Abstract
Background
Peroral endoscopic myotomy for the treatment of Zenker’s diverticulum (Z-POEM) is a novel technique that has been described in several recent reports. This method utilizes the third space (submucosal layer) to create a tunnel to facilitate complete visualization of the septum and hence cutting it entirely. Conventional endoscopic septotomy carries the risk of recurrence due to incomplete visualization of the septum. While surgical correction is a risky and lengthy procedure in old comorbid patients with Zenker’s diverticulum. The aim of this study is to assess the efficacy and safety of Z-POEM.
Methods
The study enrolled 24 patients diagnosed with Zenker’s diverticulum (ZD) who underwent Z-POEM at seven independent endoscopy centers in five different countries.
Results
Mean patient age ± standard deviation (SD) was 74.3 ± 11 years. Most of the patients were males (n = 20, 83.3%); four (16.7%) were females. More than 50% of the patients (n = 14, 58.3%) had associated comorbidities. The mean size of the diverticula was 4 cm (range 2–7 cm). The Kothari-Haber Score was used to assess clinical symptoms; values ranged from 6 to 14 (median = 9). We achieved 100% technical success with a median procedure time of 61 min and no adverse events. Median hospital stay was 1 day (range 1–5 days). There is a significant reduction in the Kothari-Haber Score after Z-POEM (P < 0.0001). Technical success was achieved in 100% of the patients. Clinical success was achieved in 23/24 (95.8%) of the patients with a median follow-up of 10 months (range 6–24 months).
Conclusion
Z-POEM is a safe and effective modality for managing ZD.
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References
Bizzotto A, Iacopini F, Landi R, et al. Zenker’s diverticulum: exploring treatment options. Acta Otorhinolaryngol Ital. 2013;33:219–29.
Ferreira LE, Simmons DT, Baron TH. Zenker’s diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. Dis Esophagus. 2008;21:1–8.
Cook IJ, Gabb M, Panagopoulos V, et al. Pharyngeal (Zenker’s) diverticulum is a disorder of upper esophageal sphincter opening. Gastroenterology. 1992;103(1229–35):2.
Venturi M, Bonavina L, Colombo L, et al. Biochemical markers of upper esophageal sphincter compliance in patients with Zenker’s diverticulum. J Surg Res. 1997;70:46–8.
Pescarus R, Shlomovitz E, Sharata AM, et al. Trans-oral cricomyotomy using a flexible endoscope: technique and clinical outcomes. Surg Endosc. 2016;30:1784–9.
Yuan Y, Zhao YF, Hu Y, et al. Surgical treatment of Zenker’s. Dig Surg. 2013;30:207–18.
Keck T, Rozsasi A, Grun PM. Surgical treatment of hypopharyngeal diverticulum (Zenker’s diverticulum). Eur Arch Otorhinolaryngol. 2010;267:587–92.
Case DJ, Baron TH. Flexible endoscopic management of Zenker’s diverticulum: the Mayo Clinic experience. Mayo Clin Proc. 2010;85:719–22.
Albers DV, Kondo A, Bernardo WM, et al. Endoscopic versus surgical approach in the treatment of Zenker’s diverticulum: systematic review and meta-analysis. Endosc Int Open. 2016;4:E678–86.
Aiolfi A, Scolari F, Saino G, et al. Current status of minimally invasive endoscopic management for Zenker diverticulum. World J Gastrointest Endosc. 2015;7:87–93.
Halland M, Grooteman KV, Baron TH. Flexible endoscopic management of Zenker’s diverticulum: characteristics and outcomes of 52 cases at a tertiary referral center. Dis Esophagus. 2016;29:273–7.
Ishaq S, Hassan C, Antonello A, et al. Flexible endoscopic treatment for Zenker’s diverticulum: a systematic review and meta-analysis. Gastrointest Endosc. 2016;83:1076–89.
Verdonck J, Morton RP. Systematic review on treatment of Zenker’s diverticulum. Eur Arch Otorhinolaryngol. 2015;272:3095–107.
Repici A. Endoscopic treatment of Zenker diverticulum. Gastroenterol Hepatol. 2010;6:628–31.
