- The Practicing Endoscopist
- Posts
- Endoscopic Resection of an Esophageal Pseudodiverticulum in Radiation-Induced Stenosis
Endoscopic Resection of an Esophageal Pseudodiverticulum in Radiation-Induced Stenosis
Novel endoscopic technique using IT Knife Nano demonstrates safe and rapid resection of esophageal pseudodiverticulum in a complex post-radiation stenosis case, highlighting an innovative approach to managing challenging upper GI complications
Peter Jakobs, MS, Josip Juraj Strossmayer Universität Osjiek, Croatia, Ameos Klinikum Halberstadt, Germany
Klaus Mönkemüller, MD, PhD, FASGE, FJGES, Professor of Medicine, Department of Gastroenterology, Ameos Klinikum Halberstadt, Germany and Carilion Memorial Hospital, Virginia Tech Carilion School of Medicine, Roanoke, USA
A 62-year-old Caucasian male patient presented with dysphagia due to post-radiogenic esophageal stenosis. The patient had a history of transglottic laryngeal carcinoma for which he had undergone laryngectomy, neck dissection on both sides and adjuvant radio-chemotherapy. An esophageal bougienage had already been performed 4 months earlier and a dilatation from 5-6 mm to 9-10 mm had been performed 3 months earlier using TTS-OTW-CRE balloon dilation with good results. When dysphagia symptoms recurred, a further examination was carried out, which showed impassable narrowing at approx. 18 cm form the incisors (Figure 1).
Figure 1. Radiation-induced stenosis and esophageal pseudodiverticulum. The impassable passage showed a ring-shaped fibrosis of the mucosa and an adjacent pseudo diverticulum (A yellow arrow) with proximal megaesophagus. B. Stenotic esophagus due to radiation induced esophagitis and pseudodiverticulum with a hemi-ring of fibrotic mucosa. In addition, a large gastric inlet patch was present at approx. 15 cm (C, light blue arrow). D. Narrow band imaging of the inlet patch.
It was decided to remove the diverticulum to eliminate the stenosis. The decision was made to use an IT KNIFE NANO (Olympus, Japan). The great advantage of this knife is that the tip is insulated with ceramic and thus considerably reduces the risk of electrosurgical injury to adjacent structures, especially when visibility is reduced (1, 2).
Figure 2. Endoscopic resection of pseudo-diverticulum using an IT-Nano knife. A. Approaching the stenosis and pseudodiverticulum with the IT-Nanoknife. B. Incision of the fibrotic hemi-ring. C. Successful resection of the pseudodiverticulum. Notice the increased esophageal lumen, which allowed for passage of the scope.
Even though the IT KNIFE NANO is noticeably more expensive than a conventional needle knife, it offers increased safety, especially for endoscopic submucosal dissection or hard-to-reach areas (4). In the above-mentioned patient with a barely passable narrowing in the esophagus, resection of the diverticular tissue using traditional knives may be extremely difficult. In addition to a steady hand, experience is also required. Thanks to the special shape of the knife used and the non-cutting ceramic tip the procedure was not only faster (total of 3 minutes), but also safer.
Figure 3. IT-Nano knife.
The patient was also placed on high dose proton pump inhibitors as there was a large gastric heterotopia or inlet patch (Figure. 1). This ectopic gastric mucosa secretes acid and could have also contributed to the stricture formation in this patient. Another option to treat Inlet patches is ablation using argon plasma coagulation, which we may consider if the stenosis recurs (4). At 6 weeks follow-up the patient is has improved clinically.
Further Reading
References:
Takamaru H, Saito Y. Characteristics and uses of IT knife nano. Mini-invasive Surg 2022;6:15. https://dx.doi.org/10.20517/2574-1225.2021.120
Suzuki T, Hara T, Kitagawa Y, Yamaguchi T. Usefulness of IT knife nano for endoscopic submucosal dissection of large colo-rectal lesions. Acta Gastroenterol Belg. 2016 Apr-Jun;79(2):186-90. PMID: 27382935.
Brechmann T, Mühlenkamp M, Schmiegel W, Viebahn B. Argon Plasma Coagulation of Gastric Inlet Patches of the Cervical Esophagus Relieves Vocal and Respiratory Symptoms in Selected Patients. Dig Dis Sci. 2023 May;68(5):1936-1943. doi: 10.1007/s10620-022-07745-9. Epub 2022 Nov 14. PMID: 36376579.
None of the authors (PJ, KM) has any conflicts of interest with any of the products or devices mentioned in this article.
Join EndoCollab: EndoCollab is your go-to platform for advancing your skills in gastroenterology and endoscopy. Gain access to exclusive content from top practitioners to enhance your practice.
Membership Features:
Video lessons on essential and advanced techniques.
Expert-led classes and practical tips.
Community-driven insights and peer discussions.
Join 1,300+ healthcare professionals taking their expertise to the next level.
Reply