Endoscopic duodenal “windsock” diverticulotomy

Tyler Stevens, Bipan Chand, Charles Winans

A 49-year-old woman presented with a 3-month history of nausea, vomiting, and weight loss. Her symptoms were severe, and she required total parenteral nutrition for nutrition support. Both CT and barium upper GI series demonstrated a large "windsock" diverticulum that obstructed the duodenal lumen. The patient was referred to undergo a surgical diverticulectomy. After a multidisciplinary discussion, a less invasive endoscopic diverticulotomy was recommended, and the patient agreed. The linked video demonstrates the endoscopic findings and therapeutic technique. Upper endoscopy showed the diverticulum arising from the proximal duodenum. The scope could not traverse the true lumen due to compression by the diverticulum. A guidewire was passed to delineate the true lumen. At that point, the diverticulum spontaneously inverted into a proximal position. The tip of the diverticulum was then clipped to the duodenal wall to increase exposure and to allow a more controlled incision. Clips were placed on the vascular pedicle of the diverticulum to prevent bleeding. An incremental incision was performed using a needle-knife to divide the diverticulum completely. Mild bleeding occurred twice and was managed with clips. A complete diverticulotomy was accomplished, allowing easy passage of the endoscope. The patient had an uneventful postprocedural recovery and was discharged the same day with instructions for dietary advancement. After 2 months, the patient reported complete symptom resolution. She was eating well, had gained weight, and had discontinued total parenteral nutrition. A repeat endoscopy confirmed a patent lumen and no recurrence of the diverticulum. This case demonstrates the feasibility and effectiveness of endoscopic diverticulotomy performed from a proximally inverted position. This "top-down" approach provided very good exposure for the incision and easy treatment of bleeding complications.