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• W4386716441 abstract "INTRODUCTION Zenker’s diverticulum, a type of pulsion diverticulum, is a sac-like outpouching of the mucosa and submucosa between the thyropharyngeus and cricopharyngeus muscles. This pseudodiverticulum is rare, presenting most commonly in fourth–fifth decades with a male preponderance. The symptoms depend on the size. Larger diverticula are generally present with dysphagia, regurgitation, halitosis, and a blocking sensation in the throat. The diagnostic modalities include upper gastrointestinal (GI) endoscopy and barium swallow study. The treatment options include open surgery or endoscopic procedures. Endoscopic septotomy, the most common endoscopic modality used to treat Zenker’s diverticulum, is associated with the major drawback of recurrence. However, the recent technique of Zenker peroral endoscopic myotomy (Z-POEM) utilizes the same concept of a conventional POEM and creates a submucosal tunnel on both sides of the septum. Tunneling is done to completely visualize the septum and the entire septum is divided. Since the entire septum is divided, recurrence will be less. In this brief note, we describe how this procedure may be done, illustrating it with a recent case of a 55-year-old male with regurgitation of food, halitosis, significant weight loss for 6 months, and intermittent dysphagia for solids for 10-year upper GI endoscopy showed an upper esophageal diverticulum beyond which the scope could be negotiated with some difficulty and was normal. Computed tomography of the neck with oral contrast revealed a 5.9 cm long Zenker’s diverticulum [Figure 1]. The Z-POEM was done under general anesthesia in the supine position. Preprocedural antibiotics were given. A Ryle’s tube was inserted to prevent injury to the opposite wall during dissection of the diverticular wall. This was done under endoscopic guidance as blind insertion may result in inadvertent placement in the diverticular lumen. The Ryle’s tube resulted in less space to maneuver the endoscope, making the procedure technically difficult. An HD flexible upper GI endoscope (GIF-HQ190, Olympus) was used with distal clear cap. Co2 insufflation with low flow setting was used. The next step was submucosal injection of saline with methylene blue on top of the septum. The third step was a mucosal incision to gain submucosal entry. Out of two approaches, we chose the “over the septum” approach. We used a hybrid knife from ERBE Vio 3 and did a 1.5 cm long vertical incision [Figures 2 and 3]. IT knife and TT knife can also be used for the same maneuver, depending on personal preference. It was followed by submucosal dissection on both sides [Figure 4]. The septum was completely exposed to the base to facilitate complete division, thereby decreasing recurrence [Figures 5 and 6]. Minor bleeding was encountered, which was controlled with Coagrasper. Then, the septum was entirely divided using cutting current, and after achieving complete hemostasis, the mucosal incision was closed with three Olympus clips (11 mm) [Figure 7]. Postprocedure antibiotics were continued, and the patient was fasted for 24 h. He was started on the oral diet after 24 h.Figure 1: CT chest with oral contrast showing a 5.9 cm Zenker’s diverticulum. CT: Computed tomographyFigure 2: Endoscopic view of Zenker’s diverticulumFigure 3: Mucosal incisionFigure 4: Submucosal dissectionFigure 5: SeptotomyFigure 6: PostseptotomyFigure 7: Closure of incision by hemoclipsThe prevalence of esophageal diverticula ranges from 0.06% to 4%. The most common among them is Zenker’s or hypopharyngeal diverticulum (75%). Zenker’s diverticulum, a type of pulsion diverticulum, is a sac-like outpouching of the mucosa and submucosa in Killian’s dehiscence which is formed by the transverse fibers of cricopharyngeus and oblique fibers of the inferior pharyngeal constrictor muscle. The prevalence is only 0.01%–0.11%.[1] According to Morton–Bartney’s classification, Zenker’s diverticulum is classified by its size as small (<2 cm), intermediate (2–4 cm), and large (more than 4 cm).[2] The symptoms depend on the size. Most of the small diverticula are asymptomatic. However, larger diverticula present with dysphagia, regurgitation, halitosis, and a blocking sensation in the throat. Among them, the most common is dysphagia (90%) as a result of esophageal compression by the diverticular pouch. The complications include of diverticula range from aspiration pneumonia, ulceration, bleeding from the diverticular pouch due to retained medicines, a fistula between diverticulum and tracheal lumen, and rarely a squamous cell carcinoma. The incidence of squamous cell carcinoma from the diverticular pouch ranges from 0.4% to 1.5% and it is due to the long-standing inflammation secondary to retained food particles in the diverticular lumen.[3,4] Upper GI endoscopy and barium swallow study are the diagnostic modalities.[3] The treatment options include open surgery or endoscopic procedures. Endoscopic septotomy, the most common endoscopic modality used to treat Zenker’s diverticulum, is associated with the major drawback of recurrence. However, the recent technique of Z-POEM utilizes the same concept of a conventional POEM and creates a submucosal tunnel on both sides of the septum. Tunneling is done to completely visualize the septum and the entire septum is divided. This procedure is associated with less recurrence as the entire septum is divided. Z-POEM also has the advantages of being minimally invasive and less time-consuming. Only a few case reports and small case series are available about Z-POEM. Desai et al. recently published their case series with 16 patients of Zenker’s diverticulum treated with Z-POEM.[5] Clinical success was 100%, with no recurrence after 18 months. No major complications were observed. Capnomediastinum was observed in two patients who settled with conservative treatment. Our patient did not develop any complications after the procedure. Maydeo et al. reported the outcomes of all esophageal diverticula, including Zenker’s and epiphrenic, treated with diverticular peroral endoscopic myotomy with a clinical success rate of 100%.[6] Z-POEM is better than endoscopic septotomy in having a low recurrence rate.[7] Larger studies are required to establish the procedure’s safety. Adequate training in POEM and endoscopic submucosal dissection and instrumentation is a prerequisite for this. At present, Z-POEM looks promising in the treatment of Zenker’s diverticulum. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest." @default.
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• W4386716441 title "Endoscopic treatment of Zenker's diverticulum" @default.
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• W4386716441 doi "https://doi.org/10.4103/ghep.ghep_10_23" @default.
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