. Okay, guys. So we finished this myotomy soon after you left, and we just wanted to show you the end of it. Of course, here we can go deeper. I'll say this is maybe five centimeters and the Zenker is maybe three. So we did extend. Here, in terms of anatomy, just to inject this blue dye so that I show you. So this is like esophageal muscularis propria. We have the mucosa, submucosa, and adventitia on this side. So once you cross the diverticulum, you're in the upper esophagus, and anatomy is pretty easy. And now this is the longitudinal incision here, and we just have to close it, and this is the diverticulum. Enlarge the diverticula, where there's a huge mucosal, redundant mucosa. I do a mucosal incision. Here, it's not very large, so I've decided not to do it today. So the way I'm going to approach this incision, I use the Microtech clips. And the reason for that, they have a short stem or short stalk, so they do allow you to visualize well the entire lesion or the entire incision, even after you place them. Open. So here, I'm starting with the largest through-the-scope clip on the market. It's called the Locado clip from Microtech, and it is 22 millimeter. It's a humongous clip. You have to be careful with it, so that we don't over-close things. Close here, please. Let's see how it responds. Okay, good. Stay there. So here, we have opportunity to look at it, and it looks good to me. What do you guys think? Looks great. Go ahead. Yeah. Okay. Next, let's continue with the 17th. So I'd like to start with a 20 or 22 millimeter. It's called Locado clip, and then continue with the other sizes. This is just to get things together, the edges together, and then go to the right of it and left of it, and continue the incision. I will say mucosal incision closure was a little harder than esophageal poem, but it got much easier once we started using these clips, and once we started tunneling over the septum. What size this is now? 16? Okay. So this clip comes in 8, 11, 16, and 22 now. Open. So let's just see if we can rotate this. And you chose the clip with the shorter arm because of the proximal location? Yeah. So two reasons. Let's turn a little bit here. Just slowly, please. And less foreign body sensation, but also look at this small space we're working with. If you're using a clip with a bigger or longer stem, it becomes an issue. Visualization can become really difficult. So that's why I like to stop there, stop rotating. So the one negative thing here with this clip is that you don't control the rotation, like, for example, with the resolution 360. And so the control is a little less optimal than the other ones. Let's close here. Open. Okay. So you see how it goes crazy on you. But I still use them just because of the short stem. I think here the other side is almost closed. Open. Okay. So let's have it horizontal, please, like that. So how often have you needed to do a mucosal incision, Mohin, on the diverticular side? I mean, do these patients come back with dysphagia because of the mucosal bridge, or does it Yeah, that's what I mentioned initially. So we do that with large diverticula. So if something is like larger, please rotate. Continue to rotate here. If larger than four, we've been doing it. Mind you that for somebody starting this procedure, the closure is going to be, stop rotating. The closure might be more difficult. So here we got to this edge, which is really important. Here you don't want to leave any incision that's open. Close. Good. Take it. Okay. Let's continue with these 17s, 16s. And you know, the other thing is, I like these clips to be very close to each other, because some kind of ischemia to this mucosal bridge that Amol is talking about. And what you do is, if you repeat each of these, you see the retraction of this skin. You know, we've been doing this now since 2017, done a bunch of them. And I think for anything less than three to four, I haven't found the need to do a mucosal incision. And Moin, if you had decided to do it for this, if it had been a large diverticulum, talk a little bit about where that would have been and, you know, what your technique would be to do that. Close. Hold on a second. Open a little bit. So we got the mucosa there. So we just have to be careful here. Close. Okay. Take it. Next. So that's a very good question, Amrita, because like this diverticulum is a little asymmetric. So you want to go where the longest axis of the diverticulum is. And this is where you want to cut the mucosa. So here you see this diverticulum is a little deviated. And it's not uncommon to see that. Just pay attention to the long axis. Similar when you do a standard surftotomy, you want to find the long axis and cut it there, rather than just whatever is most accessible to you. You want to go to where the longest axis of the diverticulum is. Open. So here we're almost done with this closure. Can we try to rotate this clip, please? Just slow down. Slowly, slowly, slowly. Continue to rotate, please. Okay, stop. You see how it can jump on you? So I'm going to compensate by moving this scope here. And hold on a second. Keep it like that. Okay, good. So very careful to make sure we have complete closure. And this looks good. Okay, close. Take it. Moin, a quick question. You mentioned about kind of wanting to induce ischemia here with these large arms of the clip. So for the esophageal poem, then, would you advise not using such long, large clips? Because in that situation, I think we really want to avoid that type of ischemia. Yeah, I mean, I think what I meant here when they are very close to each other, you know, you're just cutting the blood supply. And of course, also, you don't want any leakage, you know, any infection here, mediastinitis, neck abscesses is a big deal. You know, we treat gastric and esophageal home on an outpatient basis. But I still admit these anchors, and we get esophograms the next day. So I think with more experience, we'll probably be more comfortable with this. I think, guys, I think I'm happy with this closure. I think we are done here. Are you happy? Yes, very nice.

diverticulum

endoscopy

dysphagia

myotomy

ulcerated