Tunneling-free peroral endoscopic septotomy for Zenker diverticulum

eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJjOWYyOWVhNWE0MTlmZjE3ZmQ0OWU0NmRlOTBhZGEyNSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg3NTA1ODAzfQ.o-lkH-ESdL9WWlslq6zoL_KqGp76WB7NaRlBj3LFHPeMp4i4if3trqERJQdmPZGkconxUP2AOWoWxqafCazPsN-uUIAG8w7AGRCBzkT8XpOj1RpGxLHj87GnLMC8T1NnbIeGR2bDg2BirSlqn_znWWd8yJvnv20iTwsYLipiMlBTK12lUeTZu0Lbp0_txhGhRTM5hLB27fL9TFGcWJd2dfwKYP6OuwkfRPrWoTQ2UUV_zudDGQ524yAgA-McIZaEo03aq6ewLuaQiVg8RBirDYkvyCjqENXFjcRWJJOHm6uWvlSAeL2BX8vJDAPy0LaRKrUi7zYXg6o7Q3iI1pzF3Q(mp4, (109.26 MB) Download video Tunneling-free peroral endoscopic Zenker myotomy. The diverticulum (ZD) emerges from Killian’s triangle and mostly presents with oropharyngeal dysphagia. Several techniques have been described to transect the cricopharyngeus, variable success adverse event rates.1Repici A. Spadaccini M. Belletrutti P.J. et al.Peroral septotomy for short-septum Zenker's diverticulum.Endoscopy. 2020; 52: 563-568PubMed Google Scholar myotomy (Z-POEM) has established as an effective intervention, technical clinical rates above 97% 92%, respectively.2Young E. Singh R. Modified Zenker’s myotomy: a novel technique improve access depth of muscular dissection.VideoGIE. 2022; 7: 169-171Abstract Full Text PDF Scopus (0) Scholar,3Elkholy S. El-Sherbiny Delano-Alonso treatment (Z-POEM): multi-center international study.Esophagus. 2021; 18: 693-699Crossref PubMed (9) However, some limitations can be attributed this approach, mainly need 3 submucosal tunnels, which is technically demanding risk injuring mucosa over tunnels. More recently, another method described: (POES).1Repici Scholar,4Zhang L.Y. Nieto J. Ngamruengphong al.Zenker's diverticulum: advancing beyond tunnel.VideoGIE. 6: 562-567Abstract Differently Z-POEM, POES obviates 1 tunnel (that proximal septum); however, it still requires other 2, on diverticular esophageal sides. According recent meta-analysis retrospective studies, 2 are similar regarding safety efficacy. Here we report use tunneling-free performed 4 patients our center. Before procedure, all (mean age, 69 ± 7) had dysphagia (grade in “dysphagia, regurgitation, complications” [DRC] scale5Ishaq Siau K. Lee protocolised measurements barium SWALLOW predict severity outcomes? "Zen-Rad" study.Dysphagia. 36: 393-401Crossref (4) Scholar) regurgitation (score patients, score others [DRC]). modified Z-POEM was using gastroscope (EG-760R; Fujifilm Medical Co, Tokyo, Japan), Flush Knife BTS 1.5 mm (Fujifilm), 11-mm through-the-scope clips (Novaclip R2, Vytil, Bagnolet, France). procedure consisted following steps: injection, incision, myotomy, closure (Video 1, available online at www.videogie.org). First, mucosal incision septum along its axis (Fig. 1) created dissection knife, after injection saline plus methylene blue. Next, submucosa directly dissected cricopharyngeus 2), while both sides only injected. full-thickness then safely accomplished (ENDO CUTQ, effect duration 3, interval unit ERBE VIO300S [ERBE Elektromedizim, Tübingen, Germany]), under direct view, preserving until cricopharyngeal fibers were 3). Lastly, closed standard 4). Intraprocedural bleeding negligible mean 9 5 minutes. Antibiotic prophylaxis (third-generation cephalosporin, single-dose) given. admitted overnight, remained asymptomatic, discharged home starting liquid intake. They gradually returned non-restrictive diet 7 days, complete symptoms’ resolution 0 esophagograms confirmed impact intervention 5; retained contrast prior [left panel], normal progression afterward [right panel]). approach seems simpler faster than POES, because intraprocedural time quite shorter that those duration, 36 14 minutes4Zhang Scholar). Considering this, named “readily POES” (R-POES). Figure 6 schematic representation (Z-POEM, R-POES). Even though series small, hypothesized R-POES safer, tunneling challenging may introduce additional harm, particularly related damage. Future experience ideally randomized controlled trials, clarify short- long-term efficacy non-tunneling R-POES. Also, remains tested whether combination mucosotomy useful avoid flap-related persist larger ZD,6Ishaq Kuwai T. al.Is same POEM achalasia? Or barking up wrong tree?.Gastrointest Endosc. 91: 204-205Abstract does not reduce size pharyngeal pouch, aid cases difficulties limited working space.Figure 2Dissection septum.View Large Image ViewerDownload Hi-res image (PPT)Figure 3Dissection sides.View 4Closure incision.View 5Barium before myotomy.View 6Schematic classical (Z-POEM), (POES), “readily” E, Esophagus; Z, diverticulum.View (PPT) authors did disclose any financial relationships. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJjOWYyOWVhNWE0MTlmZjE3ZmQ0OWU0NmRlOTBhZGEyNSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjg3NTA1ODAzfQ.o-lkH-ESdL9WWlslq6zoL_KqGp76WB7NaRlBj3LFHPeMp4i4if3trqERJQdmPZGkconxUP2AOWoWxqafCazPsN-uUIAG8w7AGRCBzkT8XpOj1RpGxLHj87GnLMC8T1NnbIeGR2bDg2BirSlqn_znWWd8yJvnv20iTwsYLipiMlBTK12lUeTZu0Lbp0_txhGhRTM5hLB27fL9TFGcWJd2dfwKYP6OuwkfRPrWoTQ2UUV_zudDGQ524yAgA-McIZaEo03aq6ewLuaQiVg8RBirDYkvyCjqENXFjcRWJJOHm6uWvlSAeL2BX8vJDAPy0LaRKrUi7zYXg6o7Q3iI1pzF3Q .mp4 Help files Video 1Tunneling-free