A Novel Approach for the Treatment of Zenker’s Diverticulum: Z-POEM

>>A Novel Approach for the Treatment of Zenker’s Diverticulum: Z-POEM. As a background, treatment
of Zenker’s diverticulum can be accomplished
endoscopically or surgically. Both approaches are
effective in patients with Zenker’s diverticulum,
although the open surgical approach is considered invasive. Flexible endoscopic therapy
via endoscopic septotomy carries 90% of clinical success rate. However, complications can
occur in up to 11% of patients. Also, importantly, symptom
recurrence occurs in a substantial proportion
of patients on average 11% but up to 33% in the literature. A novel therapy, Zenker’s
peroral endoscopic myotomy, or Z-POEM, based on principles
of submucosal endoscopy, can be used to treat
Zenker’s diverticulum. Z-POEM ensures complete
division of the septum, which is believed to be necessary for long-lasting symptom relief. (upbeat music) This is an elderly patient
with a large five centimeter Zenker’s diverticulum as we can see here on the their esophagram. With significant symptoms of weight loss, dysphagia, and regurgitation. We can see here first
this large diverticulum. And the plan is to perform Zenker’s peroral endoscopic myotomy. The first injection is made
a few centimeters above the septum and then a
longitudinal incision is made with a triangular tip knife. Then using the same knife, an Endoscopic Submucosal
Dissection is performed to allow entry of the scope
with a clear cap on its tip into this submucosal space. Tunneling continues through
dissection of the submucosal fibers until the diverticulum is reached. Dissection is performed
at the level of the muscle to avoid any injury to the mucosal layer. Here in the middle we can see the septum and at 12 o’clock we can see the tunnel into this esophageal lumen. On the other side is a tunnel
within the diverticulum. First, tunneling is continued
on the diverticular side using same techniques and principles of standard bone that we
perform in the esophagus. Tunneling is continued until
the bottom of the diverticulum is reached as we can clearly see here. This is injection of the
submucosal fibers within the tunnel of the opposite side of
the divert of the septum on the esophageal side. Now we have complete
exposure of the septum and using an insulated-tip knife the septum is cut, or
dissected, completely making sure we protect the
opposite side of the esophagus. Continued dissection of
the septum is performed until the bottom of that
diverticulum is reached. Typically we encounter vessels and these can prophylactically coagulate using the coagulation forceps. To ensure safe dissection of the septum continued injection of
saline with blue dye into the submucosal space is
performed to push away the esophageal mucosa away from the septum. Here a triangular tip knife is used for complete division of the septum. Note that this knife is now
used as the septum is already a distance away from the
esophageal mucosa at 12 o’clock and thus it is safe to use this knife instead of the insulated-tip knife. Here we’re at the bottom
of the diverticulum and we’re ensuring complete
division of the septum. This is a key advantage of this procedure as we can ensure complete
division of the septum as it is believed that
standard endoscopic myotomy, although effective, recurrence is high due to the fact that we’ll
leave a little bit of septum behind at the end of the procedure. Here are a couple of clips
where place prophylactically at the bottom of the septum. This is the mucosal
incision in the hypopharynx that can be closed with the standard through-the-scope clips. These clips are small and patients typically cannot feel them. These patients are kept in
the hospital given intravenous antibiotics and esophagram
is performed the next day to ensure there is no leak
and patients can start on a soft diet the next day. There were no procedural complications. Patient was admitted to the
hospital for observation. The following say an
esophagram was obtained and there was no leak. A soft diet was started and
the patient orated that well. At two months followup
patient remains completely asymptomatic and doing well. (upbeat music)

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