Z-POEM as a Treatment Option for Zenker’s Diverticulum: Our Experience at a Tertiary Care Centre in India

Abstract Background This study was aimed to evaluate efficacy and safety of Z–peroral endoscopic myotomy (Z-POEM; submucosal tunneling endoscopic myotomy) for Zenker’s diverticulum (ZD). Methods This is a retrospective study at a single tertiary care center in India. The Z-POEM technique was performed using principles of submucosal tunneling endoscopy with prior experience from POEM technique for achalasia cardia Results Sixteen patients (male, 62.5%; mean age, 73.2 ± 5.2 years) were included with a mean Charleson’s comorbidity index of 4.32. The mean size of ZD was 34.8 ± 10.0 mm. The technical success rate was 100%. Clinical success was achieved in 100% (16/16) with a decrease in mean dysphagia score from 2.9 to 0.2 (p <0.0001). The mean procedure time was 47 ± 7.9 minutes and mean length of septotomy was 31.9 ± 9.4 mm. The mean length of hospital stay was 1.2 ± 0.4 days. No major adverse events were noted. Capnomediastinum was noted in two cases on follow-up Gastrografin study after 24 hours (12.5%). This did not merit any treatment. One patient had intraprocedural bleed which was controlled easily. At the 18-month follow-up, two (12.5%) patients reported dysphagia recurrence (Dakkak and Bennett score 1) but did not require repeat intervention. Conclusion Endoscopic management of ZD using the POEM technique is a promising technique with improved efficacy and safety. However, long-term follow-up is needed to ensure the durability of response.

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Impact of prior treatment on feasibility and outcomes of Zenker’s peroral endoscopic myotomy (Z-POEM)

Endoscopy ◽

10.1055/a-1276-0219 ◽

2020 ◽

Author(s):

Omid Sanaei ◽

Yervant Ichkhanian ◽

Oscar V. Hernández Mondragón ◽

Jose Nieto ◽

Arunkumar Krishnan ◽

...

Keyword(s):

Complete Resolution ◽

Primary Outcome ◽

Surgical Intervention ◽

Clinical Success ◽

Peroral Endoscopic Myotomy ◽

Zenker’S Diverticulum ◽

Dysphagia Score ◽

Zenker's Diverticulum ◽

Endoscopic Myotomy

Abstract Background Zenker’s peroral endoscopic myotomy (Z-POEM) is a novel procedure for the management of symptomatic Zenker’s diverticulum. This study aims to report the technical feasibility and outcomes of Z-POEM in the management of Zenker’s diverticulum after prior failed interventions. Methods Patients with persistent or recurrent symptoms after prior endoscopic and/or surgical intervention for Zenker’s diverticulum were retrospectively included. The primary outcome was clinical success, defined as complete or near complete resolution of dysphagia (dysphagia score of 0 or 1) without the need for repeat endoscopic or surgical intervention during follow-up. Results Z-POEM was technically successful in 30/32 patients (93.8 %). Clinical success was achieved in 29/30 patients (96.7 %), and Z-POEM significantly reduced the median (interquartile range [IQR]) dysphagia score of patients from 2 (1 – 2) to 0 (0) (P < 0.001) over a median duration of follow up of 166 days (IQR 39 – 566). Four patients (12.5 %) had adverse events (two inadvertent mucosotomies and two leaks found on post-procedural esophagrams). Conclusion Z-POEM is feasible, safe, and effective in the majority of patients with recurrent symptoms after prior surgical or endoscopic interventions.

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Experience and Technique for Zenker's Diverticulum Per Oral Endoscopic Myotomy: Z-POEM

The Thoracic and Cardiovascular Surgeon ◽

10.1055/s-0040-1717127 ◽

2020 ◽

Author(s):

Eitan Podgaetz ◽

Vani Konda

Keyword(s):

Third Space ◽

Zenker’S Diverticulum ◽

Complication Rates ◽

Short Term ◽

Zenker's Diverticulum ◽

Per Oral Endoscopic Myotomy ◽

Endoscopic Myotomy ◽

Invasive Techniques ◽

Per Oral

Abstract Objective With the advent of minimally invasive surgery, incisionless surgery, and third-space endoscopy, the treatment for Zenker's diverticulum has also moved toward less invasive techniques Methods New incisionless per oral techniques can be applied for cricopharyngeal myotomy in Zenker's diverticulum. Results Five patients underwent Zenker's diverticulum per oral endoscopic myotomy (Z-POEM) without complications, minimal discomfort, and narcotic consumption, with complete resolution of their symptoms by history and Eckardt scores. Conclusions Z-POEM is performed entirely endoscopically with very little associated pain or complication rates, with short-term follow-up having excellent functional and symptomatic results.

