Short-term clinical and technical outcomes of a modified Zenker’s peroral endoscopic myotomy with mucosal flap incision

Abstract

Background

Zenker’s diverticulum peroral endoscopic myotomy (Z-POEM) is an effective treatment for symptomatic Zenker’s diverticulum. A modification to Z-POEM involves mucosal flap incision (MFI). We describe the technical and clinical success of patients who underwent Z-POEM with MFI.

Methods

We included patients who underwent Z-POEM with MFI for Zenker’s diverticulum at eight international centers. The primary outcome was the rate of clinical success, assessed by post-procedure Kothari–Haber symptom score (KHSS) without re-treatment. Secondary outcomes included technical success, serious adverse events, and clinical recurrence with need for re-treatment.

Results

36 patients (age 69 [SD 9] years; 69% male) underwent Z-POEM with MFI for symptomatic Zenker’s diverticulum. Mean diverticulum size was 3.2 (SD 1.4) cm. Clinical success was achieved in 35 patients (97%). Median baseline KHSS was 6 and median post-procedure KHSS was 0 (P < 0.001). Technical success was achieved in all cases. Mean procedure time was 57 (SD 34) minutes and median follow-up time was 196 days (interquartile range 39–499). There was one adverse event (3%), which was treated endoscopically.

Conclusion

Z-POEM with MFI had high rates of technical and clinical success. Prospective evaluation is needed to further validate this technique in patients with a large Zenker’s diverticulum.

Publication History

Received: 25 January 2024

Accepted after revision: 24 October 2024

Accepted Manuscript online:
24 October 2024

Article published online:
18 December 2024

• References

• 1 Watemberg S, Landau O, Avrahami R. Zenkerʼs diverticulum: reappraisal. Am J Gastroenterol 1996; 91: 1494-1498
• 2 Keck T, Rozsasi A, Grün PM. Surgical treatment of hypopharyngeal diverticulum (Zenker’s Diverticulum). Eur Arch Otorhinolaryngol 2009; 267: 587-592
• 3 Beard K, Swanström L. Zenker’s diverticulum: flexible versus rigid repair. J Thorac Dis 2017; 9: S154-162
• 4 Elkholy S, El-Sherbiny M, Delano-Alonso R. et al. Peroral endoscopic myotomy as treatment for Zenker’s ziverticulum (Z-Poem): a multi-center international study. Esophagus 2021; 18: 693-699
• 5 Li Q, Chen W, Zhang X. et al. Submucosal tunnelling endoscopic septum division: a novel technique for treating Zenker’s diverticulum. Gastroenterology 2016; 151: 1071-1074
• 6 Che S, Joseph S, Kuchta K. et al. Outcomes after per-oral endoscopic myotomy for Zenker’s diverticula (Z-poem) and correlation with impedance planimetry (flip). Surg Endosc 2023; 38: 957-963
• 7 Zhang L, Nieto J, Ngamruengphong S. et al. Zenker’s diverticulum: advancing beyond the tunnel. Video GIE 2021; 6: 562-567
• 8 Repici A, Spandaccini M, Belletrutti P. et al. Peroral endoscopic septotomy for short-septum Zenker’s diverticulum. Endoscopy 2020; 52: 563-568
• 9 Steinway S, Zhang L, Amundson JR. et al. Long term outcomes of Zenker’s peroral endoscopic myotomy (Z-POEM) for treatment of Zenker’s diverticulum. Endosc Int Open 2023; 11: E607-E612
• 10 Brewer Gutierrez O, Ichkhanian Y, Spadaccini M. et al. Zenker’s diverticulum per-oral endoscopic myotomy techniques: changing paradigms. J Gastroenterol 2019; 156: 2134-2135
• 11 Kothari T, Kothari S, Bittner K. 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-AB290
• 12 Cotton P, Eisen G, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 13 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: 1076-1089
• 14 Weusten B, Barret M, Bredenoord A. et al. Endoscopic management of gastrointestinal motility disorders – Part 2: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2020; 52: 600-614
• 15 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
• 16 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: 613-614
• 17 Al Ghamdi SS, Farha J, Moran RA. et al. Zenker’s peroral endoscopic myotomy, or flexible or rigid septotomy for Zenker’s diverticulum: a multicenter retrospective comparison. Endoscopy 2022; 54: 345-351
• 18 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: 373-374
• 19 Hernández Mondragón O, Solórzano Pineda M, Blancas Valencia J. Zenker’s diverticulum: submucosal tunneling endoscopic septum division (Z-POEM). Dig Endosc 2018; 30: 124
• 20 Yang J, Novak S, Ujiki M. et al. An international study on the use of peroral endoscopic myotomy in the management of zenker’s diverticulum. Gastrointest Endosc 2020; 91: 163-168
• 21 Huberty V, El Bacha S, Blero D. et al. Endoscopic treatments for Zenker’s diverticulum: long-term results. Gastrointest Endosc 2012; 77: 701-707