Endoscopic septotomy of a magnet-induced neoseptum in a large mid-esophageal diverticulum

A 72-year-old man who was complaining of dysphagia, regurgitation, and difficulty with passage through the esophagus was diagnosed with a mid-esophageal diverticulum with a diameter of 40 mm. A contrast esophagogram ([Fig. 1]), a computed tomography (CT) scan ([Fig. 2]), and an endoscopic examination revealed that the diverticulum had a narrow neck and was filled with food particles. Because of the patient’s age and comorbidities, which included coronary heart disease and hypertension, and his reluctance to undergo major surgery, non-surgical treatment options were explored. Inspired by a mini-series involving three cases [1], we attempted to use magnets to perform a fusion between the esophageal wall and the wall of the diverticula to induce a neoseptum. Once the neoseptum had been formed, it would be possible to perform septotomy with electrocautery and to widen the narrow neck so that food could washout easily, thereby avoiding obstructive symptoms.

Fig. 1 Esophagogram showing a mid-esophageal diverticulum with a narrow neck.

Fig. 2 Computed tomography (CT) image of the esophageal diverticulum.

One of the ring-shaped magnets was stabilized in the gastric lumen with a grasper and the other magnet was placed at the base of the diverticulum. The magnet in the diverticulum was held steady as the gastric magnet was pulled up through the esophageal lumen. When the two magnets reached the same plane, they were attracted to each other, thereby causing the base of the diverticulum to fuse with the esophageal wall ([Fig. 3]).

Fig. 3 Radiographic image showing the magnets in position and attracted to each other to form a neoseptum.

By 4 weeks after the procedure a neoseptum had been formed through the pressure and attraction between the magnets. Diverticular septotomy with a needle-knife and marsupialization of the diverticulum were performed without complications ([Fig. 4]; [Video 1]). After 10 days, the patient was asymptomatic and a repeat contrast esophagogram showed a diverticulum with a wide neck that allowed contrast material to evacuate easily ([Fig. 5]).

Fig. 4 Endoscopic view after neoseptotomy had been performed.

Radiographic and endoscopic views of magnets being placed to induce a neoseptum and, 4 weeks later, diverticular septotomy and marsupialization of the diverticulum being performed.

Fig. 5 Esophagogram showing easy evacuation of contrast medium from the wide neck of the diverticulum after neoseptotomy.

This report is the second in the literature detailing treatment of an esophageal diverticulum using endoscopic septotomy of a neoseptum induced by magnets. These endoscopic procedures allowed the patient to avoid major surgery with satisfactory results and no complications.

Endoscopy_UCTN_Code_TTT_1AO_2AN

Competing interests: None

• Reference

• 1 Bouchard S, Huberty V, Blero D et al. Endoscopic treatment of large esophageal diverticula using a magnetic anastomosis device: report of three cases. Gastrointest Endosc 2015; 81 Suppl: AB455