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Peroral endoscopic septotomy for short-septum Zenker’s diverticulum

Endoscopy ◽

10.1055/a-1127-3304 ◽

2020 ◽

Cited By ~ 1

Author(s):

Alessandro Repici ◽

Marco Spadaccini ◽

Paul James Belletrutti ◽

Piera Alessia Galtieri ◽

Alessandro Fugazza ◽

...

Keyword(s):

Adverse Events ◽

Zenker’S Diverticulum ◽

Symptom Improvement ◽

Dysphagia Score ◽

Zenker's Diverticulum ◽

Mean Size ◽

Potential Alternative ◽

Anatomical Space ◽

Space Approach

Abstract Background Treatments of Zenker’s diverticulum aim to dissect the cricopharyngeal muscle, removing the underlying source of dysfunction. This is difficult in patients with a short-septum (≤ 20 mm) diverticulum because the limited anatomical space restricts the operating area for either rigid or flexible endoscopic approaches. The aim of this study was to investigate the efficacy and safety of a novel third-space approach, peroral endoscopic septotomy (POES), for treating symptomatic patients with short-septum Zenker’s diverticulum. Methods All patients with short-septum Zenker’s diverticulum who were referred for endoscopic repair from September 2017, were considered for the study. Outcomes included procedure-related adverse events and symptom improvement. The Dakkak – Bennett score was used to quantify dysphagia. Results 20 patients (men 12, women 8; mean age 67.9 years [SD 14.3]) underwent POES. All procedures were performed with patients under deep sedation. Mean size of Zenker’s diverticulum was 17.5 mm (SD 3.0) and mean dysphagia score was 2.7 (SD 0.5). Average procedure time was 13.8 minutes (SD 5.1). No intra- or post- procedural adverse events occurred. Septal myotomy was successfully completed in all patients. Dysphagia significantly improved in 19 out of 20 patients. Dakkak – Bennett score improved to 0.3 (SD 0.5), P < 0.0001). No recurrences were reported in a mean follow-up time of 12.0 months (SD 3.7, range 6 – 20). Conclusions POES may be considered as a potential alternative for the treatment of short-septum Zenker’s diverticulum. Further data are required to validate this technique and compare it with already available rigid and flexible approaches.

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An international study on the use of peroral endoscopic myotomy (POEM) in the management of esophageal diverticula: the first multicenter D-POEM experience

Endoscopy ◽

10.1055/a-0759-1428 ◽

2018 ◽

Vol 51 (04) ◽

pp. 346-349 ◽

Cited By ~ 22

Author(s):

Juliana Yang ◽

Xianhui Zeng ◽

Xianglei Yuan ◽

Kenneth Chang ◽

Omid Sanaei ◽

...

Keyword(s):

Clinical Success ◽

Case Series ◽

Peroral Endoscopic Myotomy ◽

Endoscopic Management ◽

Distinct Advantage ◽

Technical Success Rate ◽

Dysphagia Score ◽

Esophageal Diverticula ◽

First Case ◽

Endoscopic Myotomy

Abstract Background The aim of this study is to report a novel, multicenter experience with the diverticular peroral endoscopic myotomy (D-POEM) technique in the management of esophageal diverticula. Methods This is a multicenter, international, retrospective study involving three centers. D-POEM was performed using the principles of submucosal endoscopy. Results A total of 11 patients with an esophageal diverticulum (Zenker’s 7, mid-esophagus 1, epiphrenic 3) were included. The mean size of the esophageal diverticula was 34.5 mm. The overall technical success rate of D-POEM was 90.9 %, with a mean procedure time of 63.2 minutes. There were no adverse events. Clinical success was achieved in 100 % (10 /10), with a decrease in mean dysphagia score from 2.7 to 0.1 (P < 0.001) during a median follow-up of 145 days (interquartile range 126 – 273). Conclusion Endoscopic management of esophageal diverticula using the novel technique of D-POEM appears promising. This first case series on D-POEM suggests that the procedure is feasible, safe, and effective in the management of esophageal diverticula. D-POEM offers the distinct advantage of ensuring a complete septotomy. Larger studies are needed to confirm these intriguing results.

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Efficacy and Safety of Flexible Endoscopic Management of Zenker’s Diverticulum

Journal of Clinical Gastroenterology ◽

10.1097/mcg.0000000000000977 ◽

2018 ◽

Vol 52 (5) ◽

pp. 369-385 ◽

Cited By ~ 10

Author(s):

Deepanshu Jain ◽

Abhinav Sharma ◽

Manan Shah ◽

Upen Patel ◽

Nirav Thosani ◽

...