Barron TH. Endoscopic treatment of Zenker diverticulum. Tech Gastrointest Endosc. 2014;16:40–4.
Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42:265–71.
Reddy DN. Recent advances in third-space endoscopy. Gastroenterol Hepatol. 2018;14:224–32.
Balassone V, Pizzicannella M, Biasutto D, et al. Submucosal per-oral endoscopic myotomy for a large Zenker’s diverticulum with use of a hydrodissector knife and an over-the-scope clip closure. VideoGIE. 2018;3:373–4.
Brieau B, Leblanc S, Bordacahar B, et al. Submucosal tunneling endoscopic septum division for Zenker’s diverticulum: a reproducible procedure for endoscopists who perform peroral endoscopic myotomy. Endoscopy. 2017;49:613–4.
Hajifathalian K, Dawod Q, Saumoy M, et al. Submucosal tunneling endoscopic septum division for treatment of Zenker’s diverticulum. Endoscopy. 2018;50:E340–1.
Hernandez Mondragon OV, Solorzano Pineda MO, Blancas Valencia JM. Zenker’s diverticulum: submucosal tunneling endoscopic septum division (Z-POEM). Dig Endosc. 2018;30:124.
Juliana Y, Stephanie N, Michael U, et al. An international study on the use of peroral endoscopic myotomy in the management of Zenker’s diverticulum. Gastrointest Endosc. 2019;156:2134–5.
Maydeo A, Gaurav KP, Ankit D. Operative technical tricks and 12-month outcomes of diverticular peroral endoscopic myotomy (D-POEM) in patients with symptomatic esophageal diverticula. Endoscopy. 2019;51:1136–40.
Truptesh HK, Shivangi K, Krystle B, et al. The “Kothari-Haber” scoring system: a prospective evaluation of pre- and post-procedure outcomes for patients undergoing endoscopic myotomy for Zenker’s diverticulum. Gastrointest Endosc. 2018;87:AB289-290.
Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010;71:446–54.
Scher R, Missiorek D, editors. Management of Zenker and hypopharyngeal diverticula. Berlin: Springer International Publishing; 2018.
Dzeletovic I, Ekbom DC, Baron TH. Flexible endoscopic and surgical management of Zenker’s diverticulum. Expert Rev Gastroenterol Hepatol. 2012;6:449–66.
Ciuc D, Birla R, Panaitescu E, et al. Treatment: endoscopic or Surgical? Chirurgia. 2018;113:234–43.
Mittal C, Diehl D, Draganov P, et al. Practice patterns, techniques, and outcomes of flexible endoscopic myotomy for Zenker’s diverticulum: retrospective, multi-center study. Endoscopy. 2020 (AAM).
Elkholy S, Essam K, El-Sherbiny M. Z- POEM (per oral endoscopic myotomy) for treatment of Zenker’s diverticulum. Acta Gastroenterol Belg. 2020;83:90–1.
Bonavina L, Bona D, Abraham M, et al. Long-term results of endosurgical and open surgical approach for Zenker diverticulum. World J Gastroenterol. 2007;13:2586.
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Ethical Statement
This study had been approved from the ethical comitte of the gastroenterology division of the internal medicine department in the faculty of medicine of Cairo University.
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Mouen A. Khaskab: consultant and medical advisory board for Olympus and Boston Scientific; consultant for Medtronic. All other authors have no conflicts of interest or financial ties to disclose.
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Supplementary file1. This video illustrates the steps of the Z-POEM procedure: a identification of the septum with the narrow esophageal lumen on the right side and the wider diverticular lumen on the left. b Submucosal blue bleb is formed at a site proximal to the septum. c The tunnel was opened using a Hybrid Knife I-type. d Dissection of the submucosa on either side of the septum. e Cutting of the septum using a Hybrid Knife O-type. f Extension of the myotomy into the esophageal muscles. g Closure of the tunnel opening with endoclips. (MOV 230298 KB)
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Elkholy, S., El-Sherbiny, M., Delano-Alonso, R. et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus 18, 693–699 (2021). https://doi.org/10.1007/s10388-020-00809-7
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DOI: https://doi.org/10.1007/s10388-020-00809-7