Intramural Surgery Per Oral Endoscopic Myotomy for Zenker’s Diverticulum (Z-POEM)
Zenker’s diverticulum (ZD) is a rare diagnosis that occurs by herniation of the mucosa and submucosa at the pharyngoesophageal junction. Patients frequently present with symptoms of dysphagia, regurgitation, and occasionally aspiration. Treatment of ZD has evolved from an open left cervical operation to rigid endoscopic approaches, and most recently flexible endoscopic treatments. The minimally invasive approach provides the prospect of shorter surgery time, a shorter length of stay, and the possibility of performing the procedure without general anesthesia, thereby improving tolerance in less-fit patients with comorbidities. Systematic reviews and meta-analysis suggest endoscopic approaches have shorter recovery time with lower perioperative morbidity, however, not enough evidence is available to support one approach over the other (Howell et al. Dysphagia. 34:930–8, 2019; Crawley et al. Otolaryngol Head Neck Surg. 161:388–400, 2019; Rizzetto et al. J Gastrointest Surg. 12:2057–65, 2008; Ishaq et al. Gastrointest Endosc. 83:1076–89.e5, 2016). As in open surgery, the key step in both rigid and flexible endoscopic approaches is to perform a complete cricopharyngeal myotomy to both relieve symptoms and prevent recurrence. This can be accomplished with various endoscopic techniques and instrumentation. A few endoscopic approaches will be highlighted with a focus on per oral endoscopic myotomy of ZD (Z-POEM) modeled after the POEM procedure for achalasia. Patients undergoing Z-POEM were found to have overall technical and clinical success rates of 97.3% and 92%, respectively (Kamal et al. Dig Dis Sci. 66:3242–9, 2020). Adverse events were noted at a rate of about 6% (Kamal et al. Dig Dis Sci. 66:3242–9, 2020). Endoscopic cricopharyngeal myotomy has been found to be a safe and efficacious procedure with favorable short-term outcomes for the treatment of ZD (Jackson and Aye. Thorac Surg Clin. 28(4):507–20, 2018). Given the variability in instrumentation and techniques described, large-scale prospective studies using standardized techniques with long-term follow-up are needed to better delineate optimal approach in the flexible endoscopic treatment of ZD.
