Endoscopy 2022; 54(05): E193-E194
DOI: 10.1055/a-1481-7728
E-Videos

When Z-POEM comes to the rescue of classical diverticulotomy and vice versa

Thomas Lambin
1   Department of Endoscopy and Hepato-Gastroenterology, Edouard Herriot Hospital, Lyon, France
2   Inserm U1032, LabTAU, Lyon, France
,
Pierre Lafeuille
1   Department of Endoscopy and Hepato-Gastroenterology, Edouard Herriot Hospital, Lyon, France
,
Jérôme Rivory
1   Department of Endoscopy and Hepato-Gastroenterology, Edouard Herriot Hospital, Lyon, France
,
Laura Calavas
1   Department of Endoscopy and Hepato-Gastroenterology, Edouard Herriot Hospital, Lyon, France
,
Thierry Ponchon
1   Department of Endoscopy and Hepato-Gastroenterology, Edouard Herriot Hospital, Lyon, France
,
Mathieu Pioche
1   Department of Endoscopy and Hepato-Gastroenterology, Edouard Herriot Hospital, Lyon, France
2   Inserm U1032, LabTAU, Lyon, France
› Author Affiliations
 

If the treatment of Zenkerʼs diverticulum by flexible endoscopy seems to be the preferred option for its efficacy and safety profile [1], the recent arrival of Z-POEM (peroral endoscopic myotomy) technique has blurred the cards a little. Indeed, although the results of the Z-POEM technique seem good [2] [3], no randomized comparative data is available to choose this technique over classical diverticulotomy. The theoretical advantage of classical diverticulotomy is that it cuts the mucosal relief and performs the cricopharyngeal myotomy without having a very clear marker to be certain of the completeness of the myotomy. On the other hand, Z-POEM offers the possibility to cut the muscle completely thanks to better visualization, with almost zero risk of perforation not covered by the tunnel.

However, these two techniques are not 100 % effective. Here we present two cases of clinical failure with recurrence of dysphagia after a Z-POEM and a diverticulotomy, respectively ([Video 1]). To treat these patients, we chose a cross-over by making a Z-POEM to cut the muscle more deeply in the patient who had had a classical diverticulotomy [4] ([Fig. 1]), and on the other hand, a classical diverticulotomy to cut the residual mucosal relief in the patient who had had a Z-POEM ([Fig. 2]). In both cases it was possible to remove the residual relief of the diverticulum and a notable clinical improvement was observed.

Video 1 When Z-POEM comes to the rescue of classical diverticulotomy and vice versa.


Quality:
Zoom Image
Fig. 1 A Z-POEM was performed to cut the muscle more deeply in a patient who had had a diverticulotomy.
Zoom Image
Fig. 2 A diverticulotomy was performed to cut the residual mucosal relief in a patient who had had a Z-POEM.

These cases perhaps illustrate the complementarity of the two techniques and the possible need to combine them to cut the muscle more deeply thanks to Z-POEM while cutting the mucous relief at the end of the procedure so as not to leave residual mucous relief, which is a source of symptomatic recurrence.

Endoscopy_UCTN_Code_CPL_1AH_2AH

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Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Thomas Lambin, MD
Endoscopy Unit – Digestive Disease Department
Pavillon L – Edouard Herriot Hospital
69437 Lyon Cédex
France   

Publication History

Publication Date:
12 May 2021 (online)

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Zoom Image
Fig. 1 A Z-POEM was performed to cut the muscle more deeply in a patient who had had a diverticulotomy.
Zoom Image
Fig. 2 A diverticulotomy was performed to cut the residual mucosal relief in a patient who had had a Z-POEM.