Keyword(s):

Endoscopic Management ◽

Zenker’S Diverticulum ◽

Efficacy And Safety ◽

Zenker's Diverticulum

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Transcanal endoscopic management of epitympanic cholesteatoma: a promising technique

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20190987 ◽

2019 ◽

Vol 5 (3) ◽

pp. 573

Author(s):

Arvind Varma ◽

Aanchal Sahni

Keyword(s):

Tertiary Care ◽

Hearing Threshold ◽

Endoscopic Management ◽

Tertiary Care Centre ◽

Promising Tool ◽

Post Surgery ◽

The Mean ◽

Natural Way

Background: The objective of the study was to evaluate the role of functional endoscopic ear surgery in epitympanic cholesteatoma removal.Methods: This study included 15 cases of epitympanic cholesteatoma who underwent exclusive endoscopic surgeries for cholesteatoma removal in a tertiary care centre between December 2017 to May 2018. The improvement in hearing threshold and air bone closure was evaluated comparing the preoperative and postoperative audiogram. The incidence of recurrence and reperforation was noted postoperatively using otoendoscopy. Results: Post-surgery improvement in hearing threshold was observed. There was no incidence of recurrence and reperforation during the mean follow up period of 7.8 months.Conclusions: Endoscopic removal of epitympanic cholesteatoma is more natural way of removal of disease with less post-surgery morbidity and recurrence. It has potential to be a promising tool for treatment of epitympanic cholesteatoma in future.

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Harmonic scalpel for endoscopic treatment of Zenker's diverticulum: a critical review of the literature

Morecambe Bay Medical Journal ◽

10.48037/mbmj.v7i11.90 ◽

2017 ◽

Vol 7 (11) ◽

pp. 264-272

Author(s):

Nadim Khadem ◽

Shadaba Ahmed

Keyword(s):

Treatment Option ◽

Harmonic Scalpel ◽

Endoscopic Management ◽

Zenker’S Diverticulum ◽

Efficacy And Safety ◽

Review Of The Literature ◽

Viable Option ◽

Effective Treatment Option ◽

Zenker's Diverticulum

Introduction: Endoscopic staple-assisted diverticulostomy (ESD) is generally accepted as the preferred treatment option for patients with Zenker’s diverticulum (ZD). However, anatomical factors may preclude the use of ESD in certain patients. In recent years, the harmonicscalpel has been introduced as an alternative device for endoscopic management of ZD, which may be useful in certain cases where diverticulum anatomy prevents the use of ESD. This review aims to assess the efficacy and safety of endoscopic ZD-repair using the harmonic-scalpel, including comparative analysis of the harmonic and staple assisted approaches in terms of their surgical outcomes. Conclusion: Most studies support the use of the harmonic-scalpel as a safe and effective treatment option for ZD. Although the harmonic-assisted technique may not replace ESD as the initial treatment of choice for ZD, it may serve as a useful adjunct to treatment in selected cases. However, given the low quality of evidence and concerns regarding treatment complications, large prospective randomised trials comparing the harmonic and staple-assisted techniques are necessary in order to determine whether the harmonic-scalpel is truly a viable option for endoscopic ZD-management.

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Endoscopic management of Zenker’s diverticulum

Journal of Digestive Endoscopy ◽

10.4103/0976-5042.159235 ◽

2015 ◽

Vol 06 (02) ◽

pp. 045-054 ◽

Cited By ~ 1

Author(s):

Harpal S. Dhaliwal ◽

Saroj K. Sinha ◽

Rakesh Kochhar

Keyword(s):

Flexible Endoscopy ◽

Endoscopic Management ◽

Zenker’S Diverticulum ◽

Mortality And Morbidity ◽

Endoscopic Techniques ◽

Zenker's Diverticulum ◽

Neck Anatomy ◽

Endoscopic Myotomy ◽

Underlying Pathophysiology

AbstractZenker’s diverticulum (ZD) is a posterior hypopharyngeal mucosal and submucosal outpouching through an area of relative muscular weakness, known as Killian’s triangle. It is an uncommon but highly treatable cause of mechanical dysphagia in elderly patients. Diagnosis is established by esophagography and upper endoscopy. The treatment has evolved with the advancement in the understanding of underlying pathophysiology. Traditionally, the management had been open surgical exposure and cricopharyngeal myotomy, combined with diverticular excision, suspension or inversion. Peroral endoscopic techniques (rigid and flexible) have gained popularity as minimally invasive and effective therapeutic options, with lesser mortality and morbidity. Flexible endoscopic myotomy offers additional benefits over rigid endoscopic techniques, as it does not require general anesthesia and neck hyperextension. The initial results of flexible endoscopy are quite encouraging, but long-term data are not yet available. For the optimal outcome, flexible endotherapy requires a formidable endoscopic skill, sound knowledge of the neck anatomy and meticulous understanding of the electrosurgical principles. In this article, we have comprehensively reviewed the current understanding of the pathophysiology involved and various techniques used in the management of ZD, with a focus on flexible endoscopic techniques.

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