Peroral Endoscopic Myotomy in the Management of Zenker’s Diverticulum: A Retrospective Multicenter Study

Abstract

Background: Peroral endoscopic myotomy (POEM) is an emerging technique in the treatment of Zenker’s diverticulum (ZD). This study aimed to analyze the feasibility of Zenker’s POEM (Z-POEM) in a multicenter setting and assess its performance using a validated Kothari-Haber Scoring System newly developed for symptom measurement in ZD. Materials and methods: This was a multicenter retrospective study involving three Polish tertiary referral endoscopic units. The data of consecutive patients with symptomatic ZD treated with Z-POEM in Poland between May 2019 and August 2020 were retrieved and analyzed. Primary outcome measures were technical success and clinical success rate (<3 points in Kothari-Haber Score at 2–3 months follow-up). Secondary outcome measures included procedures’ duration, length of hospital stay, and adverse events. Results: 22 patients with symptomatic ZD were included. The mean age was 67.6 (±10.7) years, and 14 (63.6%) were male. All but two patients were treatment naïve. The average size of the ZD was 30 mm (IQR, 24–40 mm). Technical success was achieved in all patients (100%), whereas clinical success was 90.9%. The average Kothari-Haber Score was 6.35 before treatment and has dropped to 0.65 after the treatment (p < 0.0001). The mean procedure time was 48.8 (±19.3) minutes, and the median length of hospital stay was 2 days (IQR, 2–3). Three patients (13.6%) had post-procedural emphysema, of which two were mild and self-resolving (9.1%), and one was moderate (4.5%) and complicated with laryngeal edema and prolonged intubation. Conclusions: This feasibility study suggests that Z-POEM is a highly effective and safe treatment for ZD, particularly among treatment-naïve patients. Comparative studies with other treatment modalities over longer follow-up are warranted.

Modern approaches to treating Zenker's diverticulum

“…Other recent reviews have documented similar technical and clinical success rates of ZPOEM [30 ▪▪ ,31 ▪ ]. Reported clinical recurrence rates have ranged from 0 to 14.7% [32,33,34 ▪▪ ,35 ▪ ,36]. ZPOEM appears to be a relatively well tolerated procedure and has been associated with an adverse event rate ranging from 4 to 16% [29 ▪▪ ,30 ▪▪ ,37 ▪ ,38 ▪ ].…”

Submucosal endoscopy: the present and future

“…Several studies have evaluated the safety and efficacy of Z-POEM in patients with Zenker's diverticulum. [42][43][44][45][46][47][48][49] In these studies, the clinical success rate was 91% to 100% at a mean follow-up of 3 to 10 months (Table 2). [42][43][44][45][46][47][48][49] Meanwhile, AEs related to Z-POEM have been reported in 0% to 13.6% of cases.…”

“…[42][43][44][45][46][47][48][49] In these studies, the clinical success rate was 91% to 100% at a mean follow-up of 3 to 10 months (Table 2). [42][43][44][45][46][47][48][49] Meanwhile, AEs related to Z-POEM have been reported in 0% to 13.6% of cases. Although there are no randomized trials comparing Z-POEM and FES, a few retrospective comparative studies have suggested that clinical success is comparable between the two techniques.…”

Zenker’s peroral endoscopic myotomy for management of large Zenker’s diverticulum

“…An important difference between standard FES and zPOEM is that while traditional FES divides the entire septum (including the overlying mucosa), the tunneling technique employed in zPOEM allows direct access and division of the underlying muscle while leaving the overlying mucosa intact. Hence, although this allows a more liberal myotomy, the large remnant flap may cause residual symptoms and it has been suggested that large Zenker’s diverticula should undergo standard FES 8 . Accordingly, one patient with persistent symptoms following zPOEM had complete response following endoscopic incision of the redundant mucosal flap; it was noted during incision that no muscle fibers were present, confirming that her symptoms were indeed due to the residual mucosal flap.…”

“…zPOEM utilizes a submucosal tunnel to fully expose the muscular septum, thus allowing visual confirmation of a complete myotomy. Several studies have demonstrated its efficacy in the management of Zenker's diverticulum with mean diverticular size < 35 mm [6][7][8][9], but the use of zPOEM for large Zenker's diverticulum has not been evaluated. However, this is an important population in which to evaluate this technique as, in contrast to FES where the septum and overlying mucosa are divided, the mucosa is left intact during zPOEM.…”